EMQ Flashcards by bushra gul

A group of trainees meet together on the labour ward with the duty consultant on a Monday morning to discuss the noteworthy cases during which the consultant relates various experiences, situations and advice to the trainees

A: Appraisal
B: Bloom’s taxonomy of learning
C: Criterion-referenced standard setting
D: Educational supervision
E: Experiential learning
F: Formative assessments
G: Life-long adult learning
H: Linear equating standard setting
I: Norm-referenced standard setting
J: Pendleton’s rules for feedback
K: Quality assurance in education
L: Reflective practice
M: Reliability
N: Summative assessments
O: Transformative learning
P: Validity
Q: Vicarious learning

The correct answer is vicarious learning.

vɪˈkɛːrɪəs,vʌɪˈkɛːrɪəs/:
feeling is experienced by watching, listening to, or reading about other people doing something, rather than by doing it yourself.

These questions test the basic principles of teaching, learning, assessment and appraisal. For a useful article and reference see: Duthie SJ, Garden AS. The teacher, the learner and the method. The Obstetrician & Gynaecologist 2010;12:273–80.

How well did you know this?

Not at all

Perfectly

A consultant has just performed an online learning exercise on her Trust’s clinical governance issues as a pre-requisite for her consultant appraisal. The Trust has determined that every consultant must score 15 or more out of 25 before the assessment can be signed off by the appraiser

A: Appraisal
B: Bloom’s taxonomy of learning
C: Criterion-referenced standard setting
D: Educational supervision
E: Experiential learning
F: Formative assessments
G: Life-long adult learning
H: Linear equating standard setting
I: Norm-referenced standard setting
J: Pendleton’s rules for feedback
K: Quality assurance in education
L: Reflective practice
M: Reliability
N: Summative assessments
O: Transformative learning
P: Validity
Q: Vicarious learning

The answer is norm-referenced standard setting.

How well did you know this?

Not at all

Perfectly

A specialist trainee in obstetrics and gynaecology must become a member of the Royal College of Obstetricians and Gynaecologists before progressing to advanced training

A: Appraisal
B: Bloom’s taxonomy of learning
C: Criterion-referenced standard setting
D: Educational supervision
E: Experiential learning
F: Formative assessments
G: Life-long adult learning
H: Linear equating standard setting
I: Norm-referenced standard setting
J: Pendleton’s rules for feedback
K: Quality assurance in education
L: Reflective practice
M: Reliability
N: Summative assessments
O: Transformative learning
P: Validity
Q: Vicarious learning

The answer is summative assessments.

How well did you know this?

Not at all

Perfectly

An ST1 trainee describes to his clinical supervisor how he managed a postpartum haemorrhage by himself for the first time and now feels much more confident about dealing with this complication, more than after doing a skills drills on the subject

A: Appraisal
B: Bloom’s taxonomy of learning
C: Criterion-referenced standard setting
D: Educational supervision
E: Experiential learning
F: Formative assessments
G: Life-long adult learning
H: Linear equating standard setting
I: Norm-referenced standard setting
J: Pendleton’s rules for feedback
K: Quality assurance in education
L: Reflective practice
M: Reliability
N: Summative assessments
O: Transformative learning
P: Validity
Q: Vicarious learning

The correct answer is experiential learning.

How well did you know this?

Not at all

Perfectly

An ST7 advanced trainee presents a case-based discussion to her educational supervisor who realises that the trainee has only superficial knowledge with knowledge deficits on the subjects discussed. The supervisor recommends some targeted reading to address the identified educational needs. They meet together a few weeks later and the trainee describes how reading around the subject has enabled a lot of the concepts to fall into place to enhance her clinical practice as a specialist obstetrician and gynaecologist. The trainee also describes that she now understands the need for in-depth learning to be an expert in the field

A: Appraisal
B: Bloom’s taxonomy of learning
C: Criterion-referenced standard setting
D: Educational supervision
E: Experiential learning
F: Formative assessments
G: Life-long adult learning
H: Linear equating standard setting
I: Norm-referenced standard setting
J: Pendleton’s rules for feedback
K: Quality assurance in education
L: Reflective practice
M: Reliability
N: Summative assessments
O: Transformative learning
P: Validity
Q: Vicarious learning

The answer is transformative learning.

How well did you know this?

Not at all

Perfectly

A few trainees were asked to submit some questions for a local MRCOG Part 2 course. Most of the questions were gratefully accepted and incorporated into the course by the organiser; two questions were rejected because they were deemed to be outside the scope of the MRCOG Part 2 syllabus

A: Appraisal
B: Bloom’s taxonomy of learning
C: Criterion-referenced standard setting
D: Educational supervision
E: Experiential learning
F: Formative assessments
G: Life-long adult learning
H: Linear equating standard setting
I: Norm-referenced standard setting
J: Pendleton’s rules for feedback
K: Quality assurance in education
L: Reflective practice
M: Reliability
N: Summative assessments
O: Transformative learning
P: Validity
Q: Vicarious learning

Correct

The answer is validity.

How well did you know this?

Not at all

Perfectly

A 29-year-old woman, P2, has had a rapid birth of a healthy male infant at term with extensive perineal trauma. In theatre, a fourth-degree tear is diagnosed and the anorectal mucosa has been sutured and the external and internal anal sphincters now need to be sutured

A: Coated vicryl® / Braided polyglactin / Half circle, round bodied / 3-0
B: Coated vicryl® / Braided polyglactin / J needle, round bodied, heavy / 2-0
C: Coated vicryl® / Braided polyglactin / Half circle, round bodied / 0
D: Dermabond® / Topical skin adhesive / None
E: Endoloop® ligature / Braided polyglactin / None / 0
F: Mersilene® / Polyester fibre / Blunt point, half circle, double / 5 mm
G: Monocryl® / Monofilament: polypropylene / Half circle, round bodied / 1
H: Nylon / Monofilament / Straight cutting / 0
I: PDS / Monofilament: polydioxanone / Half circle, round bodied / 3-0
J: PDS / Monofilament: polydioxanone, looped / Blunt, taperpoint, half circle, heavy / 0
K: Prolene® / Monofilament: polypropylene / Curved double / 6-0
L: Prolene® / Monofilament: polypropylene / Curved, reverse cutting / 4-0
M: Stainless steel wire / Multifilament / Tapercut, round bodied / 2 mm
N: Steristrips® / Skin adhesive strips / None
O: Vicryl Rapide® / Braided polyglactin / Tapercut, half circle / 2-0

The answer is coated vicryl® / braided polyglactin / half circle, round-bodied / 3-0.

How well did you know this?

Not at all

Perfectly

A 27-year-old woman has had two second-trimester miscarriages and has had a diagnosis of cervical weakness. She is now 14 weeks pregnant and is going to have a cervical cerclage procedure in an attempt to gain a successful outcome for this pregnancy

The answer is Mersilene® / polyester fibre / blunt point, half circle, double / 5 mm.

How well did you know this?

Not at all

Perfectly

A 37-year-old woman, P4 and with a BMI of 32, has undergone a laparotomy using a midline sub-umbilical incision to remove an abdominal mass which was confirmed as a benign enlarged fibroid uterus; now the plan is to close the peritoneum and rectus sheath

The answer is PDS / monofilament: polydioxanone, looped / blunt, taperpoint, half circle, heavy /0.

How well did you know this?

Not at all

Perfectly

A 39-year-old woman in her first pregnancy has a rotational forceps delivery with an episiotomy in theatre with effective epidural analgesia after a prolonged labour. Inspection of the lower genital tract reveals damage above the episiotomy incision and a 2-cm ‘button-hole’ defect in the vagina that includes the anorectal mucosa is identified and now has to be sutured

The answer is Coated vicryl® / braided polyglactin / half circle, round bodies / 3-0.
Royal College of Obstetricians and Gynaecologists. Management of Third- and Fourth-degree Perineal Tears. Green-top Guideline 29. London: RCOG; 2015.

How well did you know this?

Not at all

Perfectly

The anatomical structure that is divided when a midline episiotomy is performed

A: Anal canal mucosa
B: Arcus tendinous fascia pelvis
C: Bulbospongiosis
D: Coccygeus
E: Deep transverse perineal muscle
F: External anal sphincter
G: Iliococcygeus
H: Ischiorectal fossa
I: Perineal body or central perineal tendon
J: Pubocervical fascia and pubovesical ligaments
K: Pubococcygeus
L: Puborectalis
M: Rectovaginal endopelvic fascia
N: Sacrospinous ligaments
O: Sacrotuberous ligaments
P: Superficial transverse perineal muscle
Q: Transverse cervical ligaments
R: Uterosacral ligaments

The correct answer is perineal body or central perineal tendon. Applied pelvic anatomy is essential knowledge for obstetricians and gynaecologists.

How well did you know this?

Not at all

Perfectly

The anatomical structure that is supported after a transvaginal tape is inserted in the surgical treatment of genuine stress incontinence

A: Anal canal mucosa
B: Arcus tendinous fascia pelvis
C: Bulbospongiosis
D: Coccygeus
E: Deep transverse perineal muscle
F: External anal sphincter
G: Iliococcygeus
H: Ischiorectal fossa
I: Perineal body or central perineal tendon
J: Pubocervical fascia and pubovesical ligaments
K: Pubococcygeus
L: Puborectalis
M: Rectovaginal endopelvic fascia
N: Sacrospinous ligaments
O: Sacrotuberous ligaments
P: Superficial transverse perineal muscle
Q: Transverse cervical ligaments
R: Uterosacral ligaments

The correct answer is pubocervical fascia and pubovesical ligaments.

How well did you know this?

Not at all

Perfectly

The anatomical structure used to support the vaginal vault in the surgical treatment of third degree utero-vaginal prolapse

A: Anal canal mucosa
B: Arcus tendinous fascia pelvis
C: Bulbospongiosis
D: Coccygeus
E: Deep transverse perineal muscle
F: External anal sphincter
G: Iliococcygeus
H: Ischiorectal fossa
I: Perineal body or central perineal tendon
J: Pubocervical fascia and pubovesical ligaments
K: Pubococcygeus
L: Puborectalis
M: Rectovaginal endopelvic fascia
N: Sacrospinous ligaments
O: Sacrotuberous ligaments
P: Superficial transverse perineal muscle
Q: Transverse cervical ligaments
R: Uterosacral ligaments

The correct answer is sacrospinous ligaments.

How well did you know this?

Not at all

Perfectly

The anatomical structure normally included in the first major pedicle that is divided and secured during a vaginal hysterectomy and after the vagina and bladder have been reflected off the cervix and surrounding tissues and the peritoneum of the pouch of Douglas has been divided and opened

A: Anal canal mucosa
B: Arcus tendinous fascia pelvis
C: Bulbospongiosis
D: Coccygeus
E: Deep transverse perineal muscle
F: External anal sphincter
G: Iliococcygeus
H: Ischiorectal fossa
I: Perineal body or central perineal tendon
J: Pubocervical fascia and pubovesical ligaments
K: Pubococcygeus
L: Puborectalis
M: Rectovaginal endopelvic fascia
N: Sacrospinous ligaments
O: Sacrotuberous ligaments
P: Superficial transverse perineal muscle
Q: Transverse cervical ligaments
R: Uterosacral ligaments

The correct answer is uterosacral ligaments.

How well did you know this?

Not at all

Perfectly

During an abdominal total hysterectomy: the anatomical structure normally included in the clamping of the paracervical tissues after the uterine artery have been secured and divided and before the vaginal angle and the surrounding tissue is secured and sutured

A: Anal canal mucosa
B: Arcus tendinous fascia pelvis
C: Bulbospongiosis
D: Coccygeus
E: Deep transverse perineal muscle
F: External anal sphincter
G: Iliococcygeus
H: Ischiorectal fossa
I: Perineal body or central perineal tendon
J: Pubocervical fascia and pubovesical ligaments
K: Pubococcygeus
L: Puborectalis
M: Rectovaginal endopelvic fascia
N: Sacrospinous ligaments
O: Sacrotuberous ligaments
P: Superficial transverse perineal muscle
Q: Transverse cervical ligaments
R: Uterosacral ligaments

The answer is transverse cervical ligaments.

How well did you know this?

Not at all

Perfectly

The anatomical structure that is reconstructed during the surgical repair of a rectocele

A: Anal canal mucosa
B: Arcus tendinous fascia pelvis
C: Bulbospongiosis
D: Coccygeus
E: Deep transverse perineal muscle
F: External anal sphincter
G: Iliococcygeus
H: Ischiorectal fossa
I: Perineal body or central perineal tendon
J: Pubocervical fascia and pubovesical ligaments
K: Pubococcygeus
L: Puborectalis
M: Rectovaginal endopelvic fascia
N: Sacrospinous ligaments
O: Sacrotuberous ligaments
P: Superficial transverse perineal muscle
Q: Transverse cervical ligaments
R: Uterosacral ligaments

The correct answer is rectovaginal endopelvic fascia.

How well did you know this?

Not at all

Perfectly

May be divided when opening the peritoneum during a laparotomy and is also known as the urachus.

A: Anterior division of the internal iliac
B: Ascending cervical branch of vaginal artery
C: Deep circumflex
D: Inferior epigastric
E: Internal iliac
F: Internal pudendal
G: Lateral sacral
H: Middle rectal
I: Obturator
J: Ovarian
K: Posterior division of the internal iliac
L: Superior gluteal
M: Umbilical
N: Uterine
O: Vaginal

The answer is umbilical. Knowledge of the blood supply to the pelvis and anterior abdominal wall is essential. Radiopaedia.org has a useful mnemonic to help you remember the branches of the internal iliac artery.

How well did you know this?

Not at all

Perfectly

May become thrombosed in the puerperium and is a rare cause of acute localised abdominal pain

A: Anterior division of the internal iliac
B: Ascending cervical branch of vaginal artery
C: Deep circumflex
D: Inferior epigastric
E: Internal iliac
F: Internal pudendal
G: Lateral sacral
H: Middle rectal
I: Obturator
J: Ovarian
K: Posterior division of the internal iliac
L: Superior gluteal
M: Umbilical
N: Uterine
O: Vaginal

The answer is ovarian.

How well did you know this?

Not at all

Perfectly

Occasionally may need to be ligated in cases of acute pelvic or obstetric haemorrhage

A: Anterior division of the internal iliac
B: Ascending cervical branch of vaginal artery
C: Deep circumflex
D: Inferior epigastric
E: Internal iliac
F: Internal pudendal
G: Lateral sacral
H: Middle rectal
I: Obturator
J: Ovarian
K: Posterior division of the internal iliac
L: Superior gluteal
M: Umbilical
N: Uterine
O: Vaginal

The answer is anterior division of the internal iliac. Note that the answer is ‘anterior division of the internal iliac’ rather than ‘internal iliac’ in order to avoid postoperative ischaemic pain in the buttock when the posterior division is occluded.

How well did you know this?

Not at all

Perfectly

Needs to be secured when closing the anterior vagina during a total hysterectomy

A: Anterior division of the internal iliac
B: Ascending cervical branch of vaginal artery
C: Deep circumflex
D: Inferior epigastric
E: Internal iliac
F: Internal pudendal
G: Lateral sacral
H: Middle rectal
I: Obturator
J: Ovarian
K: Posterior division of the internal iliac
L: Superior gluteal
M: Umbilical
N: Uterine
O: Vaginal

The answer is ascending cervical branch of vaginal artery.

How well did you know this?

Not at all

Perfectly

Biophysical blood flow analyses (Doppler) may be used in the second trimester of pregnancy to assess possible perinatal outcomes

A: Anterior division of the internal iliac
B: Ascending cervical branch of vaginal artery
C: Deep circumflex
D: Inferior epigastric
E: Internal iliac
F: Internal pudendal
G: Lateral sacral
H: Middle rectal
I: Obturator
J: Ovarian
K: Posterior division of the internal iliac
L: Superior gluteal
M: Umbilical
N: Uterine
O: Vaginal

The answer is uterine.

How well did you know this?

Not at all

Perfectly

May be damaged when injecting local anaesthetic during a regional block for instrumental deliveries

A: Anterior division of the internal iliac
B: Ascending cervical branch of vaginal artery
C: Deep circumflex
D: Inferior epigastric
E: Internal iliac
F: Internal pudendal
G: Lateral sacral
H: Middle rectal
I: Obturator
J: Ovarian
K: Posterior division of the internal iliac
L: Superior gluteal
M: Umbilical
N: Uterine
O: Vaginal

The answer is internal pudendal.

How well did you know this?

Not at all

Perfectly

Occlusion has been shown to be an effective treatment for women with leiomyomata (fibroids)

A: Anterior division of the internal iliac
B: Ascending cervical branch of vaginal artery
C: Deep circumflex
D: Inferior epigastric
E: Internal iliac
F: Internal pudendal
G: Lateral sacral
H: Middle rectal
I: Obturator
J: Ovarian
K: Posterior division of the internal iliac
L: Superior gluteal
M: Umbilical
N: Uterine
O: Vaginal

The answer is uterine.

How well did you know this?

Not at all

Perfectly

May be damaged during insertion of a second access port during laparoscopy and sometimes results in either a sub-rectus haematoma or postoperative haemorrhage

A: Anterior division of the internal iliac
B: Ascending cervical branch of vaginal artery
C: Deep circumflex
D: Inferior epigastric
E: Internal iliac
F: Internal pudendal
G: Lateral sacral
H: Middle rectal
I: Obturator
J: Ovarian
K: Posterior division of the internal iliac
L: Superior gluteal
M: Umbilical
N: Uterine
O: Vaginal

The answer is inferior epigastric.

How well did you know this?

Not at all

Perfectly

Biophysical blood flow analyses (Doppler) may be used in the third trimester of pregnancy to assess possible perinatal outcomes ``` A: Anterior division of the internal iliac B: Ascending cervical branch of vaginal artery C: Deep circumflex D: Inferior epigastric E: Internal iliac F: Internal pudendal G: Lateral sacral H: Middle rectal I: Obturator J: Ovarian K: Posterior division of the internal iliac L: Superior gluteal M: Umbilical N: Uterine O: Vaginal ```

The answer is umbilical.

Initial suturing during a surgical repair of a right mediolateral episiotomy will prevent postpartum haemorrhage ``` A: Anterior division of the internal iliac B: Ascending cervical branch of vaginal artery C: Deep circumflex D: Inferior epigastric E: Internal iliac F: Internal pudendal G: Lateral sacral H: Middle rectal I: Obturator J: Ovarian K: Posterior division of the internal iliac L: Superior gluteal M: Umbilical N: Uterine O: Vaginal ```

The answer is vaginal.

A 48-year-old woman had an abdominal total hysterectomy and bilateral salpingo-oophorectomy to remove an ovarian tumour and is seen on the ward round on day 2. She had a poor night with abdominal pain and bloating and has just started vomiting. On examination: she looks pale and sweaty; the abdomen is distended with minimal bowel sounds and generalised tenderness; temperature is 36.8°C; pulse rate is 110 bpm; BP is 120/65 mmHg; respiratory rate is 14 breaths/min; BMI is 36 ``` A: Acute renal failure B: Allergic reaction C: Bowel perforation D: Chest infection E: Cerebrovascular accident F: Deep vein thrombosis G: Delirium tremens H: Intra-abdominal haemorrhage I: Myocardial infarction J: Paralytic ileus K: Pulmonary atelectasis L: Pulmonary embolism M: Small bowel obstruction N: Subcutaneous haematoma O: Sub-rectus haematoma P: Septic shock Q: Urinary tract infection R: Vaginal vault haematoma S: Wound dehiscence T: Wound infection ```

The correct answer is paralytic ileus. This is a classic post-operative ward round diagnosis after a proper examination of the cardiovascular and respiratory systems.

A 25-year-old woman underwent an uncomplicated laparoscopy and dye test to investigate primary subfertility. There was some minimal-stage endometriosis, which was diathermised, and the fallopian tubes were patent. Eight hours after the operation the woman is experiencing a lot of pain requiring opiate analgesia. The abdomen is very tender around the secondary port site in the left iliac fossa; is slightly distended; oozing blood-stain fluid, despite a pressure dressing. Observations: pulse rate is 110 bpm; BP is 140/75 mmHg; temperature is 36.5°C; respiratory rate is 18 breaths/min ``` A: Acute renal failure B: Allergic reaction C: Bowel perforation D: Chest infection E: Cerebrovascular accident F: Deep vein thrombosis G: Delirium tremens H: Intra-abdominal haemorrhage I: Myocardial infarction J: Paralytic ileus K: Pulmonary atelectasis L: Pulmonary embolism M: Small bowel obstruction N: Subcutaneous haematoma O: Sub-rectus haematoma P: Septic shock Q: Urinary tract infection R: Vaginal vault haematoma S: Wound dehiscence T: Wound infection ```

The answer is sub-rectus haematoma. See explanation to question 1.

A 38-year-old woman, P4, has just arrived back on the gynaecology ward after an uncomplicated surgical management of miscarriage to stop uterine haemorrhage following a spontaneous miscarriage at 14 weeks of gestation. The estimated blood loss was recorded as 800 ml and haemostasis was achieved satisfactorily with intravenous oxytocics, and has been maintained. She is taking daily thyroxine 150 microgram and prenisolone 10 mg for arthritis and had no known allergies and is a non-smoker. She becomes acutely unwell and on examination: she looks unwell with cold extremities and is drowsy; abdomen is soft and non-tender with no masses or rashes; vaginal examination is normal with no vaginal bleeding. Observations: pulse rate is 120 bpm; BP is 90/50 mmHg; temperature is 35.7°C; respiratory rate is 26 breaths/min ``` A: Acute renal failure B: Allergic reaction C: Bowel perforation D: Chest infection E: Cerebrovascular accident F: Deep vein thrombosis G: Delirium tremens H: Intra-abdominal haemorrhage I: Myocardial infarction J: Paralytic ileus K: Pulmonary atelectasis L: Pulmonary embolism M: Small bowel obstruction N: Subcutaneous haematoma O: Sub-rectus haematoma P: Septic shock Q: Urinary tract infection R: Vaginal vault haematoma S: Wound dehiscence T: Wound infection ```

The correct answer is septic shock. See explanation to question 1.

A 42-year-old woman had a vaginal hysterectomy on the afternoon list the day before and is seen on the Day 1 ward round. She looks pale and feels unwell and faint and complains of difficulty getting her breath and pains in her chest and shoulders. There is no vaginal bleeding and the urine catheter sample is clear but she has passed only 100 ml overnight despite receiving more than a litre of normal saline overnight. The abdomen is slightly distended and tender; bowel sounds are present. Observations: pulse rate is 105 bpm; BP is 120/50 mmHg; temperature is 36.7°C; respiratory rate is 25 breaths/min ``` A: Acute renal failure B: Allergic reaction C: Bowel perforation D: Chest infection E: Cerebrovascular accident F: Deep vein thrombosis G: Delirium tremens H: Intra-abdominal haemorrhage I: Myocardial infarction J: Paralytic ileus K: Pulmonary atelectasis L: Pulmonary embolism M: Small bowel obstruction N: Subcutaneous haematoma O: Sub-rectus haematoma P: Septic shock Q: Urinary tract infection R: Vaginal vault haematoma S: Wound dehiscence T: Wound infection ```

The correct answer is intra-abdominal haemorrhage. See explanation to question 1.

``` A 75-year-old woman, with a BMI of 24 and who is a non-smoker, had a laparotomy through a mid-line surgical incision for an abdominal and pelvic mass 3 days ago and the tumour was deemed to be inoperable. She has developed some central and right-sided chest pain and is feeling unwell and breathless and has become restless. On examination: abdomen is soft and non-tender; wound satisfactory; chest dull to percussion both bases and poor air entry with some crepitations that clear with coughing. Observations: pulse rate is 96 bpm; BP is 110/60 mmHg; temperature is 38.7°C; respiratory rate is 21 breaths/min A: Acute renal failure B: Allergic reaction C: Bowel perforation D: Chest infection E: Cerebrovascular accident F: Deep vein thrombosis G: Delirium tremens H: Intra-abdominal haemorrhage I: Myocardial infarction J: Paralytic ileus K: Pulmonary atelectasis L: Pulmonary embolism M: Small bowel obstruction N: Subcutaneous haematoma O: Sub-rectus haematoma P: Septic shock Q: Urinary tract infection R: Vaginal vault haematoma S: Wound dehiscence T: Wound infection ```

The correct answer is chest infection. See explanation to question 1.

``` A 70-year-old woman, P1, with a BMI of 34 and type 2 diabetes and who is a smoker (15 cigarettes a day) had an uncomplicated laparoscopic hysterectomy and bilateral salpingo-oophorectomy two days ago to treat endometrial cancer. She has developed some central and right-sided chest pain and is feeling unwell and breathless and has become restless. On examination: she looks pale and moderately distressed; abdomen is soft and non-tender; wounds satisfactory; chest percussion and breath sounds are normal; lower limbs normal and mobile. Observations: pulse rate is 102 bpm; BP is 140/750 mmHg; temperature is 36.7°C; respiratory rate is 22 breaths/min A: Acute renal failure B: Allergic reaction C: Bowel perforation D: Chest infection E: Cerebrovascular accident F: Deep vein thrombosis G: Delirium tremens H: Intra-abdominal haemorrhage I: Myocardial infarction J: Paralytic ileus K: Pulmonary atelectasis L: Pulmonary embolism M: Small bowel obstruction N: Subcutaneous haematoma O: Sub-rectus haematoma P: Septic shock Q: Urinary tract infection R: Vaginal vault haematoma S: Wound dehiscence T: Wound infection ```

The correct answer is pulmonary embolism. See explanation to question 1.

A 31-year-old nulliparous woman is referred with a long history of frequency, passing urine as much as every 30–60 minutes during the day and associated with pain and irritation. There is very occasional nocturia and she also suffers from intermittent lower abdominal pains. Her LMP was 2 weeks ago and her periods are irregular and heavy coming every 5–7 weeks. She is not sexually active and smokes 5–10 cigarettes a day. The GP has taken several urine samples for culture and they have all been negative. On examination: BP is 120/65 mmHg, BMI is 24; abdominal and vaginal examination is normal apart from some vague suprapubic, vaginal and urethral tenderness. Urine analysis is normal; full blood count is normal; thyroid and renal function are normal ``` A: Atonic bladder B: Bladder calculus C: Bladder diverticulum D: Bladder tumour E: Chronic cystitis F: Detrusor over-activity G: Endometriosis of the bladder H: Overactive bladder I: Overflow incontinence J: Painful bladder syndrome K: Sensory urgency L: Tuberculosis of the renal tract M: Urethral syndrome N: Urinary tract infection O: Urodynamic stress incontinence P: Uterine tumour Q: Vesicovaginal fistula ```

The answer is urethral syndrome. History taking is essential in gynaecology. Urethral syndrome is also known as symptomatic abacteriuria. It has many of the same symptoms as urethritis, which is an infection and inflammation of the urethra. These symptoms include abdominal pain and frequent, painful urination. Both conditions cause irritation to your urethra. Urethritis usually develops because of a bacteria or virus, but urethral syndrome often has no clear cause.

A 35-year-old woman, P4, complains about many years of urinary urgency, frequency and occasional incontinence. She is a teacher and describes an almost constant sensation of needing to pass urine and finds it impossible to wait for the break between classes to void. The episodes of incontinence are associated with increasing urgency but are rare. Gynaecological examination is normal. A bladder diary shows frequency 12 times/day; functional bladder capacity 300 ml; average voided volume 150 ml. Cystometry shows: no incontinence; the first desire to void occurs at 100 ml; strong desire at 300 ml; no observed increase in bladder pressure during filling ``` A: Atonic bladder B: Bladder calculus C: Bladder diverticulum D: Bladder tumour E: Chronic cystitis F: Detrusor over-activity G: Endometriosis of the bladder H: Overactive bladder I: Overflow incontinence J: Painful bladder syndrome K: Sensory urgency L: Tuberculosis of the renal tract M: Urethral syndrome N: Urinary tract infection O: Urodynamic stress incontinence P: Uterine tumour Q: Vesicovaginal fistula ```

The correct answer is sensory urgency. Sensory urgency describes patients complaining of urinary urgency but without demonstrable detrusor instability. The International Continence Society [1] has defined urgency as a strong desire to void accompanied by fear of leakage or fear of pain, which may be associated with two types of detrusor dysfunction: urgency with overactive detrusor dysfunction is motor urgency, whereas urgency with detrusor hypersensitivity is sensory urgency. The problem remains of defining what exactly is meant by detrusor hypersensitivity but many authors have investigated patients with urinary urgency unaccompanied by objective evidence of detrusor instability and a number of terms have been used — primary vesical sensory urgency [2], urge syndrome [3] and sensory urge incontinence

A 27-year-old woman had an emergency caesarean section for an obstructed labour after an unsuccessful trial of forceps in theatre with epidural analgesia. Since the operation, which was 3 days ago, she has been having problems with passing urine and has leaked urine with minimal sensation to void. There is no recorded damage or surgical difficulties with the bladder in the operation notes. She now has an indwelling catheter with intermittent spigot and release every 4 hours. The urine draining is clear with adequate urine output ``` A: Atonic bladder B: Bladder calculus C: Bladder diverticulum D: Bladder tumour E: Chronic cystitis F: Detrusor over-activity G: Endometriosis of the bladder H: Overactive bladder I: Overflow incontinence J: Painful bladder syndrome K: Sensory urgency L: Tuberculosis of the renal tract M: Urethral syndrome N: Urinary tract infection O: Urodynamic stress incontinence P: Uterine tumour Q: Vesicovaginal fistula ```

The answer is atonic bladder.

A 72-year-old nulliparous woman is referred with intermittent episodes of what is thought to be vaginal bleeding for the last 6 months mainly when she is on the toilet. She has urinary frequency and nocturia twice or three times a night and occasional leaks of urine. She has type 2 diabetes and suffers from hypertension, and takes medications for both conditions. She smokes 20 cigarettes a day and occasionally leaks urine when coughing. On examination: BP is 150/90 mmHg; BMI is 34; abdominal palpation is normal; vaginal examination shows an atrophic vaginal, normal cervix and pelvis with no blood seen. Urine analysis shows: protein 2+; blood 3+; glucose 3+; an ultrasound scan of the kidneys, bladder, uterus and ovaries is normal ``` A: Atonic bladder B: Bladder calculus C: Bladder diverticulum D: Bladder tumour E: Chronic cystitis F: Detrusor over-activity G: Endometriosis of the bladder H: Overactive bladder I: Overflow incontinence J: Painful bladder syndrome K: Sensory urgency L: Tuberculosis of the renal tract M: Urethral syndrome N: Urinary tract infection O: Urodynamic stress incontinence P: Uterine tumour Q: Vesicovaginal fistula ```

The answer is bladder tumour.

A 59-year-old woman, P2, is referred with urinary leakage when coughing, sneezing, lifting, bending and changing position and she has had to wear incontinence pads. On examination her BMI is 30 and there is evidence of lower genital tract atrophy; there is no demonstrable stress incontinence. Filling cystometry shows: an early first desire to void at 75 ml; urgency at 140 ml associated with high pressure detrusor contraction, which reached 40 cm/H20 and resulted in completed bladder emptying ``` A: Atonic bladder B: Bladder calculus C: Bladder diverticulum D: Bladder tumour E: Chronic cystitis F: Detrusor over-activity G: Endometriosis of the bladder H: Overactive bladder I: Overflow incontinence J: Painful bladder syndrome K: Sensory urgency L: Tuberculosis of the renal tract M: Urethral syndrome N: Urinary tract infection O: Urodynamic stress incontinence P: Uterine tumour Q: Vesicovaginal fistula ```

The answer is detrusor over-activity. This a urodynamic diagnosis while over-active bladder is a clinical diagnosis.

``` A 33-year-old woman, P1, is referred with a long history of urinary frequency and urgency and annoying nocturia that is depriving her of sleep. It is not associated with leaks or bed-wetting but there is lower abdominal pain when she empties her bladder. These symptoms are much worse during menstruation and there is also some deep pain experienced during sexual intercourse. Three months ago she had a Mirena® intrauterine device inserted by her GP for contraception and she confirms that her symptoms have improved to some extent on the basis that she is now amenorrhoeic. On examination: BP is 135/70 mmHg; BMI is 28; abdominal palpation is normal with some suprapubic tenderness; vaginal examination is normal with some vague tenderness in the posterior and anterior fornices. Several urine cultures have been negative and an ultrasound scan of the kidneys, bladder, uterus and ovaries is normal A: Atonic bladder B: Bladder calculus C: Bladder diverticulum D: Bladder tumour E: Chronic cystitis F: Detrusor over-activity G: Endometriosis of the bladder H: Overactive bladder I: Overflow incontinence J: Painful bladder syndrome K: Sensory urgency L: Tuberculosis of the renal tract M: Urethral syndrome N: Urinary tract infection O: Urodynamic stress incontinence P: Uterine tumour Q: Vesicovaginal fistula ```

The answer is painful bladder syndrome. See question 1 to see how the clinical history of painful bladder syndrome differs from the urethral syndrome.

A 29-year-old woman, P2+1 is referred with irregular vaginal bleeding since she had an uncomplicated termination of pregnancy 3 months ago. On examination – BMI: 19; she looks pale and unwell; the abdomen is soft and not tender; the vaginal examination revealed a bulky uterus, normal closed cervix; no pelvic masses; a small red friable lesion of 2 cm in the left periurethral space ``` A: B-cell lymphoma of the ovary B: Carcinomatosis C: Cervical carcinoma D: Choriocarcinoma E: Endodermal sinus tumour F: Endometrial adenocarcinoma G: Krukenberg tumour H: Malignant dermoid teratoma I: Malignant melanoma J: Mixed mesodermal tumour K: Mucinous cystadenocarcinoma L: Ovarian endometroid carcinoma M: Pelvic actinomycotic granulomata N: Squamous cell carcinoma O: Tubo-ovarian abscess P: Uterine sarcoma ```

The answer is choriocarcinoma. Presentations of advanced gynaecological tumours are self-explanatory but you can discuss these with your local trainee-friendly gynaecological oncologist if you would like further information.

A healthy 23-year-old woman, P0+1, presents to her GP with pelvic pain. Ultrasound examination of the pelvis shows an 8 cm diameter, solid mass arising from the left ovary, there is no free fluid, and the right ovary and uterus are normal. She had an uncomplicated termination of pregnancy 6 months ago. Her periods have been normal and she has a Mirena® IUS for contraception. There is no relevant past medical or surgical history and her family history is unremarkable. The following blood results were obtained: • liver function tests: normal • full blood count: normal • urea, creatinine and electrolytes: normal • hCG < 5 IU/l • AFP: 24 600 U/ml • CA125: 27 U/ml ``` A: B-cell lymphoma of the ovary B: Carcinomatosis C: Cervical carcinoma D: Choriocarcinoma E: Endodermal sinus tumour F: Endometrial adenocarcinoma G: Krukenberg tumour H: Malignant dermoid teratoma I: Malignant melanoma J: Mixed mesodermal tumour K: Mucinous cystadenocarcinoma L: Ovarian endometroid carcinoma M: Pelvic actinomycotic granulomata N: Squamous cell carcinoma O: Tubo-ovarian abscess P: Uterine sarcoma ```

The answer is endodermal sinus tumour.

A 69-year-old P4 woman is referred by her GP with increasing drowsiness and confusion. Abdominal examination is normal and there is no lymphadenopathy; rectal examination reveals a firm fixed pelvic mass. Blood tests reveal that she is uraemic. ``` A: B-cell lymphoma of the ovary B: Carcinomatosis C: Cervical carcinoma D: Choriocarcinoma E: Endodermal sinus tumour F: Endometrial adenocarcinoma G: Krukenberg tumour H: Malignant dermoid teratoma I: Malignant melanoma J: Mixed mesodermal tumour K: Mucinous cystadenocarcinoma L: Ovarian endometroid carcinoma M: Pelvic actinomycotic granulomata N: Squamous cell carcinoma O: Tubo-ovarian abscess P: Uterine sarcoma ```

The answer is cervical carcinoma.

A 42-year-old woman, P3, is admitted to the intensive care unit in status epilepticus. She has not suffered from epilepsy in the past. She smokes 25 cigarettes a day and otherwise is in good health. She has been sterilised. While she was being catheterised the nurse noticed a small dark-brown raised lesion near the uretheral orifice on the left labia about 1 cm in diameter and with bilateral inguinal lymphadenopathy ``` A: B-cell lymphoma of the ovary B: Carcinomatosis C: Cervical carcinoma D: Choriocarcinoma E: Endodermal sinus tumour F: Endometrial adenocarcinoma G: Krukenberg tumour H: Malignant dermoid teratoma I: Malignant melanoma J: Mixed mesodermal tumour K: Mucinous cystadenocarcinoma L: Ovarian endometroid carcinoma M: Pelvic actinomycotic granulomata N: Squamous cell carcinoma O: Tubo-ovarian abscess P: Uterine sarcoma ```

The answer is malignant melanoma.

A 64-year-old woman is admitted with a bowel obstruction. She has a 2-day history of abdominal pain and vomiting. She has a past medical history of irritable bowel syndrome, diverticulosis and breast cancer, which was treated successfully over 5 years ago. During the laparotomy the surgeon confirms a diverticular abscess and obstruction of the sigmoid colon. He calls for a gynaecologist to give an opinion about bilateral ovarian enlargement up to about 6–7 cm, solid with nodules covering the surfaces ``` A: B-cell lymphoma of the ovary B: Carcinomatosis C: Cervical carcinoma D: Choriocarcinoma E: Endodermal sinus tumour F: Endometrial adenocarcinoma G: Krukenberg tumour H: Malignant dermoid teratoma I: Malignant melanoma J: Mixed mesodermal tumour K: Mucinous cystadenocarcinoma L: Ovarian endometroid carcinoma M: Pelvic actinomycotic granulomata N: Squamous cell carcinoma O: Tubo-ovarian abscess P: Uterine sarcoma ```

The answer is Krukenberg tumour.

A 59-year-old woman, P2, is referred with vague abdominal pains, malaise, heart burn and weight loss. An ultrasound scan shows bilateral enlarged (9–10-cm diameter each) ovaries with multiple cysts, a normal uterus, no free fluid; normal liver and kidneys. There is a family history of bowel cancer and she has been on combined HRT since the menopause. Blood results: • liver function tests: normal • full blood count: normal • urea, creatinine and electrolytes: normal • hCG < 5 IU/l • AFP: 19 U/ml • CA125: 251 U/ml ``` A: B-cell lymphoma of the ovary B: Carcinomatosis C: Cervical carcinoma D: Choriocarcinoma E: Endodermal sinus tumour F: Endometrial adenocarcinoma G: Krukenberg tumour H: Malignant dermoid teratoma I: Malignant melanoma J: Mixed mesodermal tumour K: Mucinous cystadenocarcinoma L: Ovarian endometroid carcinoma M: Pelvic actinomycotic granulomata N: Squamous cell carcinoma O: Tubo-ovarian abscess P: Uterine sarcoma ```

The answer is mucinous cystadenocarcinoma.

A couple are referred to the fertility service because the 24-year-old male partner has developed testicular cancer that will require orchidectomy followed by chemotherapy. They wish to have his semen stored for artificial insemination of his wife if he were to become azoospermic in the future A: Abandon operative procedure and reschedule B: Defer the operative procedure C: Fraser competence must be demonstrable before obtaining consent D: Obtain legal advice on individuals who withhold consent for treatment E: Obtain legal advice on interpretation on the Abortion Act 1967 F: Obtain legal advice on interpretation on the Human Fertilisation and Embryology Act 1990 and the Code of Practice of Human Fertilisation and Embryology Authority Act 2009 G: Obtain legal advice on interpretation on the Mental Capacity Act 2005 H: Parental consent must be obtained before proceeding I: Paternal consent must be obtained before proceeding J: Perform additional procedure without explicit consent to do so K: Proceed without consent in order to save the fetus’ life L: Proceed without consent in order to save the woman’s life M: Respect the rights of the putative father of the fetus to withhold consent N: Respect the rights of the unborn fetus and proceed to delivery O: Respect the rights of the woman to withhold consent for treatment P: Specific consent is unnecessary Q: Verbal consent alone is acceptable R: Verbal consent with witness and case note documentation S: Written consent must be obtained

The answer is written consent must be obtained. Royal College of Obstetricians and Gynaecologists. Obtaining Valid Consent. Clinical Governance Advice 6. London: RCOG; 2015.

A 13-year-old girl requires a hymenotomy to treat her cryptamenorrhoea A: Abandon operative procedure and reschedule B: Defer the operative procedure C: Fraser competence must be demonstrable before obtaining consent D: Obtain legal advice on individuals who withhold consent for treatment E: Obtain legal advice on interpretation on the Abortion Act 1967 F: Obtain legal advice on interpretation on the Human Fertilisation and Embryology Act 1990 and the Code of Practice of Human Fertilisation and Embryology Authority Act 2009 G: Obtain legal advice on interpretation on the Mental Capacity Act 2005 H: Parental consent must be obtained before proceeding I: Paternal consent must be obtained before proceeding J: Perform additional procedure without explicit consent to do so K: Proceed without consent in order to save the fetus’ life L: Proceed without consent in order to save the woman’s life M: Respect the rights of the putative father of the fetus to withhold consent N: Respect the rights of the unborn fetus and proceed to delivery O: Respect the rights of the woman to withhold consent for treatment P: Specific consent is unnecessary Q: Verbal consent alone is acceptable R: Verbal consent with witness and case note documentation S: Written consent must be obtained

The answer is parental consent must be obtained before proceeding.

A 14-year-old girl attends the gynaecology clinic requesting a termination of pregnancy. Her last period was 10 weeks ago. She does not want her parents to know A: Abandon operative procedure and reschedule B: Defer the operative procedure C: Fraser competence must be demonstrable before obtaining consent D: Obtain legal advice on individuals who withhold consent for treatment E: Obtain legal advice on interpretation on the Abortion Act 1967 F: Obtain legal advice on interpretation on the Human Fertilisation and Embryology Act 1990 and the Code of Practice of Human Fertilisation and Embryology Authority Act 2009 G: Obtain legal advice on interpretation on the Mental Capacity Act 2005 H: Parental consent must be obtained before proceeding I: Paternal consent must be obtained before proceeding J: Perform additional procedure without explicit consent to do so K: Proceed without consent in order to save the fetus’ life L: Proceed without consent in order to save the woman’s life M: Respect the rights of the putative father of the fetus to withhold consent N: Respect the rights of the unborn fetus and proceed to delivery O: Respect the rights of the woman to withhold consent for treatment P: Specific consent is unnecessary Q: Verbal consent alone is acceptable R: Verbal consent with witness and case note documentation S: Written consent must be obtained

The answer is Fraser competence must be demonstrable before obtaining consent.

A 19-year-old woman suffering from Down syndrome is referred to the gynaecology clinic with an abdominal mass that needs an exploratory laparotomy. She is an orphan and lives in a residential care home and is accompanied to the clinic by one of the home’s healthcare assistants. She has a low IQ A: Abandon operative procedure and reschedule B: Defer the operative procedure C: Fraser competence must be demonstrable before obtaining consent D: Obtain legal advice on individuals who withhold consent for treatment E: Obtain legal advice on interpretation on the Abortion Act 1967 F: Obtain legal advice on interpretation on the Human Fertilisation and Embryology Act 1990 and the Code of Practice of Human Fertilisation and Embryology Authority Act 2009 G: Obtain legal advice on interpretation on the Mental Capacity Act 2005 H: Parental consent must be obtained before proceeding I: Paternal consent must be obtained before proceeding J: Perform additional procedure without explicit consent to do so K: Proceed without consent in order to save the fetus’ life L: Proceed without consent in order to save the woman’s life M: Respect the rights of the putative father of the fetus to withhold consent N: Respect the rights of the unborn fetus and proceed to delivery O: Respect the rights of the woman to withhold consent for treatment P: Specific consent is unnecessary Q: Verbal consent alone is acceptable R: Verbal consent with witness and case note documentation S: Written consent must be obtained

The answer is obtain legal advice on interpretation on the Mental Capacity Act 2005.

An 18-year-old woman is to be seen by the consultant gynaecologist who is accompanied by a medical student as a part of his clinical attachment A: Abandon operative procedure and reschedule B: Defer the operative procedure C: Fraser competence must be demonstrable before obtaining consent D: Obtain legal advice on individuals who withhold consent for treatment E: Obtain legal advice on interpretation on the Abortion Act 1967 F: Obtain legal advice on interpretation on the Human Fertilisation and Embryology Act 1990 and the Code of Practice of Human Fertilisation and Embryology Authority Act 2009 G: Obtain legal advice on interpretation on the Mental Capacity Act 2005 H: Parental consent must be obtained before proceeding I: Paternal consent must be obtained before proceeding J: Perform additional procedure without explicit consent to do so K: Proceed without consent in order to save the fetus’ life L: Proceed without consent in order to save the woman’s life M: Respect the rights of the putative father of the fetus to withhold consent N: Respect the rights of the unborn fetus and proceed to delivery O: Respect the rights of the woman to withhold consent for treatment P: Specific consent is unnecessary Q: Verbal consent alone is acceptable R: Verbal consent with witness and case note documentation S: Written consent must be obtained

The answer is verbal consent alone is acceptable.

A 39-year-old woman, P4, has attended the day case surgical unit for a surgical termination of pregnancy and insertion of a Mirena® IUS for which she consented for a week before in the outpatient clinic. She now appears somewhat upset and reticent about undergoing the procedure A: Abandon operative procedure and reschedule B: Defer the operative procedure C: Fraser competence must be demonstrable before obtaining consent D: Obtain legal advice on individuals who withhold consent for treatment E: Obtain legal advice on interpretation on the Abortion Act 1967 F: Obtain legal advice on interpretation on the Human Fertilisation and Embryology Act 1990 and the Code of Practice of Human Fertilisation and Embryology Authority Act 2009 G: Obtain legal advice on interpretation on the Mental Capacity Act 2005 H: Parental consent must be obtained before proceeding I: Paternal consent must be obtained before proceeding J: Perform additional procedure without explicit consent to do so K: Proceed without consent in order to save the fetus’ life L: Proceed without consent in order to save the woman’s life M: Respect the rights of the putative father of the fetus to withhold consent N: Respect the rights of the unborn fetus and proceed to delivery O: Respect the rights of the woman to withhold consent for treatment P: Specific consent is unnecessary Q: Verbal consent alone is acceptable R: Verbal consent with witness and case note documentation S: Written consent must be obtained

The answer is defer the operative procedure.

A 41-year-old woman is seen at 20 weeks of gestation in her first pregnancy. The anomaly scan was normal and Down syndrome screening was low risk. She is a nonsmoker and has no relevant past medical, surgical or family history. Clinical examination reveals, BP: 120/70 mmHg; BMI: 23; cardiovascular and respiratory systems normal. Blood group is O Rhesus negative, no red cell antibodies detected; full blood count normal - you are the most senior obstetrician at a consultant-led hospital antenatal clinic and you must determine the gestation for the next review in the clinic and the action required at that visit from the option list. All other antenatal visits will be performed by the community midwife. A: 20 weeks of gestation; review with results of the fetal anomaly scan and full blood count B: 22 weeks of gestation; review results of recent glucose tolerance test C: 28 weeks of gestation; perform an ultrasound scan to measure fetal biometry, full blood count and red cell antibody detection test D: 28 weeks of gestation; perform full blood count, red cell antibody detection test and review results of the recent glucose tolerance test E: 30 weeks of gestation; review with results of full blood count F: 30 weeks of gestation; review with results of full blood count and recent glucose tolerance test G: 32 weeks of gestation; perform an ultrasound scan for placental localisation H: 32 weeks of gestation; perform an ultrasound scan to measure fetal biometry I: 36 weeks of gestation; arrange an elective caesarean section at 39 weeks of gestation J: 36 weeks of gestation; with a possible induction of labour at 38–40 weeks of gestation K: 39 weeks of gestation; arrange an elective caesarean section at 41 weeks of gestation L: 39 weeks of gestation; arrange induction of labour at or about term if all is normal with the pregnancy M: 41 weeks of gestation; perform cervical assessment and membrane sweep and arrange induction of labour at term + 12 days N: 41 weeks of gestation; to assess whether a vaginal birth is still a realistic and achievable option

The answer is 39 weekof gestation; arrange induction of labour at or about term if all is normal with the pregnancy. Royal College of Obstetricians and Gynaecologists. Induction of Labour at Term in Older Mothers. Scientific Impact Paper No 34. London; RCOG; 2013.

A 32-year-old woman is seen at 14 weeks of gestation in her first pregnancy. The Down syndrome screening was low risk. She was admitted to hospital with a threatened miscarriage at 9 weeks of gestation, associated with the ultrasound scan appearance of sub-chorionic haematoma; she received anti-D immunoglobulin; the vaginal bleeding and abdominal pain resolved spontaneously during 3 days hospitalisation. The sub-chorionic hematoma had reduced in size by the time of the 12-week scan. She is a non-smoker and has no relevant past medical, surgical or family history. Clinical examination reveals, BP: 130/75 mmHg; BMI: 26; cardiovascular and respiratory systems normal. Blood group AB Rhesus negative, no red cell antibodies detected; full blood count normal - you are the most senior obstetrician at a consultant-led hospital antenatal clinic and you must determine the gestation for the next review in the clinic and the action required at that visit from the option list. All other antenatal visits will be performed by the community midwife. A: 20 weeks of gestation; review with results of the fetal anomaly scan and full blood count B: 22 weeks of gestation; review results of recent glucose tolerance test C: 28 weeks of gestation; perform an ultrasound scan to measure fetal biometry, full blood count and red cell antibody detection test D: 28 weeks of gestation; perform full blood count, red cell antibody detection test and review results of the recent glucose tolerance test E: 30 weeks of gestation; review with results of full blood count F: 30 weeks of gestation; review with results of full blood count and recent glucose tolerance test G: 32 weeks of gestation; perform an ultrasound scan for placental localisation H: 32 weeks of gestation; perform an ultrasound scan to measure fetal biometry I: 36 weeks of gestation; arrange an elective caesarean section at 39 weeks of gestation J: 36 weeks of gestation; with a possible induction of labour at 38–40 weeks of gestation K: 39 weeks of gestation; arrange an elective caesarean section at 41 weeks of gestation L: 39 weeks of gestation; arrange induction of labour at or about term if all is normal with the pregnancy M: 41 weeks of gestation; perform cervical assessment and membrane sweep and arrange induction of labour at term + 12 days N: 41 weeks of gestation; to assess whether a vaginal birth is still a realistic and achievable option

The answer is 28 weeks of gestation; perform an | ultrasound scan to measure fetal biometry, full blood count and red cell antibody detection test.

A 26-year-old woman is seen at 14 weeks in her second pregnancy after a normal ultrasound scan. The first pregnancy was complicated by a placenta praevia that required a caesarean section at 36 weeks of gestation with a good outcome. The Down syndrome screening was low risk. She is a non-smoker and has no relevant past medical, surgical or family history. Clinical examination reveals, BP: 110/60 mmHg; BMI: 21; cardiovascular and respiratory systems normal. Blood group B Rhesus positive, no red cell antibodies detected; full blood count is normal. She is very keen to attempt a vaginal birth this pregnancy and this is discussed in detail - you are the most senior obstetrician at a consultant-led hospital antenatal clinic and you must determine the gestation for the next review in the clinic and the action required at that visit from the option list. All other antenatal visits will be performed by the community midwife. A: 20 weeks of gestation; review with results of the fetal anomaly scan and full blood count B: 22 weeks of gestation; review results of recent glucose tolerance test C: 28 weeks of gestation; perform an ultrasound scan to measure fetal biometry, full blood count and red cell antibody detection test D: 28 weeks of gestation; perform full blood count, red cell antibody detection test and review results of the recent glucose tolerance test E: 30 weeks of gestation; review with results of full blood count F: 30 weeks of gestation; review with results of full blood count and recent glucose tolerance test G: 32 weeks of gestation; perform an ultrasound scan for placental localisation H: 32 weeks of gestation; perform an ultrasound scan to measure fetal biometry I: 36 weeks of gestation; arrange an elective caesarean section at 39 weeks of gestation J: 36 weeks of gestation; with a possible induction of labour at 38–40 weeks of gestation K: 39 weeks of gestation; arrange an elective caesarean section at 41 weeks of gestation L: 39 weeks of gestation; arrange induction of labour at or about term if all is normal with the pregnancy M: 41 weeks of gestation; perform cervical assessment and membrane sweep and arrange induction of labour at term + 12 days N: 41 weeks of gestation; to assess whether a vaginal birth is still a realistic and achievable option

The answer is 41 weeks of gestation; to assess whether a vaginal birth is still a realistic and achievable option.

A 36-year-old woman is seen at 15 weeks of gestation in her second pregnancy with the same partner. The first pregnancy was complicated by pre-eclampsia and required a caesarean section at 38 weeks of gestation, the birthweight was 3977 g. The Down syndrome screening was low risk. There is a strong family history of hypertension and diabetes. Clinical examination reveals, BP: 135/80 mmHg; BMI: 32; cardiovascular and respiratory systems normal. Urine analysis is negative; blood group O Rhesus positive, red cell antibodies not detected; full blood count is normal. You have recommended daily low-dose aspirin during the pregnancy and she is very keen to attempt a vaginal birth this pregnancy. - you are the most senior obstetrician at a consultant-led hospital antenatal clinic and you must determine the gestation for the next review in the clinic and the action required at that visit from the option list. All other antenatal visits will be performed by the community midwife. A: 20 weeks of gestation; review with results of the fetal anomaly scan and full blood count B: 22 weeks of gestation; review results of recent glucose tolerance test C: 28 weeks of gestation; perform an ultrasound scan to measure fetal biometry, full blood count and red cell antibody detection test D: 28 weeks of gestation; perform full blood count, red cell antibody detection test and review results of the recent glucose tolerance test E: 30 weeks of gestation; review with results of full blood count F: 30 weeks of gestation; review with results of full blood count and recent glucose tolerance test G: 32 weeks of gestation; perform an ultrasound scan for placental localisation H: 32 weeks of gestation; perform an ultrasound scan to measure fetal biometry I: 36 weeks of gestation; arrange an elective caesarean section at 39 weeks of gestation J: 36 weeks of gestation; with a possible induction of labour at 38–40 weeks of gestation K: 39 weeks of gestation; arrange an elective caesarean section at 41 weeks of gestation L: 39 weeks of gestation; arrange induction of labour at or about term if all is normal with the pregnancy M: 41 weeks of gestation; perform cervical assessment and membrane sweep and arrange induction of labour at term + 12 days N: 41 weeks of gestation; to assess whether a vaginal birth is still a realistic and achievable option

The answer is 28 weeks of gestation; perform full blood count, red cell antibody detection test and review results of recent glucose tolerance test. With a strong family history of diabetes, a glucose tolerance test result is most important, although third-trimester ultrasound fetal biometry may be an aspect of the management of this case.

A 33-year-old woman is seen at 14 weeks of gestation in her first pregnancy. The Down syndrome screening was low risk. She has a 6 year history of severe Crohn’s disease and currently taking prednisone 20 mg daily. She is a non-smoker and has no relevant past surgical or family history. On clinical examination she looked pale; BP: 125/75 mmHg; BMI: 18.1; cardiovascular and respiratory systems normal. Urine analysis shows glucose 2+; a random capillary blood sugar 5.8 mmol/l; blood group B Rhesus positive, no red cell antibodies detected; full blood count shows haemoglobin of 91 g/l and otherwise normal - you are the most senior obstetrician at a consultant-led hospital antenatal clinic and you must determine the gestation for the next review in the clinic and the action required at that visit from the option list. All other antenatal visits will be performed by the community midwife. A: 20 weeks of gestation; review with results of the fetal anomaly scan and full blood count B: 22 weeks of gestation; review results of recent glucose tolerance test C: 28 weeks of gestation; perform an ultrasound scan to measure fetal biometry, full blood count and red cell antibody detection test D: 28 weeks of gestation; perform full blood count, red cell antibody detection test and review results of the recent glucose tolerance test E: 30 weeks of gestation; review with results of full blood count F: 30 weeks of gestation; review with results of full blood count and recent glucose tolerance test G: 32 weeks of gestation; perform an ultrasound scan for placental localisation H: 32 weeks of gestation; perform an ultrasound scan to measure fetal biometry I: 36 weeks of gestation; arrange an elective caesarean section at 39 weeks of gestation J: 36 weeks of gestation; with a possible induction of labour at 38–40 weeks of gestation K: 39 weeks of gestation; arrange an elective caesarean section at 41 weeks of gestation L: 39 weeks of gestation; arrange induction of labour at or about term if all is normal with the pregnancy M: 41 weeks of gestation; perform cervical assessment and membrane sweep and arrange induction of labour at term + 12 days N: 41 weeks of gestation; to assess whether a vaginal birth is still a realistic and achievable option

The answer is 20 weeks of gestation; review with results of the fetal anomaly scan and full blood count.

A 24-year-old woman is seen at 14 weeks of gestation in her second pregnancy. In the first pregnancy she was delivered by rotational forceps at term of a healthy male infant (birthweight 3987 g) with a 3a perineal laceration and required intrapartum antibiotic prophylaxis for group B Streptococcus. The Down syndrome screening was low risk. She is a nonsmoker and has no relevant past medical, surgical or family history. Clinical examination reveals, BP: 110/60 mmHg; BMI: 24; cardiovascular and respiratory systems normal. Blood group O Rhesus positive, no red cell antibodies detected; full blood count is normal. She is unsure about the mode of delivery for this pregnancy. You counsel her about the risks and benefits of vaginal birth and caesarean section - you are the most senior obstetrician at a consultant-led hospital antenatal clinic and you must determine the gestation for the next review in the clinic and the action required at that visit from the option list. All other antenatal visits will be performed by the community midwife. A: 20 weeks of gestation; review with results of the fetal anomaly scan and full blood count B: 22 weeks of gestation; review results of recent glucose tolerance test C: 28 weeks of gestation; perform an ultrasound scan to measure fetal biometry, full blood count and red cell antibody detection test D: 28 weeks of gestation; perform full blood count, red cell antibody detection test and review results of the recent glucose tolerance test E: 30 weeks of gestation; review with results of full blood count F: 30 weeks of gestation; review with results of full blood count and recent glucose tolerance test G: 32 weeks of gestation; perform an ultrasound scan for placental localisation H: 32 weeks of gestation; perform an ultrasound scan to measure fetal biometry I: 36 weeks of gestation; arrange an elective caesarean section at 39 weeks of gestation J: 36 weeks of gestation; with a possible induction of labour at 38–40 weeks of gestation K: 39 weeks of gestation; arrange an elective caesarean section at 41 weeks of gestation L: 39 weeks of gestation; arrange induction of labour at or about term if all is normal with the pregnancy M: 41 weeks of gestation; perform cervical assessment and membrane sweep and arrange induction of labour at term + 12 days N: 41 weeks of gestation; to assess whether a vaginal birth is still a realistic and achievable option

The answer is 36 weeks of gestation; with a possible induction of labour between 38–40 weeks of gestation. She needs to be seen again in the third trimester to reassess her preferred option for delivery and agree a plan of management that may include induction of labour

A 35-year-old P2 woman with a BMI of 29 delivered a healthy male infant of 4.4 kg by non-rotational forceps for a persistent occipito-posterior position after a 22-hour labour complicated by an 800-ml primary postpartum hemorrhage. She smokes between ten and 15 cigarettes a day and is otherwise well and had an uncomplicated antenatal course. She wishes to breastfeed her son For each of the clinical scenarios described, choose the single most appropriate action to help reduce the risk of thrombosis from the option list. Each option may be used once, more than once, or not at all. A: Aspirin 75-mg tablets daily B: Assess maternal clotting screen tests and, if abnormal, commence low molecular weight heparin (LMWH) by subcutaneous injections daily C: Check maternal D-dimers levels and, if raised, commence daily LMWH by subcutaneous injections daily D: Clopidogrel 75-mg tablets daily for at least 6 weeks after delivery E: Commence an infusion with unfractionated heparin and monitor maternal-activated partial thromboplastin time (APTT) test each day F: Commence daily antenatal LMWH by subcutaneous injections G: Early mobilisation avoiding maternal dehydration H: Liaise with physician involved in the haematology/obstetric clinic to consider the administration of antenatal LMWH by subcutaneous injections daily I: Postnatal warfarin treatment for at least 6 weeks maintaining maternal international normalised ratio levels between 2.0 and 2.5 J: Prescribe LMWH by subcutaneous injection daily for at least 7 days after delivery K: Prescribe postnatal LMWH by subcutaneous injections daily for at least 6 weeks L: Thromboprophylaxis not required at present; perform a maternal thrombophilia screen and review the results with the woman M: Tranexamic acid 1 g three times a day for at least 6 weeks after delivery

The answer is early mobilisation avoiding maternal dehydration. Royal College of Obstetricians and Gynaecologists. Reducing the Risk of Thrombosis and Embolism during Pregnancy and the Puerperium. Green-top Guideline 37a. London: RCOG; 2015.

A 37-year-old P1 books at 12 weeks of gestation. Her first pregnancy was complicated by pre-eclampsia late in the third trimester that warranted an induction of labour and resulted in a normal birth of a 2.6-kg healthy female infant. The pueriperium was complicated by left leg, below the knee, proven deep vein thrombosis that was treated successfully with anticoagulants and a subsequent thrombophilia screen was negative. She is a non-smoker and is otherwise healthy and there is no family history of thrombosis. Physical examination is unremarkable apart from some varicose veins in the left lower leg; BP is 125/75 mmHg; BMI is 32 For each of the clinical scenarios described, choose the single most appropriate action to help reduce the risk of thrombosis from the option list. Each option may be used once, more than once, or not at all. A: Aspirin 75-mg tablets daily B: Assess maternal clotting screen tests and, if abnormal, commence low molecular weight heparin (LMWH) by subcutaneous injections daily C: Check maternal D-dimers levels and, if raised, commence daily LMWH by subcutaneous injections daily D: Clopidogrel 75-mg tablets daily for at least 6 weeks after delivery E: Commence an infusion with unfractionated heparin and monitor maternal-activated partial thromboplastin time (APTT) test each day F: Commence daily antenatal LMWH by subcutaneous injections G: Early mobilisation avoiding maternal dehydration H: Liaise with physician involved in the haematology/obstetric clinic to consider the administration of antenatal LMWH by subcutaneous injections daily I: Postnatal warfarin treatment for at least 6 weeks maintaining maternal international normalised ratio levels between 2.0 and 2.5 J: Prescribe LMWH by subcutaneous injection daily for at least 7 days after delivery K: Prescribe postnatal LMWH by subcutaneous injections daily for at least 6 weeks L: Thromboprophylaxis not required at present; perform a maternal thrombophilia screen and review the results with the woman M: Tranexamic acid 1 g three times a day for at least 6 weeks after delivery

The answer is commence daily antenatal LMWH by subcutaneous injections.

A 19-year-old nulliparous single woman with a BMI of 21 was delivered of a healthy male infant by rotational forceps delivery complicated by a 1200-ml postpartum hemorrhage. She received antenatal daily LMWH subcutaneous injections as she had a strong family history of thromboembolic disease and has a factor V Leiden gene mutation (heterozygote) although she has never had a thrombotic episodes. She is adamant that she does not want to continue to inject herself while breastfeeding and caring for her baby - For each of the clinical scenarios described, choose the single most appropriate action to help reduce the risk of thrombosis from the option list. Each option may be used once, more than once, or not at all. A: Aspirin 75-mg tablets daily B: Assess maternal clotting screen tests and, if abnormal, commence low molecular weight heparin (LMWH) by subcutaneous injections daily C: Check maternal D-dimers levels and, if raised, commence daily LMWH by subcutaneous injections daily D: Clopidogrel 75-mg tablets daily for at least 6 weeks after delivery E: Commence an infusion with unfractionated heparin and monitor maternal-activated partial thromboplastin time (APTT) test each day F: Commence daily antenatal LMWH by subcutaneous injections G: Early mobilisation avoiding maternal dehydration H: Liaise with physician involved in the haematology/obstetric clinic to consider the administration of antenatal LMWH by subcutaneous injections daily I: Postnatal warfarin treatment for at least 6 weeks maintaining maternal international normalised ratio levels between 2.0 and 2.5 J: Prescribe LMWH by subcutaneous injection daily for at least 7 days after delivery K: Prescribe postnatal LMWH by subcutaneous injections daily for at least 6 weeks L: Thromboprophylaxis not required at present; perform a maternal thrombophilia screen and review the results with the woman M: Tranexamic acid 1 g three times a day for at least 6 weeks after delivery

The answer is postnatal warfarin treatment for at least 6 weeks maintaining maternal international normalised ratio levels between 2.0 and 2.5.

A 34-year-old P2 attends her antenatal booking visit and states that her mother had a clot in her leg after her last pregnancy. She has no medical problems and no previous venous thromboembolic episodes. She not taking any regular medications but is allergic to codeine and smokes 5 cigarettes a day. An ultrasound scan reveals a dichorionic diamniotic twin pregnancy at 12 weeks of gestation. Physical examination is normal; BP is 130/70 mmHg; BMI is 28 For each of the clinical scenarios described, choose the single most appropriate action to help reduce the risk of thrombosis from the option list. Each option may be used once, more than once, or not at all. A: Aspirin 75-mg tablets daily B: Assess maternal clotting screen tests and, if abnormal, commence low molecular weight heparin (LMWH) by subcutaneous injections daily C: Check maternal D-dimers levels and, if raised, commence daily LMWH by subcutaneous injections daily D: Clopidogrel 75-mg tablets daily for at least 6 weeks after delivery E: Commence an infusion with unfractionated heparin and monitor maternal-activated partial thromboplastin time (APTT) test each day F: Commence daily antenatal LMWH by subcutaneous injections G: Early mobilisation avoiding maternal dehydration H: Liaise with physician involved in the haematology/obstetric clinic to consider the administration of antenatal LMWH by subcutaneous injections daily I: Postnatal warfarin treatment for at least 6 weeks maintaining maternal international normalised ratio levels between 2.0 and 2.5 J: Prescribe LMWH by subcutaneous injection daily for at least 7 days after delivery K: Prescribe postnatal LMWH by subcutaneous injections daily for at least 6 weeks L: Thromboprophylaxis not required at present; perform a maternal thrombophilia screen and review the results with the woman M: Tranexamic acid 1 g three times a day for at least 6 weeks after delivery

The answer is thromboprophylaxis not required at present; perform a maternal thrombophilia screen and review the results with the woman.

A 23-year-old nulliparous woman is referred to the hospital antenatal clinic by a community midwife at 23 weeks of gestation with persistent proteinuria (+++ to ++++ on dipstick urinalysis) and pedal and periobital odema following a 'flu-like illness' earlier in the pregnancy. Numerous midstream urine samples have been negative for infection. There is no relevant past medical, family or surgical history and she is a non-smoker. Physical examination reveals pitting ankle odema but otherwise is normal; BP is 135/85 mmHg; BMI is 21. Test results: • 24-hour protein excretion test 6 g per day • normal serum electrolytes • serum creatinine 95 micromol/l (normal: 50–110 micromol/l) • normal full blood count • liver function normal • serum albumin 20 g/l (normal: 35–50 g/l) • urine microscopy negative She has been seen by the renal medicine team today For each of the clinical scenarios described, choose the single most appropriate action to help reduce the risk of thrombosis from the option list. Each option may be used once, more than once, or not at all. A: Aspirin 75-mg tablets daily B: Assess maternal clotting screen tests and, if abnormal, commence low molecular weight heparin (LMWH) by subcutaneous injections daily C: Check maternal D-dimers levels and, if raised, commence daily LMWH by subcutaneous injections daily D: Clopidogrel 75-mg tablets daily for at least 6 weeks after delivery E: Commence an infusion with unfractionated heparin and monitor maternal-activated partial thromboplastin time (APTT) test each day F: Commence daily antenatal LMWH by subcutaneous injections G: Early mobilisation avoiding maternal dehydration H: Liaise with physician involved in the haematology/obstetric clinic to consider the administration of antenatal LMWH by subcutaneous injections daily I: Postnatal warfarin treatment for at least 6 weeks maintaining maternal international normalised ratio levels between 2.0 and 2.5 J: Prescribe LMWH by subcutaneous injection daily for at least 7 days after delivery K: Prescribe postnatal LMWH by subcutaneous injections daily for at least 6 weeks L: Thromboprophylaxis not required at present; perform a maternal thrombophilia screen and review the results with the woman M: Tranexamic acid 1 g three times a day for at least 6 weeks after delivery

The answer is liaise with physician involved in the haematology/obstetric clinic to consider the administration of antenatal LMWH by subcutaneous injections daily.

A 36-year-old P4 woman with a BMI of 31 who smokes ten cigarettes a day underwent an uncomplicated elective caesarean section for a transverse lie at term. There is no relevant past medical, family or surgical history. She plans to bottle-feed her healthy newborn For each of the clinical scenarios described, choose the single most appropriate action to help reduce the risk of thrombosis from the option list. Each option may be used once, more than once, or not at all. A: Aspirin 75-mg tablets daily B: Assess maternal clotting screen tests and, if abnormal, commence low molecular weight heparin (LMWH) by subcutaneous injections daily C: Check maternal D-dimers levels and, if raised, commence daily LMWH by subcutaneous injections daily D: Clopidogrel 75-mg tablets daily for at least 6 weeks after delivery E: Commence an infusion with unfractionated heparin and monitor maternal-activated partial thromboplastin time (APTT) test each day F: Commence daily antenatal LMWH by subcutaneous injections G: Early mobilisation avoiding maternal dehydration H: Liaise with physician involved in the haematology/obstetric clinic to consider the administration of antenatal LMWH by subcutaneous injections daily I: Postnatal warfarin treatment for at least 6 weeks maintaining maternal international normalised ratio levels between 2.0 and 2.5 J: Prescribe LMWH by subcutaneous injection daily for at least 7 days after delivery K: Prescribe postnatal LMWH by subcutaneous injections daily for at least 6 weeks L: Thromboprophylaxis not required at present; perform a maternal thrombophilia screen and review the results with the woman M: Tranexamic acid 1 g three times a day for at least 6 weeks after delivery

The answer is prescribe postnatal LMWH by subcutaneous injections daily for at least 6 weeks.

A 23-year-old has undergone an induction of labour at 41 weeks + 6 days in her first pregnancy. The antenatal care was complicated with an admission to hospital with a small painful antepartum haemorrhage at 34 weeks of gestation. The symptoms settled spontaneously and all investigations and monitoring were normal; her blood group is AB Rh positive. Vaginal prostaglandin gel insertion established labour within 3 hours and the labour progressed such that 6 hours later the cervix was 8 cm dilated with meconium-stained liquor with a satisfactory CTG, and epidural anaesthesia was instigated. Three hours later, the fetal head was one-fifth palpable abdominally; the cervix was 9 cm dilated; the position was left occipto-lateral with minimal caput and moulding; the CTG had a baseline of 165 beats per minute with no baseline variability; no accelerations or decelerations and a small amount of post-examination vaginal bleeding was noted. The fetal heart rate then unexpectedly drops to 85 beats per minute and does not recover For the following clinical scenarios, chose the single most appropriate management option from the list. Each answer may be used once, more than once or not at all. A: Administer terbutaline to the mother B: Ask the attendant midwife to perform a vaginal examination and artificial rupture of fetal membranes C: Commence oxytocin infusion and reassess progress of the labour in 30 minutes D: Commence oxytocin infusion and reassess progress of the labour in 2 hours E: Commence oxytocin infusion and reassess progress of the labour in 4 hours F: Deliver by category 1 caesarean section G: Deliver by category 2 caesarean section H: Epidural analgesia to be commenced followed by oxytocin infusion I: Induce labour by ARM and commence oxytocin infusion J: Manual cervical dilation prior to instrumental delivery in theatre K: Perform fetal blood sample for a pH estimation L: Prepare for assisted/instrumental delivery in the labour room M: Reassess progress of the labour in 30 minutes N: Reassess progress of the labour in 2 hours O: Transfer to operating theatre for a reassessment with view to an instrumental delivery P: Ultrasound scanning to confirm the fetal presenting part and placental localisation

The answer is transfer to the operating theatre for a reassessment with view to an instrumental delivery.

A 34-year-old woman, P2, is admitted in strong labour at 37 weeks of gestation. She has had all her antenatal care with her community midwife. She has had two normal births of healthy babies both weighing over 3.3 kg. There have been no problems during this pregnancy. As she arrives she begins involuntary pushing, meconium-stained liquor is draining and the attending midwife examines her and diagnoses a breech presentation with sacro-anterior position. The fetal heart rate is dropping to 80 beats per minute with each contraction with slow recovery back to 120 beats per minute in between contractions. She is contracting three times every 10 minutes and is distressed with pain but pushing well. The breech is descending through the birth canal satisfactorily and the station is now well below the ischial spines. The fetal heart rate baseline is now 100 beats per minute with decelerations down to 50 beats per minute during maternal pushing effort For the following clinical scenarios, chose the single most appropriate management option from the list. Each answer may be used once, more than once or not at all. A: Administer terbutaline to the mother B: Ask the attendant midwife to perform a vaginal examination and artificial rupture of fetal membranes C: Commence oxytocin infusion and reassess progress of the labour in 30 minutes D: Commence oxytocin infusion and reassess progress of the labour in 2 hours E: Commence oxytocin infusion and reassess progress of the labour in 4 hours F: Deliver by category 1 caesarean section G: Deliver by category 2 caesarean section H: Epidural analgesia to be commenced followed by oxytocin infusion I: Induce labour by ARM and commence oxytocin infusion J: Manual cervical dilation prior to instrumental delivery in theatre K: Perform fetal blood sample for a pH estimation L: Prepare for assisted/instrumental delivery in the labour room M: Reassess progress of the labour in 30 minutes N: Reassess progress of the labour in 2 hours O: Transfer to operating theatre for a reassessment with view to an instrumental delivery P: Ultrasound scanning to confirm the fetal presenting part and placental localisation

The answer is prepare for assisted/instrumental delivery in the labour room.

A 31-year-old woman in her first pregnancy and with a BMI of 25 is admitted in spontaneous labour at 41 weeks of gestation after a straightforward normal pregnancy. She has had most of her antenatal care with her community midwife. She reports reduced fetal movements for the last 24 hours and a small amount of fresh vaginal bleeding prior to admission. She is distressed and contracting four times every 10 minutes. On examination: SFH is 34 cm; longitudinal lie; presenting part is cephalic with two-fifths palpable. A vaginal examination reveals that the cervix is 5 cm dilated; presenting part vertex; right occipto-lateral position with minimal caput and moulding; blood-stained liquor is draining. The CTG shows 40 minutes of trace with a normal baseline rate of 140; little or no baseline variability, no accelerations; no decelerations For the following clinical scenarios, chose the single most appropriate management option from the list. Each answer may be used once, more than once or not at all. A: Administer terbutaline to the mother B: Ask the attendant midwife to perform a vaginal examination and artificial rupture of fetal membranes C: Commence oxytocin infusion and reassess progress of the labour in 30 minutes D: Commence oxytocin infusion and reassess progress of the labour in 2 hours E: Commence oxytocin infusion and reassess progress of the labour in 4 hours F: Deliver by category 1 caesarean section G: Deliver by category 2 caesarean section H: Epidural analgesia to be commenced followed by oxytocin infusion I: Induce labour by ARM and commence oxytocin infusion J: Manual cervical dilation prior to instrumental delivery in theatre K: Perform fetal blood sample for a pH estimation L: Prepare for assisted/instrumental delivery in the labour room M: Reassess progress of the labour in 30 minutes N: Reassess progress of the labour in 2 hours O: Transfer to operating theatre for a reassessment with view to an instrumental delivery P: Ultrasound scanning to confirm the fetal presenting part and placental localisation

The answer is deliver by category 1 caesarean section.

A 21-year-old woman, P1 and with a BMI of 22, is admitted in spontaneous labour at 37 weeks of gestation after a straightforward normal pregnancy. She has had all her antenatal care with her community midwife and had a normal birth of her first child, birthweight 3305 g. She reports reduced fetal movements for the last 24 hours; there is no history of any vaginal bleeding. She is contracting twice every 10 minutes. On examination: symphysial fundal height (SFH) is 38 cm; longitudinal lie; presenting part is cephalic with three-fifths palpable. The fetal heart rate is 140 beats per minute and regular with one audible deceleration. The CTG shows 20 minutes of trace with a normal baseline rate of 140; little or no baseline variability, no accelerations; no decelerations For the following clinical scenarios, chose the single most appropriate management option from the list. Each answer may be used once, more than once or not at all. A: Administer terbutaline to the mother B: Ask the attendant midwife to perform a vaginal examination and artificial rupture of fetal membranes C: Commence oxytocin infusion and reassess progress of the labour in 30 minutes D: Commence oxytocin infusion and reassess progress of the labour in 2 hours E: Commence oxytocin infusion and reassess progress of the labour in 4 hours F: Deliver by category 1 caesarean section G: Deliver by category 2 caesarean section H: Epidural analgesia to be commenced followed by oxytocin infusion I: Induce labour by ARM and commence oxytocin infusion J: Manual cervical dilation prior to instrumental delivery in theatre K: Perform fetal blood sample for a pH estimation L: Prepare for assisted/instrumental delivery in the labour room M: Reassess progress of the labour in 30 minutes N: Reassess progress of the labour in 2 hours O: Transfer to operating theatre for a reassessment with view to an instrumental delivery P: Ultrasound scanning to confirm the fetal presenting part and placental localisation

The answer is ask the attendant midwife to perform a vaginal examination and artificial rupture of fetal membranes.

A 17-year-old woman, in her first pregnancy and with a BMI 21, is admitted from home at 23 weeks of gestation in spontaneous labour after a large amount of vaginal bleeding and abdominal pain, which woke her up. Prior to this episode her pregnancy had been progressing normally. She is very distressed and pale. On examination her BP is 140/85 mmHg; pulse is 104 beats per minute; uterus hard and tender; fetal heat rate 104 beats per minute with audible decelerations to 60 beats per minute; vaginal examination cervix is 6 cm dilated; presenting part breech with membranes intact and fresh bleeding and clots For the following clinical scenarios, chose the single most appropriate management option from the list. Each answer may be used once, more than once or not at all. A: Administer terbutaline to the mother B: Ask the attendant midwife to perform a vaginal examination and artificial rupture of fetal membranes C: Commence oxytocin infusion and reassess progress of the labour in 30 minutes D: Commence oxytocin infusion and reassess progress of the labour in 2 hours E: Commence oxytocin infusion and reassess progress of the labour in 4 hours F: Deliver by category 1 caesarean section G: Deliver by category 2 caesarean section H: Epidural analgesia to be commenced followed by oxytocin infusion I: Induce labour by ARM and commence oxytocin infusion J: Manual cervical dilation prior to instrumental delivery in theatre K: Perform fetal blood sample for a pH estimation L: Prepare for assisted/instrumental delivery in the labour room M: Reassess progress of the labour in 30 minutes N: Reassess progress of the labour in 2 hours O: Transfer to operating theatre for a reassessment with view to an instrumental delivery P: Ultrasound scanning to confirm the fetal presenting part and placental localisation

The answer is commence oxytocin infusion and reassess progress of the labour in 30 minutes. Note that this is a real live example – caesarean section/hysterotomy is dangerous for the mother and the fetus is very unlikely to survive the insults of extreme prematurity and abruption; the only way to stop the haemorrhage is by uterine contraction until the baby is delivered/miscarried. Although this is a consultant decision, this is a good vicarious learning opportunity.

A 41-year-old woman, in her first pregnancy and with a BMI of 32, is admitted in spontaneous labour at 39 weeks of gestation after a straightforward normal pregnancy. She has had most of her antenatal care with her community midwife. She reports reduced fetal movements for the last 24 hours; there is no history of any vaginal bleeding. She is distressed and contracting four times every 10 minutes. On examination: symphysial fundal height (SFH) is 35 cm; longitudinal lie; presenting part is cephalic with one-fifth palpable. The fetal heart rate is 140 beats per minute and regular with one audible deceleration. A vaginal examination reveals the cervix is 8 cm dilated; presenting part vertex; occipto-anterior position with minimal caput and moulding; clear liquor is draining. The CTG shows 20 minutes of trace with a normal baseline rate of 140; little or no baseline variability, no accelerations; no decelerations For the following clinical scenarios, chose the single most appropriate management option from the list. Each answer may be used once, more than once or not at all. A: Administer terbutaline to the mother B: Ask the attendant midwife to perform a vaginal examination and artificial rupture of fetal membranes C: Commence oxytocin infusion and reassess progress of the labour in 30 minutes D: Commence oxytocin infusion and reassess progress of the labour in 2 hours E: Commence oxytocin infusion and reassess progress of the labour in 4 hours F: Deliver by category 1 caesarean section G: Deliver by category 2 caesarean section H: Epidural analgesia to be commenced followed by oxytocin infusion I: Induce labour by ARM and commence oxytocin infusion J: Manual cervical dilation prior to instrumental delivery in theatre K: Perform fetal blood sample for a pH estimation L: Prepare for assisted/instrumental delivery in the labour room M: Reassess progress of the labour in 30 minutes N: Reassess progress of the labour in 2 hours O: Transfer to operating theatre for a reassessment with view to an instrumental delivery P: Ultrasound scanning to confirm the fetal presenting part and placental localisation

The answer is perform fetal blood sample for a pH estimation.

Room 1: A 23-year-old woman with diabetes being induced at 37 weeks of gestation needs an intravenous line and commencement of a dextrose/insulin sliding scale; most recent blood sugar 7.9 mmol/l You are the ST5 registrar for labour ward doing a review of the activities currently going on in the 14 labour ward rooms with the senior labour ward midwife, an ST2 trainee for labour ward duties and an ST1 trainee who is mainly responsible for the gynaecology ward but is available for labour ward duties when necessary. There is also a labour ward clerk available for logistic and administrative duties only. Choose the single most appropriate professional needed to perform the task in each of the rooms described with the appropriate priority level from the option list. A: Professional: Obstetric registrar ST5 Prority: Now B: Professional: Obstetric registrar ST5 Prority: After first task; within 30 minutes C: Professional: Obstetric registrar ST5 Prority: After second task; within 60 minutes D: Professional: Senior midwife in-charge Prority: Now E: Professional: Senior midwife in-charge Prority: After first task; within 30 minutes F: Professional: Senior midwife in-charge Prority: After second task; within 60 minutes G: Professional: Obstetric doctor ST2 Prority: Now H: Professional: Obstetric doctor ST2 Prority: After first task; within 30 minutes I: Professional: Obstetric doctor ST2 Prority: After second task; within 60 minutes J: Professional: Gynaecology on-call doctor ST1 Prority: Now K: Professional: Gynaecology on-call doctor ST1 Prority: After first task; within 30 minutes L: Professional: Gynaecology on-call doctor ST1 Prority: After second task; within 60 minutes M: Professional: Labour ward clerk Prority: Now N: Professional: Labour ward clerk Prority: After first task; within 30 minutes O: Professional: Labour ward clerk Prority: After second task; within 60 minutes

The answer is Professional: Gynaecology on-call doctor ST1 Prority: After first task; within 30 minutes

Room 2: P1 in spontaneous labour at 41 weeks of gestation with clear liquor and good progress needs CTG review You are the ST5 registrar for labour ward doing a review of the activities currently going on in the 14 labour ward rooms with the senior labour ward midwife, an ST2 trainee for labour ward duties and an ST1 trainee who is mainly responsible for the gynaecology ward but is available for labour ward duties when necessary. There is also a labour ward clerk available for logistic and administrative duties only. Choose the single most appropriate professional needed to perform the task in each of the rooms described with the appropriate priority level from the option list. A: Professional: Obstetric registrar ST5 Prority: Now B: Professional: Obstetric registrar ST5 Prority: After first task; within 30 minutes C: Professional: Obstetric registrar ST5 Prority: After second task; within 60 minutes D: Professional: Senior midwife in-charge Prority: Now E: Professional: Senior midwife in-charge Prority: After first task; within 30 minutes F: Professional: Senior midwife in-charge Prority: After second task; within 60 minutes G: Professional: Obstetric doctor ST2 Prority: Now H: Professional: Obstetric doctor ST2 Prority: After first task; within 30 minutes I: Professional: Obstetric doctor ST2 Prority: After second task; within 60 minutes J: Professional: Gynaecology on-call doctor ST1 Prority: Now K: Professional: Gynaecology on-call doctor ST1 Prority: After first task; within 30 minutes L: Professional: Gynaecology on-call doctor ST1 Prority: After second task; within 60 minutes M: Professional: Labour ward clerk Prority: Now N: Professional: Labour ward clerk Prority: After first task; within 30 minutes O: Professional: Labour ward clerk Prority: After second task; within 60 minutes

The answer is Professional: Senior midwife in-charge Prority: Now

Room 3: P1 just about to deliver; thick fresh meconium-stained liquor; need to summon paediatrician to be present at the birth You are the ST5 registrar for labour ward doing a review of the activities currently going on in the 14 labour ward rooms with the senior labour ward midwife, an ST2 trainee for labour ward duties and an ST1 trainee who is mainly responsible for the gynaecology ward but is available for labour ward duties when necessary. There is also a labour ward clerk available for logistic and administrative duties only. Choose the single most appropriate professional needed to perform the task in each of the rooms described with the appropriate priority level from the option list. A: Professional: Obstetric registrar ST5 Prority: Now B: Professional: Obstetric registrar ST5 Prority: After first task; within 30 minutes C: Professional: Obstetric registrar ST5 Prority: After second task; within 60 minutes D: Professional: Senior midwife in-charge Prority: Now E: Professional: Senior midwife in-charge Prority: After first task; within 30 minutes F: Professional: Senior midwife in-charge Prority: After second task; within 60 minutes G: Professional: Obstetric doctor ST2 Prority: Now H: Professional: Obstetric doctor ST2 Prority: After first task; within 30 minutes I: Professional: Obstetric doctor ST2 Prority: After second task; within 60 minutes J: Professional: Gynaecology on-call doctor ST1 Prority: Now K: Professional: Gynaecology on-call doctor ST1 Prority: After first task; within 30 minutes L: Professional: Gynaecology on-call doctor ST1 Prority: After second task; within 60 minutes M: Professional: Labour ward clerk Prority: Now N: Professional: Labour ward clerk Prority: After first task; within 30 minutes O: Professional: Labour ward clerk Prority: After second task; within 60 minutes

The answer is Professional: Labour ward clerk Prority: Now

Room 4: P0, 22 weeks of gestation, just admitted in what appears to be early spontaneous labour; midwife cannot hear the fetal heart You are the ST5 registrar for labour ward doing a review of the activities currently going on in the 14 labour ward rooms with the senior labour ward midwife, an ST2 trainee for labour ward duties and an ST1 trainee who is mainly responsible for the gynaecology ward but is available for labour ward duties when necessary. There is also a labour ward clerk available for logistic and administrative duties only. Choose the single most appropriate professional needed to perform the task in each of the rooms described with the appropriate priority level from the option list. A: Professional: Obstetric registrar ST5 Prority: Now B: Professional: Obstetric registrar ST5 Prority: After first task; within 30 minutes C: Professional: Obstetric registrar ST5 Prority: After second task; within 60 minutes D: Professional: Senior midwife in-charge Prority: Now E: Professional: Senior midwife in-charge Prority: After first task; within 30 minutes F: Professional: Senior midwife in-charge Prority: After second task; within 60 minutes G: Professional: Obstetric doctor ST2 Prority: Now H: Professional: Obstetric doctor ST2 Prority: After first task; within 30 minutes I: Professional: Obstetric doctor ST2 Prority: After second task; within 60 minutes J: Professional: Gynaecology on-call doctor ST1 Prority: Now K: Professional: Gynaecology on-call doctor ST1 Prority: After first task; within 30 minutes L: Professional: Gynaecology on-call doctor ST1 Prority: After second task; within 60 minutes M: Professional: Labour ward clerk Prority: Now N: Professional: Labour ward clerk Prority: After first task; within 30 minutes O: Professional: Labour ward clerk Prority: After second task; within 60 minutes

The answer is Professional: Obstetric registrar ST5 Prority: After second task; within 60 minutes.

Room 5: Woman delivered normally; needs transferring to the postnatal ward to allow the room to be made ready for the woman labouring in the waiting room You are the ST5 registrar for labour ward doing a review of the activities currently going on in the 14 labour ward rooms with the senior labour ward midwife, an ST2 trainee for labour ward duties and an ST1 trainee who is mainly responsible for the gynaecology ward but is available for labour ward duties when necessary. There is also a labour ward clerk available for logistic and administrative duties only. Choose the single most appropriate professional needed to perform the task in each of the rooms described with the appropriate priority level from the option list. A: Professional: Obstetric registrar ST5 Prority: Now B: Professional: Obstetric registrar ST5 Prority: After first task; within 30 minutes C: Professional: Obstetric registrar ST5 Prority: After second task; within 60 minutes D: Professional: Senior midwife in-charge Prority: Now E: Professional: Senior midwife in-charge Prority: After first task; within 30 minutes F: Professional: Senior midwife in-charge Prority: After second task; within 60 minutes G: Professional: Obstetric doctor ST2 Prority: Now H: Professional: Obstetric doctor ST2 Prority: After first task; within 30 minutes I: Professional: Obstetric doctor ST2 Prority: After second task; within 60 minutes J: Professional: Gynaecology on-call doctor ST1 Prority: Now K: Professional: Gynaecology on-call doctor ST1 Prority: After first task; within 30 minutes L: Professional: Gynaecology on-call doctor ST1 Prority: After second task; within 60 minutes M: Professional: Labour ward clerk Prority: Now N: Professional: Labour ward clerk Prority: After first task; within 30 minutes O: Professional: Labour ward clerk Prority: After second task; within 60 minutes

The answer is Professional: Labour ward clerk Prority: After first task; within 30 minutes.

Room 6: P1 with previous caesarean section with grade 1 anterior placenta praevia admitted at 36 weeks of gestation with a small APH; CTG normal; blood cross-matched; Hb 113 g/l; consultant needed to do caesarean section, which was agreed and arranged for 1 hours’ time You are the ST5 registrar for labour ward doing a review of the activities currently going on in the 14 labour ward rooms with the senior labour ward midwife, an ST2 trainee for labour ward duties and an ST1 trainee who is mainly responsible for the gynaecology ward but is available for labour ward duties when necessary. There is also a labour ward clerk available for logistic and administrative duties only. Choose the single most appropriate professional needed to perform the task in each of the rooms described with the appropriate priority level from the option list. A: Professional: Obstetric registrar ST5 Prority: Now B: Professional: Obstetric registrar ST5 Prority: After first task; within 30 minutes C: Professional: Obstetric registrar ST5 Prority: After second task; within 60 minutes D: Professional: Senior midwife in-charge Prority: Now E: Professional: Senior midwife in-charge Prority: After first task; within 30 minutes F: Professional: Senior midwife in-charge Prority: After second task; within 60 minutes G: Professional: Obstetric doctor ST2 Prority: Now H: Professional: Obstetric doctor ST2 Prority: After first task; within 30 minutes I: Professional: Obstetric doctor ST2 Prority: After second task; within 60 minutes J: Professional: Gynaecology on-call doctor ST1 Prority: Now K: Professional: Gynaecology on-call doctor ST1 Prority: After first task; within 30 minutes L: Professional: Gynaecology on-call doctor ST1 Prority: After second task; within 60 minutes M: Professional: Labour ward clerk Prority: Now N: Professional: Labour ward clerk Prority: After first task; within 30 minutes O: Professional: Labour ward clerk Prority: After second task; within 60 minutes

The answer is Professional: Senior midwife in-charge Prority: After second task; within 60 minutes.

Room 7: P1 who had a normal birth 65 minutes ago with a retained placenta; not bleeding; observations normal; bladder catheterised; manual removal of placenta needs to be organised You are the ST5 registrar for labour ward doing a review of the activities currently going on in the 14 labour ward rooms with the senior labour ward midwife, an ST2 trainee for labour ward duties and an ST1 trainee who is mainly responsible for the gynaecology ward but is available for labour ward duties when necessary. There is also a labour ward clerk available for logistic and administrative duties only. Choose the single most appropriate professional needed to perform the task in each of the rooms described with the appropriate priority level from the option list. A: Professional: Obstetric registrar ST5 Prority: Now B: Professional: Obstetric registrar ST5 Prority: After first task; within 30 minutes C: Professional: Obstetric registrar ST5 Prority: After second task; within 60 minutes D: Professional: Senior midwife in-charge Prority: Now E: Professional: Senior midwife in-charge Prority: After first task; within 30 minutes F: Professional: Senior midwife in-charge Prority: After second task; within 60 minutes G: Professional: Obstetric doctor ST2 Prority: Now H: Professional: Obstetric doctor ST2 Prority: After first task; within 30 minutes I: Professional: Obstetric doctor ST2 Prority: After second task; within 60 minutes J: Professional: Gynaecology on-call doctor ST1 Prority: Now K: Professional: Gynaecology on-call doctor ST1 Prority: After first task; within 30 minutes L: Professional: Gynaecology on-call doctor ST1 Prority: After second task; within 60 minutes M: Professional: Labour ward clerk Prority: Now N: Professional: Labour ward clerk Prority: After first task; within 30 minutes O: Professional: Labour ward clerk Prority: After second task; within 60 minutes

The answer is Professional: Obstetric doctor ST2 Prority: Now.

Room 8: P1 in normal spontaneous labour, fetal bradycardia (80 b/m) in second stage of labour; clear liquor You are the ST5 registrar for labour ward doing a review of the activities currently going on in the 14 labour ward rooms with the senior labour ward midwife, an ST2 trainee for labour ward duties and an ST1 trainee who is mainly responsible for the gynaecology ward but is available for labour ward duties when necessary. There is also a labour ward clerk available for logistic and administrative duties only. Choose the single most appropriate professional needed to perform the task in each of the rooms described with the appropriate priority level from the option list. A: Professional: Obstetric registrar ST5 Prority: Now B: Professional: Obstetric registrar ST5 Prority: After first task; within 30 minutes C: Professional: Obstetric registrar ST5 Prority: After second task; within 60 minutes D: Professional: Senior midwife in-charge Prority: Now E: Professional: Senior midwife in-charge Prority: After first task; within 30 minutes F: Professional: Senior midwife in-charge Prority: After second task; within 60 minutes G: Professional: Obstetric doctor ST2 Prority: Now H: Professional: Obstetric doctor ST2 Prority: After first task; within 30 minutes I: Professional: Obstetric doctor ST2 Prority: After second task; within 60 minutes J: Professional: Gynaecology on-call doctor ST1 Prority: Now K: Professional: Gynaecology on-call doctor ST1 Prority: After first task; within 30 minutes L: Professional: Gynaecology on-call doctor ST1 Prority: After second task; within 60 minutes M: Professional: Labour ward clerk Prority: Now N: Professional: Labour ward clerk Prority: After first task; within 30 minutes O: Professional: Labour ward clerk Prority: After second task; within 60 minutes

The answer is Professional: Obstetric registrar ST5 Prority: Now.

Room 9: 19-year-old woman, P3 with a BMI 43, just admitted in labour. All is normal so far but the woman forgot her hand-held notes; hospital case notes are needed You are the ST5 registrar for labour ward doing a review of the activities currently going on in the 14 labour ward rooms with the senior labour ward midwife, an ST2 trainee for labour ward duties and an ST1 trainee who is mainly responsible for the gynaecology ward but is available for labour ward duties when necessary. There is also a labour ward clerk available for logistic and administrative duties only. Choose the single most appropriate professional needed to perform the task in each of the rooms described with the appropriate priority level from the option list. A: Professional: Obstetric registrar ST5 Prority: Now B: Professional: Obstetric registrar ST5 Prority: After first task; within 30 minutes C: Professional: Obstetric registrar ST5 Prority: After second task; within 60 minutes D: Professional: Senior midwife in-charge Prority: Now E: Professional: Senior midwife in-charge Prority: After first task; within 30 minutes F: Professional: Senior midwife in-charge Prority: After second task; within 60 minutes G: Professional: Obstetric doctor ST2 Prority: Now H: Professional: Obstetric doctor ST2 Prority: After first task; within 30 minutes I: Professional: Obstetric doctor ST2 Prority: After second task; within 60 minutes J: Professional: Gynaecology on-call doctor ST1 Prority: Now K: Professional: Gynaecology on-call doctor ST1 Prority: After first task; within 30 minutes L: Professional: Gynaecology on-call doctor ST1 Prority: After second task; within 60 minutes M: Professional: Labour ward clerk Prority: Now N: Professional: Labour ward clerk Prority: After first task; within 30 minutes O: Professional: Labour ward clerk Prority: After second task; within 60 minutes

The answer is Professional: Labour ward clerk Prority: After second task; within 60 minutes.

Room 10: 41-year-old woman having a second-trimester termination of pregnancy for trisomy 13 has just aborted and is bleeding; placenta delivered; intravenous line needs re-inserting for administration of oxytocin infusion - You are the ST5 registrar for labour ward doing a review of the activities currently going on in the 14 labour ward rooms with the senior labour ward midwife, an ST2 trainee for labour ward duties and an ST1 trainee who is mainly responsible for the gynaecology ward but is available for labour ward duties when necessary. There is also a labour ward clerk available for logistic and administrative duties only. Choose the single most appropriate professional needed to perform the task in each of the rooms described with the appropriate priority level from the option list. A: Professional: Obstetric registrar ST5 Prority: Now B: Professional: Obstetric registrar ST5 Prority: After first task; within 30 minutes C: Professional: Obstetric registrar ST5 Prority: After second task; within 60 minutes D: Professional: Senior midwife in-charge Prority: Now E: Professional: Senior midwife in-charge Prority: After first task; within 30 minutes F: Professional: Senior midwife in-charge Prority: After second task; within 60 minutes G: Professional: Obstetric doctor ST2 Prority: Now H: Professional: Obstetric doctor ST2 Prority: After first task; within 30 minutes I: Professional: Obstetric doctor ST2 Prority: After second task; within 60 minutes J: Professional: Gynaecology on-call doctor ST1 Prority: Now K: Professional: Gynaecology on-call doctor ST1 Prority: After first task; within 30 minutes L: Professional: Gynaecology on-call doctor ST1 Prority: After second task; within 60 minutes M: Professional: Labour ward clerk Prority: Now N: Professional: Labour ward clerk Prority: After first task; within 30 minutes O: Professional: Labour ward clerk Prority: After second task; within 60 minutes

The answer is Professional: Gynaecology on-call doctor ST1 Prority: Now.

Room 11: P2 in spontaneous labour who has just started feeling urges to push with a breech presentation; normal progress in the first stage of labour; planned vaginal birth; CTG normal; fresh meconium-stained liquor is draining - You are the ST5 registrar for labour ward doing a review of the activities currently going on in the 14 labour ward rooms with the senior labour ward midwife, an ST2 trainee for labour ward duties and an ST1 trainee who is mainly responsible for the gynaecology ward but is available for labour ward duties when necessary. There is also a labour ward clerk available for logistic and administrative duties only. Choose the single most appropriate professional needed to perform the task in each of the rooms described with the appropriate priority level from the option list. A: Professional: Obstetric registrar ST5 Prority: Now B: Professional: Obstetric registrar ST5 Prority: After first task; within 30 minutes C: Professional: Obstetric registrar ST5 Prority: After second task; within 60 minutes D: Professional: Senior midwife in-charge Prority: Now E: Professional: Senior midwife in-charge Prority: After first task; within 30 minutes F: Professional: Senior midwife in-charge Prority: After second task; within 60 minutes G: Professional: Obstetric doctor ST2 Prority: Now H: Professional: Obstetric doctor ST2 Prority: After first task; within 30 minutes I: Professional: Obstetric doctor ST2 Prority: After second task; within 60 minutes J: Professional: Gynaecology on-call doctor ST1 Prority: Now K: Professional: Gynaecology on-call doctor ST1 Prority: After first task; within 30 minutes L: Professional: Gynaecology on-call doctor ST1 Prority: After second task; within 60 minutes M: Professional: Labour ward clerk Prority: Now N: Professional: Labour ward clerk Prority: After first task; within 30 minutes O: Professional: Labour ward clerk Prority: After second task; within 60 minutes

The answer is Professional: Obstetric registrar ST5 Prority: After first task; within 30 minutes.

Room 12: 23-year-old P0 having an induction of labour at 37 weeks of gestation for pre-eclampsia needs a review of blood results, urine output and blood pressure; currently asymptomatic and BP is 145/95 mmHg - You are the ST5 registrar for labour ward doing a review of the activities currently going on in the 14 labour ward rooms with the senior labour ward midwife, an ST2 trainee for labour ward duties and an ST1 trainee who is mainly responsible for the gynaecology ward but is available for labour ward duties when necessary. There is also a labour ward clerk available for logistic and administrative duties only. Choose the single most appropriate professional needed to perform the task in each of the rooms described with the appropriate priority level from the option list. A: Professional: Obstetric registrar ST5 Prority: Now B: Professional: Obstetric registrar ST5 Prority: After first task; within 30 minutes C: Professional: Obstetric registrar ST5 Prority: After second task; within 60 minutes D: Professional: Senior midwife in-charge Prority: Now E: Professional: Senior midwife in-charge Prority: After first task; within 30 minutes F: Professional: Senior midwife in-charge Prority: After second task; within 60 minutes G: Professional: Obstetric doctor ST2 Prority: Now H: Professional: Obstetric doctor ST2 Prority: After first task; within 30 minutes I: Professional: Obstetric doctor ST2 Prority: After second task; within 60 minutes J: Professional: Gynaecology on-call doctor ST1 Prority: Now K: Professional: Gynaecology on-call doctor ST1 Prority: After first task; within 30 minutes L: Professional: Gynaecology on-call doctor ST1 Prority: After second task; within 60 minutes M: Professional: Labour ward clerk Prority: Now N: Professional: Labour ward clerk Prority: After first task; within 30 minutes O: Professional: Labour ward clerk Prority: After second task; within 60 minutes

The answser is Professional: Obstetric doctor ST2 Prority: After second task; within 60 minutes.

Room 13: P2 in normal spontaneous labour; no problems; delivery imminent; attendant midwife needs assistance with management of the third stage of labour -You are the ST5 registrar for labour ward doing a review of the activities currently going on in the 14 labour ward rooms with the senior labour ward midwife, an ST2 trainee for labour ward duties and an ST1 trainee who is mainly responsible for the gynaecology ward but is available for labour ward duties when necessary. There is also a labour ward clerk available for logistic and administrative duties only. Choose the single most appropriate professional needed to perform the task in each of the rooms described with the appropriate priority level from the option list. A: Professional: Obstetric registrar ST5 Prority: Now B: Professional: Obstetric registrar ST5 Prority: After first task; within 30 minutes C: Professional: Obstetric registrar ST5 Prority: After second task; within 60 minutes D: Professional: Senior midwife in-charge Prority: Now E: Professional: Senior midwife in-charge Prority: After first task; within 30 minutes F: Professional: Senior midwife in-charge Prority: After second task; within 60 minutes G: Professional: Obstetric doctor ST2 Prority: Now H: Professional: Obstetric doctor ST2 Prority: After first task; within 30 minutes I: Professional: Obstetric doctor ST2 Prority: After second task; within 60 minutes J: Professional: Gynaecology on-call doctor ST1 Prority: Now K: Professional: Gynaecology on-call doctor ST1 Prority: After first task; within 30 minutes L: Professional: Gynaecology on-call doctor ST1 Prority: After second task; within 60 minutes M: Professional: Labour ward clerk Prority: Now N: Professional: Labour ward clerk Prority: After first task; within 30 minutes O: Professional: Labour ward clerk Prority: After second task; within 60 minutes

The answer is Professional: Senior midwife in-charge Prority: After first task; within 30 minutes.

Room 14: P1 delivered and third stage complete; estimated blood loss of 300 ml; needs perineal laceration to be sutured You are the ST5 registrar for labour ward doing a review of the activities currently going on in the 14 labour ward rooms with the senior labour ward midwife, an ST2 trainee for labour ward duties and an ST1 trainee who is mainly responsible for the gynaecology ward but is available for labour ward duties when necessary. There is also a labour ward clerk available for logistic and administrative duties only. Choose the single most appropriate professional needed to perform the task in each of the rooms described with the appropriate priority level from the option list. A: Professional: Obstetric registrar ST5 Prority: Now B: Professional: Obstetric registrar ST5 Prority: After first task; within 30 minutes C: Professional: Obstetric registrar ST5 Prority: After second task; within 60 minutes D: Professional: Senior midwife in-charge Prority: Now E: Professional: Senior midwife in-charge Prority: After first task; within 30 minutes F: Professional: Senior midwife in-charge Prority: After second task; within 60 minutes G: Professional: Obstetric doctor ST2 Prority: Now H: Professional: Obstetric doctor ST2 Prority: After first task; within 30 minutes I: Professional: Obstetric doctor ST2 Prority: After second task; within 60 minutes J: Professional: Gynaecology on-call doctor ST1 Prority: Now K: Professional: Gynaecology on-call doctor ST1 Prority: After first task; within 30 minutes L: Professional: Gynaecology on-call doctor ST1 Prority: After second task; within 60 minutes M: Professional: Labour ward clerk Prority: Now N: Professional: Labour ward clerk Prority: After first task; within 30 minutes O: Professional: Labour ward clerk Prority: After second task; within 60 minutes

Teh answer is Professional: Obstetric doctor ST2 Prority: After first task; within 30 minutes.

A 44-year-old nulliparous woman with type 2 diabetes and a BMI of 37 is shown to have endometrial complex hyperplasia without cellular atypia following a hysteroscopy and biopsy for intermenstrual and prolonged vaginal bleeding. A recent cervical smear was normal For each of the clinical scenarios described, choose the most appropriate management option from the list. Each option may be used once, more than once, or not at all. A: Combined oral contraceptive pill containing 20 micrograms ethinylestradiol B: Desogestrel 75 micrograms tablet daily and review in 3 months C: Endometrial resection D: Hysterectomy with bilateral salpingo-oophorectomy E: Hysteroscopy and endometrial curettage F: Levonorgestrel-IUS (Mirena®) G: Medroxyprogesterone acetate 10 mg tablet daily for 90 days then review H: Medroxyprogesterone acetate 10-mg tablet for 10 days in every 28 for 6 months I: Norethisterone 5-mg tablet daily for 7 days every 6 weeks J: Perform a cervical cytological smear K: Raloxifene 60-mg tablet daily L: Reassure and discharge M: Sequential combined HRT N: Sub-total hysterectomy O: Total hysterectomy P: Vaginal estrogen therapy

The answer is levonorgestrel-IUS (Mirena®). Note that the management of women with endometrial hyperplasia is generally answered poorly in the Part 2 MRCOG examination. It must be understood that the endometrial histology remaining in the uterus may be worse than the report on the biopsied sample and the overall risk of developing an endometrial tumour should be considered. Also, not all uterine tumours are hormone-dependent. Otify M, Fuller J, Ross J, Shaikh H, Johns J. Endometrial pathology in the postmenopausal woman – an evidence based approach to management. The Obstetrician & Gynaecologist2015;17:299–38.

A 52-year-old woman, P3 with a BMI of 32 presents to her general practitioner with irregular vaginal bleeding. A transvaginal ultrasound scan of the pelvis demonstrates an endometrial thickness of 14 mm and the histology of an outpatient biopsy of the endometrium revealed simple hyperplasia with no cellular atypia. Abdominal and pelvic examination is normal apart from a grade 1 cystocele For each of the clinical scenarios described, choose the most appropriate management option from the list. Each option may be used once, more than once, or not at all. A: Combined oral contraceptive pill containing 20 micrograms ethinylestradiol B: Desogestrel 75 micrograms tablet daily and review in 3 months C: Endometrial resection D: Hysterectomy with bilateral salpingo-oophorectomy E: Hysteroscopy and endometrial curettage F: Levonorgestrel-IUS (Mirena®) G: Medroxyprogesterone acetate 10 mg tablet daily for 90 days then review H: Medroxyprogesterone acetate 10-mg tablet for 10 days in every 28 for 6 months I: Norethisterone 5-mg tablet daily for 7 days every 6 weeks J: Perform a cervical cytological smear K: Raloxifene 60-mg tablet daily L: Reassure and discharge M: Sequential combined HRT N: Sub-total hysterectomy O: Total hysterectomy P: Vaginal estrogen therapy

The answer is hysteroscopy and endometrial curettage.

A 48-year-old woman, P1 with a BMI of 27, had an endometrial ablation for heavy menstrual bleeding and was found to have complex endometrial hyperplasia with moderate cellular atypia on a biopsy taken at the time of the procedure, although the pre-treatment hysteroscopy was recorded as normal in the operative notes. The pelvic examination at the same time was unremarkable For each of the clinical scenarios described, choose the most appropriate management option from the list. Each option may be used once, more than once, or not at all. A: Combined oral contraceptive pill containing 20 micrograms ethinylestradiol B: Desogestrel 75 micrograms tablet daily and review in 3 months C: Endometrial resection D: Hysterectomy with bilateral salpingo-oophorectomy E: Hysteroscopy and endometrial curettage F: Levonorgestrel-IUS (Mirena®) G: Medroxyprogesterone acetate 10 mg tablet daily for 90 days then review H: Medroxyprogesterone acetate 10-mg tablet for 10 days in every 28 for 6 months I: Norethisterone 5-mg tablet daily for 7 days every 6 weeks J: Perform a cervical cytological smear K: Raloxifene 60-mg tablet daily L: Reassure and discharge M: Sequential combined HRT N: Sub-total hysterectomy O: Total hysterectomy P: Vaginal estrogen therapy

The answer is hysterectomy with bilateral salpingo-oophorectomy.

A 53-year-old woman, P2 with a BMI of 25 presents with light vaginal bleeding following 6 months of amenorrhoea. Abdominal and pelvic examinations are normal apart from a slightly enlarged uterus. A transvaginal ultrasound scan of the pelvis shows several small subserosal fibroids with a regular endometrial thickness of 3.9 mm. She is concerned because there is a family history of Lynch syndrome (hereditary non-polyposis colonic cancer) For each of the clinical scenarios described, choose the most appropriate management option from the list. Each option may be used once, more than once, or not at all. A: Combined oral contraceptive pill containing 20 micrograms ethinylestradiol B: Desogestrel 75 micrograms tablet daily and review in 3 months C: Endometrial resection D: Hysterectomy with bilateral salpingo-oophorectomy E: Hysteroscopy and endometrial curettage F: Levonorgestrel-IUS (Mirena®) G: Medroxyprogesterone acetate 10 mg tablet daily for 90 days then review H: Medroxyprogesterone acetate 10-mg tablet for 10 days in every 28 for 6 months I: Norethisterone 5-mg tablet daily for 7 days every 6 weeks J: Perform a cervical cytological smear K: Raloxifene 60-mg tablet daily L: Reassure and discharge M: Sequential combined HRT N: Sub-total hysterectomy O: Total hysterectomy P: Vaginal estrogen therapy

The answer is hysteroscopy and endometrial curettage.

A 44-year-old nulligravid woman with type 2 diabetes and a BMI of 37 is shown to have endometrial complex hyperplasia without cellular atypia after a hysteroscopy and biopsy investigating intermenstrual and prolonged vaginal bleeding. A recent cervical smear was normal and she is known to have a significant uterine Müllerian fusion defect associated with a structural renal tract abnormality with normal renal function For each of the clinical scenarios described, choose the most appropriate management option from the list. Each option may be used once, more than once, or not at all. A: Combined oral contraceptive pill containing 20 micrograms ethinylestradiol B: Desogestrel 75 micrograms tablet daily and review in 3 months C: Endometrial resection D: Hysterectomy with bilateral salpingo-oophorectomy E: Hysteroscopy and endometrial curettage F: Levonorgestrel-IUS (Mirena®) G: Medroxyprogesterone acetate 10 mg tablet daily for 90 days then review H: Medroxyprogesterone acetate 10-mg tablet for 10 days in every 28 for 6 months I: Norethisterone 5-mg tablet daily for 7 days every 6 weeks J: Perform a cervical cytological smear K: Raloxifene 60-mg tablet daily L: Reassure and discharge M: Sequential combined HRT N: Sub-total hysterectomy O: Total hysterectomy P: Vaginal estrogen therapy

The answer is medroxyprogesterone acetate 10-mg tablet daily for 90 days.

A 40-year-old woman, P2, is taking tamoxifen following surgery for an estrogen receptor- and progesterone-positive breast cancer 2 years ago. She is referred by her breast surgeon for consultation because she has been experiencing irregular vaginal bleeding for the last few months. The histology following a hysteroscopy and curettage shows endometrial hyperplasia with mild cellular atypia and segments of a benign endometrial polyp. She has been sterilised and her last routine cervical smear was normal For each of the clinical scenarios described, choose the most appropriate management option from the list. Each option may be used once, more than once, or not at all. A: Combined oral contraceptive pill containing 20 micrograms ethinylestradiol B: Desogestrel 75 micrograms tablet daily and review in 3 months C: Endometrial resection D: Hysterectomy with bilateral salpingo-oophorectomy E: Hysteroscopy and endometrial curettage F: Levonorgestrel-IUS (Mirena®) G: Medroxyprogesterone acetate 10 mg tablet daily for 90 days then review H: Medroxyprogesterone acetate 10-mg tablet for 10 days in every 28 for 6 months I: Norethisterone 5-mg tablet daily for 7 days every 6 weeks J: Perform a cervical cytological smear K: Raloxifene 60-mg tablet daily L: Reassure and discharge M: Sequential combined HRT N: Sub-total hysterectomy O: Total hysterectomy P: Vaginal estrogen therapy

The answer is hysterectomy with bilateral salpingo-oophorectomy.

A 28-year-old woman had a surgical evacuation of the uterus for an incomplete spontaneous miscarriage 3 months ago and the histology confirmed a molar pregnancy. She has had irregular vaginal bleeding since the procedure with episodes of dyspnoea and haemoptysis. Investigation results are as follows: • full blood count: haemoglobin 9.6 g/l, otherwise normal • liver and renal function tests: normal • blood group: A Rh positive • serum hCG: 98 457 IU/l; CA125: 275 U/l; AFP: 24 u/l; TSH: 1.4 mU/l • pelvic ultrasound scan: 4.5-cm intrauterine lesion ? polyp; bilateral ovarian enlargement with multiple small cysts in both ovaries (6 cm and 7 cm maximum diameters); no free fluid • CXR: three parenchymal nodules ranging from 1.0–2.5 cm in left upper lobe; heart size normal; no hilar enlargement • MRI scan: no evidence of other metastatic lesions From the following clinical scenarios below, choose the single most appropriate management option from the option list. Where relevant, it can be assumed that in each case the woman has been registered with the nearest Trophoblastic Screening and Treatment Centre. Each answer may be used once, more than once or not at all. A: Dilatation of the cervix and uterine curettage B: Hysterectomy and bilateral salpingo-oophorectomy C: Intramuscular methotrexate and folinic acid D: Intravenous multiagent chemotherapy E: Measure serum hCG 6–8 weeks after the pregnancy F: Medical termination of pregnancy G: Oxytocin infusion to stop uterine haemorrhage prior to suction evacuation of the uterus H: Prenatal invasive testing for fetal karyotype I: Prostaglandin cervical ripening prior to suction evacuation of the uterus J: Second suction evacuation of the uterus K: Suction evacuation of the uterus L: Suction evacuation of the uterus and insertion of Mirena® intrauterine delivery system M: Suction evacuation of the uterus and postoperative anti-D prophylaxis N: Suction evacuation of the uterus with antibiotic prophylaxis O: Tests and treatment not required

The answer is intramuscular methotrexate and folinic acid. Royal College of Obstetricians and Gynaecologists. Gestational Trophoblastic Disease. Green-top Guideline 38. London: RCOG; 2010.

A 34-year-old woman, P3, presents with some vaginal bleeding at 16 weeks of gestation and a pelvic ultrasound scan indicates a diagnosis of a partial molar pregnancy. On examination the uterus is palpated at the level of the umbilicus; the cervix looks normal and is closed; there is fresh blood and clots in the vaginal. Investigation results are as follows: • full blood count: haemoglobin 9.2 g/l, otherwise normal • Liver and renal function tests normal • blood group: AB Rh positive • serum hCG: 148 457 IU/l; TSH: 3.1 mU/l From the following clinical scenarios below, choose the single most appropriate management option from the option list. Where relevant, it can be assumed that in each case the woman has been registered with the nearest Trophoblastic Screening and Treatment Centre. Each answer may be used once, more than once or not at all. A: Dilatation of the cervix and uterine curettage B: Hysterectomy and bilateral salpingo-oophorectomy C: Intramuscular methotrexate and folinic acid D: Intravenous multiagent chemotherapy E: Measure serum hCG 6–8 weeks after the pregnancy F: Medical termination of pregnancy G: Oxytocin infusion to stop uterine haemorrhage prior to suction evacuation of the uterus H: Prenatal invasive testing for fetal karyotype I: Prostaglandin cervical ripening prior to suction evacuation of the uterus J: Second suction evacuation of the uterus K: Suction evacuation of the uterus L: Suction evacuation of the uterus and insertion of Mirena® intrauterine delivery system M: Suction evacuation of the uterus and postoperative anti-D prophylaxis N: Suction evacuation of the uterus with antibiotic prophylaxis O: Tests and treatment not required

The answer is medical termination of pregnancy.

A 24-year-old nulliparous woman presents with some vaginal bleeding at 10 weeks of gestation and a pelvic ultrasound scan indicates a diagnosis of a molar pregnancy. On examination the uterus is 14-week sized; the cervix looks normal and is closed; there is fresh blood and clots in the vaginal. Investigation results are as follows: • full blood count: haemoglobin 10.2 g/l, otherwise normal • liver and renal function tests: normal • blood group: AB Rh negative • serum hCG: 148 457 iu/l; TSH: 1.9 mU/l From the following clinical scenarios below, choose the single most appropriate management option from the option list. Where relevant, it can be assumed that in each case the woman has been registered with the nearest Trophoblastic Screening and Treatment Centre. Each answer may be used once, more than once or not at all. A: Dilatation of the cervix and uterine curettage B: Hysterectomy and bilateral salpingo-oophorectomy C: Intramuscular methotrexate and folinic acid D: Intravenous multiagent chemotherapy E: Measure serum hCG 6–8 weeks after the pregnancy F: Medical termination of pregnancy G: Oxytocin infusion to stop uterine haemorrhage prior to suction evacuation of the uterus H: Prenatal invasive testing for fetal karyotype I: Prostaglandin cervical ripening prior to suction evacuation of the uterus J: Second suction evacuation of the uterus K: Suction evacuation of the uterus L: Suction evacuation of the uterus and insertion of Mirena® intrauterine delivery system M: Suction evacuation of the uterus and postoperative anti-D prophylaxis N: Suction evacuation of the uterus with antibiotic prophylaxis O: Tests and treatment not required

The answer is suction evacuation of the uterus and post-operative anti-D prophylaxis.

A 27-year-old woman, P1, presents with heavy vaginal bleeding and crampy period-like pains at 10 weeks of gestation. On examination she looks pale; BP: 100/60 mmHg; pulse rate: 104 bpm; the uterus is 14-week sized; the cervix is open and there is a lot fresh blood and clots in the vaginal together with copious vesicular placental tissue. Investigation results are as follows: • full blood count: haemoglobin 7.9 g/l, otherwise normal • blood group: O Rh positive From the following clinical scenarios below, choose the single most appropriate management option from the option list. Where relevant, it can be assumed that in each case the woman has been registered with the nearest Trophoblastic Screening and Treatment Centre. Each answer may be used once, more than once or not at all. A: Dilatation of the cervix and uterine curettage B: Hysterectomy and bilateral salpingo-oophorectomy C: Intramuscular methotrexate and folinic acid D: Intravenous multiagent chemotherapy E: Measure serum hCG 6–8 weeks after the pregnancy F: Medical termination of pregnancy G: Oxytocin infusion to stop uterine haemorrhage prior to suction evacuation of the uterus H: Prenatal invasive testing for fetal karyotype I: Prostaglandin cervical ripening prior to suction evacuation of the uterus J: Second suction evacuation of the uterus K: Suction evacuation of the uterus L: Suction evacuation of the uterus and insertion of Mirena® intrauterine delivery system M: Suction evacuation of the uterus and postoperative anti-D prophylaxis N: Suction evacuation of the uterus with antibiotic prophylaxis O: Tests and treatment not required

The answer is suction evacuation of the uterus.

A 41-year-old woman has a surgical evacuation of the uterus for an incomplete spontaneous miscarriage in her first pregnancy 6 months ago and the histology showed a molar pregnancy. She has had irregular vaginal bleeding since the procedure with no other symptoms. Investigation results are as follows: • full blood count: haemoglobin 10.6 g/l, otherwise normal • liver and renal function tests: normal • blood group: A Rh negative • serum hCG: 488 457 IU/l; CA125: 121 U/l • thyroid function tests: normal • pelvic ultrasound scan: 5.5-cm intrauterine lesion ? polyp; bilateral ovarian enlargement with multiple small cysts in both ovaries (6-cm and 7-cm maximum diameters); no free fluid • CXR: normal • MRI scan: no evidence of metastatic lesions From the following clinical scenarios below, choose the single most appropriate management option from the option list. Where relevant, it can be assumed that in each case the woman has been registered with the nearest Trophoblastic Screening and Treatment Centre. Each answer may be used once, more than once or not at all. A: Dilatation of the cervix and uterine curettage B: Hysterectomy and bilateral salpingo-oophorectomy C: Intramuscular methotrexate and folinic acid D: Intravenous multiagent chemotherapy E: Measure serum hCG 6–8 weeks after the pregnancy F: Medical termination of pregnancy G: Oxytocin infusion to stop uterine haemorrhage prior to suction evacuation of the uterus H: Prenatal invasive testing for fetal karyotype I: Prostaglandin cervical ripening prior to suction evacuation of the uterus J: Second suction evacuation of the uterus K: Suction evacuation of the uterus L: Suction evacuation of the uterus and insertion of Mirena® intrauterine delivery system M: Suction evacuation of the uterus and postoperative anti-D prophylaxis N: Suction evacuation of the uterus with antibiotic prophylaxis O: Tests and treatment not required

The answer is intravenous multi-agent chemotherapy. Although this may seem a bit too specialised for an ST5 it is in the guideline and trainees should be aware of the conditions are to warrant intravenous chemotherapy, that is to say, a deep knowledge of the subject rather than a superficial one.

A 39-year-old woman, P4, presents at 10 weeks of gestation with recurrent vomiting. On examination the uterus is palpated at approximately 16-week sized. A pelvic ultrasound scan indicates a twin pregnancy with a possible diagnosis of a partial molar pregnancy in one of the twins. Investigation results are as follows: • full blood count: haemoglobin 9.2 g/l, otherwise normal • liver and renal function tests: normal • blood group: AB Rh positive • serum hCG: 348 457 IU/l; • thyroid function – free T4: 26 pmol/l; free T3: 6.3 pmol/l; TSH < 0.1 mU/l From the following clinical scenarios below, choose the single most appropriate management option from the option list. Where relevant, it can be assumed that in each case the woman has been registered with the nearest Trophoblastic Screening and Treatment Centre. Each answer may be used once, more than once or not at all. A: Dilatation of the cervix and uterine curettage B: Hysterectomy and bilateral salpingo-oophorectomy C: Intramuscular methotrexate and folinic acid D: Intravenous multiagent chemotherapy E: Measure serum hCG 6–8 weeks after the pregnancy F: Medical termination of pregnancy G: Oxytocin infusion to stop uterine haemorrhage prior to suction evacuation of the uterus H: Prenatal invasive testing for fetal karyotype I: Prostaglandin cervical ripening prior to suction evacuation of the uterus J: Second suction evacuation of the uterus K: Suction evacuation of the uterus L: Suction evacuation of the uterus and insertion of Mirena® intrauterine delivery system M: Suction evacuation of the uterus and postoperative anti-D prophylaxis N: Suction evacuation of the uterus with antibiotic prophylaxis O: Tests and treatment not required

The answer is prenatal invasive testing for fetal karyotype.

A 39-year-old woman has just delivered a healthy female infant after an uncomplicated second pregnancy and plan to breastfeed; her blood group is B Rh negative. Ten years before she had a termination of pregnancy for a partial molar pregnancy with appropriate monitoring and was discharged after 6 months with no further treatment necessary From the following clinical scenarios below, choose the single most appropriate management option from the option list. Where relevant, it can be assumed that in each case the woman has been registered with the nearest Trophoblastic Screening and Treatment Centre. Each answer may be used once, more than once or not at all. A: Dilatation of the cervix and uterine curettage B: Hysterectomy and bilateral salpingo-oophorectomy C: Intramuscular methotrexate and folinic acid D: Intravenous multiagent chemotherapy E: Measure serum hCG 6–8 weeks after the pregnancy F: Medical termination of pregnancy G: Oxytocin infusion to stop uterine haemorrhage prior to suction evacuation of the uterus H: Prenatal invasive testing for fetal karyotype I: Prostaglandin cervical ripening prior to suction evacuation of the uterus J: Second suction evacuation of the uterus K: Suction evacuation of the uterus L: Suction evacuation of the uterus and insertion of Mirena® intrauterine delivery system M: Suction evacuation of the uterus and postoperative anti-D prophylaxis N: Suction evacuation of the uterus with antibiotic prophylaxis O: Tests and treatment not required

The answer is measure serum hCG 6–8 weeks after the pregnancy.

A 23-year-old nulliparous woman presents with 1 week of brown vaginal bleeding; her LMP was 14 weeks ago; she does not feel as if she is pregnant any more. On examination the uterus is 10 week-sized; the cervix looks normal and is closed; there is old blood and brown discharge in the vagina. A pelvic ultrasound scan shows a small fetus with no fetal heart action and a collapsed gestational sac. Investigation results are as follows: • full blood count: haemoglobin 11.2 g/l, otherwise normal • blood group: AB Rh negative • serum hCG: 2057 IU/l • thyroid function: normal. After an evacuation of the uterus the histology confirms fetal parts and normal trophoblast with areas of molar degeneration From the following clinical scenarios below, choose the single most appropriate management option from the option list. Where relevant, it can be assumed that in each case the woman has been registered with the nearest Trophoblastic Screening and Treatment Centre. Each answer may be used once, more than once or not at all. A: Dilatation of the cervix and uterine curettage B: Hysterectomy and bilateral salpingo-oophorectomy C: Intramuscular methotrexate and folinic acid D: Intravenous multiagent chemotherapy E: Measure serum hCG 6–8 weeks after the pregnancy F: Medical termination of pregnancy G: Oxytocin infusion to stop uterine haemorrhage prior to suction evacuation of the uterus H: Prenatal invasive testing for fetal karyotype I: Prostaglandin cervical ripening prior to suction evacuation of the uterus J: Second suction evacuation of the uterus K: Suction evacuation of the uterus L: Suction evacuation of the uterus and insertion of Mirena® intrauterine delivery system M: Suction evacuation of the uterus and postoperative anti-D prophylaxis N: Suction evacuation of the uterus with antibiotic prophylaxis O: Tests and treatment not required

The answer is tests and treatment not required.

A 28-year-old nulliparous woman got off a bus and slipped and suffered a depressed fracture of the acetabulum. A DEXA bone mineral density scan reveals osteopenia of the hip and lumbar vertebrae (T-score –2.0, –2.2 respectively). She has been amenorrhoeic since insertions of Nexplanon® (etonogestrel), which she has been using for 8 years. Her BMI is 17; BP is 120/60 mmHg For each of the scenarios described below, choose the single most cost-effective and appropriate contraception. Each option may be used once, more than once, or not at all. A: Copper T 380A® intrauterine contraceptive device B: Desogestrel 75 microgram tablets C: Ethinylestradiol 35 microgram + cyproterone acetate 2 mg tablets D: Ethinylestradiol 30 microgram + desogestrel 150 microgram tablets E: Ethinylestradiol 30 microgram + drospirenone 3 mg tablets F: Ethinylestradiol 35 microgram + gestodene 75 microgram tablets G: Ethinylestradiol 30 microgram+ levonorgestrel 150 microgram tablets H: Ethinylestradiol 20 microgram + norethisterone acetate 1 mg tablets I: IM injection of medroxyprogesterone acetate 150 mg J: Implant containing etonogestrel 68 mg K: Levonorgestrel-releasing intrauterine delivery system L: Mestranol 50 microgram + norethisterone 1 mg tablets M: Norethisterone 350 microgram tablets N: Silicone contraceptive diaphragm with nonoxinol ‘9’ 2% gel O: Transdermal patch containing ethinylestradiol + norelgestromin P: Vaginal ring containing ethinylestradiol + etonogestrel

The correct answer is ethinylestradiol 30 microgram + levonorgestrel 150 microgram tablets. The key to answering the questions in this EMQ is the phrase in the instructions: “the single mostcost-effective and appropriate contraception”. See also the British National Formulary.

A 40-year-old P3 married woman has finished her tamoxifen treatment for breast cancer, which was diagnosed 5 years ago. Her periods are now regular and normal and her cervical smears and follow-up mammograms have all been normal. She is now seeking advice about contraception. Her BMI is 23; BP is 135/75 mmHg For each of the scenarios described below, choose the single most cost-effective and appropriate contraception. Each option may be used once, more than once, or not at all. A: Copper T 380A® intrauterine contraceptive device B: Desogestrel 75 microgram tablets C: Ethinylestradiol 35 microgram + cyproterone acetate 2 mg tablets D: Ethinylestradiol 30 microgram + desogestrel 150 microgram tablets E: Ethinylestradiol 30 microgram + drospirenone 3 mg tablets F: Ethinylestradiol 35 microgram + gestodene 75 microgram tablets G: Ethinylestradiol 30 microgram+ levonorgestrel 150 microgram tablets H: Ethinylestradiol 20 microgram + norethisterone acetate 1 mg tablets I: IM injection of medroxyprogesterone acetate 150 mg J: Implant containing etonogestrel 68 mg K: Levonorgestrel-releasing intrauterine delivery system L: Mestranol 50 microgram + norethisterone 1 mg tablets M: Norethisterone 350 microgram tablets N: Silicone contraceptive diaphragm with nonoxinol ‘9’ 2% gel O: Transdermal patch containing ethinylestradiol + norelgestromin P: Vaginal ring containing ethinylestradiol + etonogestrel

The correct answer is copper T 380A® intrauterine contraceptive device. Estrogen-containing preparations are contraindicated for women with ER+ breast cancer, which this must be as she has been treated with tamoxifen. Progestagens too are contraindicated with PR+ tumours and generally best avoided altogether. Pregnancy must be avoided too and so the most reliable option for this multiparous woman is the CuT 380A and will last for 10 years. Strictly speaking, the Mirena may be used once tamoxifen treatment has been completed but is more expensive and is effective for 5 years according to the licence in the UK.

A 37-year-old divorced woman, P4, presents with heavy regular periods after being advised to stop the combined oral contraceptive pill 2 years ago. The use of condoms has become unacceptable. Her BMI is 29; BP is 135/85 mmHg For each of the scenarios described below, choose the single most cost-effective and appropriate contraception. Each option may be used once, more than once, or not at all. A: Copper T 380A® intrauterine contraceptive device B: Desogestrel 75 microgram tablets C: Ethinylestradiol 35 microgram + cyproterone acetate 2 mg tablets D: Ethinylestradiol 30 microgram + desogestrel 150 microgram tablets E: Ethinylestradiol 30 microgram + drospirenone 3 mg tablets F: Ethinylestradiol 35 microgram + gestodene 75 microgram tablets G: Ethinylestradiol 30 microgram+ levonorgestrel 150 microgram tablets H: Ethinylestradiol 20 microgram + norethisterone acetate 1 mg tablets I: IM injection of medroxyprogesterone acetate 150 mg J: Implant containing etonogestrel 68 mg K: Levonorgestrel-releasing intrauterine delivery system L: Mestranol 50 microgram + norethisterone 1 mg tablets M: Norethisterone 350 microgram tablets N: Silicone contraceptive diaphragm with nonoxinol ‘9’ 2% gel O: Transdermal patch containing ethinylestradiol + norelgestromin P: Vaginal ring containing ethinylestradiol + etonogestrel

The correct answer is levonorgestrel-releasing intrauterine delivery system. This is the most effective choice for this multiparous woman with heavy regular periods and contraceptive needs.

A 24-year-old nulliparous woman is soon to be married and requests contraception. She complains of unsightly acne and some hair growth on her upper lip and chin. Her periods are normal and come every 5–6 weeks. On examination: she is moderately hirsute and has some mild facial acne and seborrhoea but otherwise is normal; BP is 120/66 mmHg; BMI is 28 For each of the scenarios described below, choose the single most cost-effective and appropriate contraception. Each option may be used once, more than once, or not at all. A: Copper T 380A® intrauterine contraceptive device B: Desogestrel 75 microgram tablets C: Ethinylestradiol 35 microgram + cyproterone acetate 2 mg tablets D: Ethinylestradiol 30 microgram + desogestrel 150 microgram tablets E: Ethinylestradiol 30 microgram + drospirenone 3 mg tablets F: Ethinylestradiol 35 microgram + gestodene 75 microgram tablets G: Ethinylestradiol 30 microgram+ levonorgestrel 150 microgram tablets H: Ethinylestradiol 20 microgram + norethisterone acetate 1 mg tablets I: IM injection of medroxyprogesterone acetate 150 mg J: Implant containing etonogestrel 68 mg K: Levonorgestrel-releasing intrauterine delivery system L: Mestranol 50 microgram + norethisterone 1 mg tablets M: Norethisterone 350 microgram tablets N: Silicone contraceptive diaphragm with nonoxinol ‘9’ 2% gel O: Transdermal patch containing ethinylestradiol + norelgestromin P: Vaginal ring containing ethinylestradiol + etonogestrel

The correct answer is ethinylestradiol 35 microgram + cyproterone acetate 2 mg tablets. This combined OCP is licensed to treat hirsutism and acne. All androgen-based progestagens should be avoided in this case, i.e those derived from 19-nortesterone (anything with a 'nor' in the name). Cyprotone acetate is an androgen antagonist with a progestagenic action (agonist).

A 32-year-old nulliparous woman is 12 weeks pregnant and is anxious to know the prevalence of chickenpox-complicating pregnancy because her father recently died of the disease in his early 50s while receiving treatment for non-Hodgkin's lymphoma For each of the scenarios about chickenpox in pregnancy choose the most accurate percentage likelihood. Each option may be used once, more than once, or not at all. ``` A: Less than 1% B: 1–10% C: 11–20% D: 21–40% E: 41–59% F: 60–70% G: 71–85% H: 86–95% I: Greater than 95% ```

The answer is less than 1% (3/1000 pregnancies). See Royal College of Obstetricians and Gynaecologists. Chickenpox in Pregnancy. Green-top Guideline 13. London: RCOG. 2015. Note that natural history questions are among the toughest in the Part 2 MRCOG examination.

A 19-year-old nulliparous woman has contracted chickenpox at 25 weeks of gestation. She suffers mild to moderate asthma and is currently using Synbicort Turbohaler® 200/6 inhalation powder (budesonide 200 microgram and formoterol fumerate dehydrate 6 microgram in each inhalation) and is under good symptomatic control without any oral steroids. She is anxious to know the chances of developing pneumonia as a complication For each of the scenarios about chickenpox in pregnancy choose the most accurate percentage likelihood. Each option may be used once, more than once, or not at all. ``` A: Less than 1% B: 1–10% C: 11–20% D: 21–40% E: 41–59% F: 60–70% G: 71–85% H: 86–95% I: Greater than 95% ```

The answer is 1–10% (5%). See explanation to question 1.

A 28-year-old woman, P2, has contracted chickenpox at 40 weeks of gestation during an otherwise uncomplicated pregnancy and she is worried about the risks for her baby and, in particular, the chance that her newborn will develop clinical chickenpox For each of the scenarios about chickenpox in pregnancy choose the most accurate percentage likelihood. Each option may be used once, more than once, or not at all. ``` A: Less than 1% B: 1–10% C: 11–20% D: 21–40% E: 41–59% F: 60–70% G: 71–85% H: 86–95% I: Greater than 95% ```

The asnwer is 21–40% (23%). See explanation to question 1.

A 22-year-old woman, P3, developed chickenpox early in her pregnancy while living abroad in Africa. She did not have access to zoster immunoglobulin at that time. She has arrived in the UK as an asylum seeker at 34 weeks of gestation. She now enquires about the risk of her baby being affected by chickenpox infection in the womb (fetal varicella syndrome) For each of the scenarios about chickenpox in pregnancy choose the most accurate percentage likelihood. Each option may be used once, more than once, or not at all. ``` A: Less than 1% B: 1–10% C: 11–20% D: 21–40% E: 41–59% F: 60–70% G: 71–85% H: 86–95% I: Greater than 95% ```

The answer is 1–10% (2.8%). See explanation to question 1.

A mother of a 15-year-old enquires whether her daughter should be immunised against chickenpox because, in the past, the mother had a child severely affected by fetal varicella syndrome. After counselling, she wishes to know if her daughter were to have an immunity test for chickenpox, what would be the likelihood she will be seropositive For each of the scenarios about chickenpox in pregnancy choose the most accurate percentage likelihood. Each option may be used once, more than once, or not at all. ``` A: Less than 1% B: 1–10% C: 11–20% D: 21–40% E: 41–59% F: 60–70% G: 71–85% H: 86–95% I: Greater than 95% ```

The answer is 86–95% (90%). See explanation to question 1.

The chance that she will suffer some degree of faecal urgency Each outcome or complication described below refers to a 35-year-old woman in her first pregnancy who suffered a third degree (3c) injury to the perineum following a non-rotational forceps delivery with a right medio-lateral episiotomy of a 4.1 kg healthy female infant; a primary surgical repair was performed in theatre without complication. Choose the single most likely percentage risk at 12 months after the birth. Each option may be used once, more than once, or not at all. ``` A: Less than 1% B: 1–10% C: 11–20% D: 21–40% E: 41–59% F: 60–80% G: 81–90% H: 91–95% I: Greater than 95% ```

The answer is 21–40%. See Royal College of Obstetricians and Gynaecologists. Management of Third- and Fourth-degree Perineal Tears. Green-top Guideline 29. London: RCOG. 2015. It is important to know complication rates in order to inform and counsel women correctly.

The likelihood that she will be asymptomatic Each outcome or complication described below refers to a 35-year-old woman in her first pregnancy who suffered a third degree (3c) injury to the perineum following a non-rotational forceps delivery with a right medio-lateral episiotomy of a 4.1 kg healthy female infant; a primary surgical repair was performed in theatre without complication. Choose the single most likely percentage risk at 12 months after the birth. Each option may be used once, more than once, or not at all. ``` A: Less than 1% B: 1–10% C: 11–20% D: 21–40% E: 41–59% F: 60–80% G: 81–90% H: 91–95% I: Greater than 95% ```

The answer is 60–80%. See explanation to question 1.

The maximum reported risk that she will develop worsening faecal symptoms after a second vaginal birth Each outcome or complication described below refers to a 35-year-old woman in her first pregnancy who suffered a third degree (3c) injury to the perineum following a non-rotational forceps delivery with a right medio-lateral episiotomy of a 4.1 kg healthy female infant; a primary surgical repair was performed in theatre without complication. Choose the single most likely percentage risk at 12 months after the birth. Each option may be used once, more than once, or not at all. ``` A: Less than 1% B: 1–10% C: 11–20% D: 21–40% E: 41–59% F: 60–80% G: 81–90% H: 91–95% I: Greater than 95% ```

The answer is 21–40%. See explanation to question 1.

A couple are referred to the Fertility Clinic after 2 years trying to conceive. The woman is 26 years old with a BMI of 31. They conceived spontaneously 3 years ago and she gave birth to a healthy male, birth weight 3456 g, by caesarean section for a late secondary arrest and obstructed labour. It was complicated by a post-operative pyrexia that required 48-hours of intravenous antibiotics. She is currently menstruating regularly each month with day 21 progesterone estimations of 55 nmol/l and 41 nmol/l from consecutive months, organised by her GP. There are no obvious problems with sexual intercourse and its frequency. Clinical examination of both partners is normal. Semen analysis shows: 25 million sperm/ml; volume 1.6 ml; normal morphological forms 10%; progressive motility 41%. Rubella antibodies detected For the following clinical scenarios below choose the next most appropriate test or procedure from the option list to investigate the couple’s subfertility. Each answer may be used once, more than once or not at all. A: Androstenedione, 17-hydroxyprogesterone, testosterone, dihydroepiandrostenedione sulfate B: Anti-mullerian hormone levels C: Estradiol, prolactin, FSH, LH taken same day D: Estradiol, prolactin, FSH, LH taken in the early follicular phase of the menstrual cycle E: Full blood count and serum iron levels F: Hysterosalpingo-contrast sonography G: Hysterosalpingogram H: Hysteroscopy I: Karyotype J: Laparoscopy and dye hydrotubation K: Molecular genetic test for cystic fibrosis L: Pelvic ultrasound scan M: Postcoital test N: Psychosexual assessment and counselling O: Sexual therapy assessment and advice P: Sperm antibody titre Q: Testosterone, prolactin, FSH, LH R: Urine pregnancy test

The answer is laparoscopy and dye hydrotubation. Tubal blockage is the most common cause of secondary subfertility and is especially likely in this case following the infection serious infection after the caesarean section.

A couple are referred to the Fertility Clinic after 2 years trying to conceive. Both partners have been married before; the woman is 31 years old and has never been pregnant; the male partner is 36 years old had one child 10 years ago and chemotherapy for a lymphoma 3 years ago. The woman is currently menstruating regularly each month, with day 21 progesterone estimations of 45 nmol/l and 32 nmol/l from consecutive months, organised by her GP. There are no obvious problems with sexual intercourse and its frequency. Clinical examinations of both partners are normal. Semen analyses shows: 0.5–1.0 million sperm/ml; volume 1.1–1.7 ml; normal morphological forms 3–5%; progressive motility 7–10%. Rubella antibodiesare not detected For the following clinical scenarios below choose the next most appropriate test or procedure from the option list to investigate the couple’s subfertility. Each answer may be used once, more than once or not at all. A: Androstenedione, 17-hydroxyprogesterone, testosterone, dihydroepiandrostenedione sulfate B: Anti-mullerian hormone levels C: Estradiol, prolactin, FSH, LH taken same day D: Estradiol, prolactin, FSH, LH taken in the early follicular phase of the menstrual cycle E: Full blood count and serum iron levels F: Hysterosalpingo-contrast sonography G: Hysterosalpingogram H: Hysteroscopy I: Karyotype J: Laparoscopy and dye hydrotubation K: Molecular genetic test for cystic fibrosis L: Pelvic ultrasound scan M: Postcoital test N: Psychosexual assessment and counselling O: Sexual therapy assessment and advice P: Sperm antibody titre Q: Testosterone, prolactin, FSH, LH R: Urine pregnancy test

The correct answer is testosterone, prolactin, FSH, LH. Investigation of the male partner with severe oligospermia after physical examination is essential.

A couple are referred to the Fertility Clinic after 1 year trying to conceive for the first time. The woman is 29 years old and her LMP was 3 weeks ago; she says she used to have regular periods but now she menstruates infrequently every 5–6 months after putting on a lot of weight. She has had type 2 diabetes for 2 years and is taking metformin twice a day and folic acid 5 mg daily; she smokes 5–10 cigarettes a day. The male partner is a 38 years old and has three children from a previous relationship; he is a non-smoker. There are no obvious problems with sexual intercourse and its frequency. Clinical examination of both partners is otherwise normal apart from a female BMI of 34. Semen analysis shows: 15 million sperm/ml; volume 2.6 ml; normal morphological forms 3%; progressive motility 31%. Rubella antibodies not detected For the following clinical scenarios below choose the next most appropriate test or procedure from the option list to investigate the couple’s subfertility. Each answer may be used once, more than once or not at all. A: Androstenedione, 17-hydroxyprogesterone, testosterone, dihydroepiandrostenedione sulfate B: Anti-mullerian hormone levels C: Estradiol, prolactin, FSH, LH taken same day D: Estradiol, prolactin, FSH, LH taken in the early follicular phase of the menstrual cycle E: Full blood count and serum iron levels F: Hysterosalpingo-contrast sonography G: Hysterosalpingogram H: Hysteroscopy I: Karyotype J: Laparoscopy and dye hydrotubation K: Molecular genetic test for cystic fibrosis L: Pelvic ultrasound scan M: Postcoital test N: Psychosexual assessment and counselling O: Sexual therapy assessment and advice P: Sperm antibody titre Q: Testosterone, prolactin, FSH, LH R: Urine pregnancy test

The correct answer is estradiol, prolactin, FSH, LH taken on the day. The oligomenorrhoea investigations must include tests to exclude ovarian failure and hyperprolactinaemia as possible causes.

A young couple are referred to the Fertility Clinic after trying to conceive for the first time since their arranged marriage over 2 years ago. The woman is 20 years old and is currently menstruating regularly each month, with day 21 progesterone estimations of 65 nmol/l and 39 nmol/l from consecutive months, organised by her GP. Clinical examinations of both partners are normal although the woman’s hymenal membrane is noted to be intact and she has a BMI of 34. Semen analysis shows: 40 million sperm/ml; volume 1.7 ml; normal morphological forms 31%; progressive motility 42%. Rubella antibodies not detected For the following clinical scenarios below choose the next most appropriate test or procedure from the option list to investigate the couple’s subfertility. Each answer may be used once, more than once or not at all. A: Androstenedione, 17-hydroxyprogesterone, testosterone, dihydroepiandrostenedione sulfate B: Anti-mullerian hormone levels C: Estradiol, prolactin, FSH, LH taken same day D: Estradiol, prolactin, FSH, LH taken in the early follicular phase of the menstrual cycle E: Full blood count and serum iron levels F: Hysterosalpingo-contrast sonography G: Hysterosalpingogram H: Hysteroscopy I: Karyotype J: Laparoscopy and dye hydrotubation K: Molecular genetic test for cystic fibrosis L: Pelvic ultrasound scan M: Postcoital test N: Psychosexual assessment and counselling O: Sexual therapy assessment and advice P: Sperm antibody titre Q: Testosterone, prolactin, FSH, LH R: Urine pregnancy test

The correct answer is sexual therapy assessment and advice.

A couple are referred to the Fertility Clinic after 1 year trying to conceive. The woman is 34 years old with a BMI of 29. They conceived spontaneously 15 months ago and the pregnancy was terminated surgically at 14 weeks of gestation, without complications, after a diagnosis of Down syndrome was confirmed following a high risk screening test result. Since the pregnancy the woman has been troubled by vaginal bleeding in between her periods every month associated with more period pains and general pelvic discomfort. Her recent cervical smear was normal; vaginal and endocervical swabs were reported as: normal vaginal flora. There are no obvious problems with sexual intercourse and its frequency. Clinical examinations of both partners are normal. Semen analysis shows: 25 million sperm/ml; volume 1.6 ml; normal morphological forms 10%; progressive motility 41%. Rubella antibodies detected For the following clinical scenarios below choose the next most appropriate test or procedure from the option list to investigate the couple’s subfertility. Each answer may be used once, more than once or not at all. A: Androstenedione, 17-hydroxyprogesterone, testosterone, dihydroepiandrostenedione sulfate B: Anti-mullerian hormone levels C: Estradiol, prolactin, FSH, LH taken same day D: Estradiol, prolactin, FSH, LH taken in the early follicular phase of the menstrual cycle E: Full blood count and serum iron levels F: Hysterosalpingo-contrast sonography G: Hysterosalpingogram H: Hysteroscopy I: Karyotype J: Laparoscopy and dye hydrotubation K: Molecular genetic test for cystic fibrosis L: Pelvic ultrasound scan M: Postcoital test N: Psychosexual assessment and counselling O: Sexual therapy assessment and advice P: Sperm antibody titre Q: Testosterone, prolactin, FSH, LH R: Urine pregnancy test

The correct answer is urine pregnancy test. In cases of irregular vaginal bleeding after pregnancy it is important first to exclude gestational trophoblastic disease.

A couple are referred to the Fertility Clinic after 1 year trying to conceive for the first time. The woman is 29 years old and 3 years ago she had an episode of heavy painful menstrual bleeding and painful sexual intercourse that was treated successfully by the insertion of a Mirena® and she is amenorrhoeic. Her husband is 25 years old has had type 1 diabetes for 10 years and is taking insulin and smokes 5–10 cigarettes a day. There are no obvious problems with sexual intercourse and its frequency. Clinical examination of both partners is otherwise normal apart from a female BMI of 33. Semen analysis shows: 15 million sperm/ml; volume 2.6 ml; normal morphological forms 3%; progressive motility 31%. Rubella antibodies not detected For the following clinical scenarios below choose the next most appropriate test or procedure from the option list to investigate the couple’s subfertility. Each answer may be used once, more than once or not at all. A: Androstenedione, 17-hydroxyprogesterone, testosterone, dihydroepiandrostenedione sulfate B: Anti-mullerian hormone levels C: Estradiol, prolactin, FSH, LH taken same day D: Estradiol, prolactin, FSH, LH taken in the early follicular phase of the menstrual cycle E: Full blood count and serum iron levels F: Hysterosalpingo-contrast sonography G: Hysterosalpingogram H: Hysteroscopy I: Karyotype J: Laparoscopy and dye hydrotubation K: Molecular genetic test for cystic fibrosis L: Pelvic ultrasound scan M: Postcoital test N: Psychosexual assessment and counselling O: Sexual therapy assessment and advice P: Sperm antibody titre Q: Testosterone, prolactin, FSH, LH R: Urine pregnancy test

The answer is pelvic ultrasound scan. You need to assess if the Mirena is still in the uterus as it is presumed the coil strings were not seen if the examination was normal.

A healthy 32-year-old P3 has a 12-hour history of increasingly severe bouts of central abdominal pain with vomiting during the height of the pain, which slowly passes off, with loss of appetite. She gave birth to a healthy male infant, birth weight 3456 g, 4 days ago and is breastfeeding. The lochia and uterine involution have been recorded by the midwife as being normal. The pregnancy was uncomplicated throughout. The anomaly ultrasound scan at 20 weeks of gestation was normal apart from a simple right ovarian cyst that measured 8–9 cm diameter. She is a non-smoker and was well prior to the onset of the pain and has never experienced anything like this pain in the past. On examination: she looks distressed, pale and dehydrated; the abdomen is very tender in the lower half with no peritonism, and the uterus is just palpable; no other masses. Vaginal examination is normal. Observations are as follows: Pulse rate (bpm) 110 Temperature (ºC) 37.2 Blood pressure (mmHg) 140/90 Urine analysis blood 2+ ketones 3+ protein trace Respiratory rate (breaths/min) 12 O2 Saturation on air (%) 98 The following clinical scenarios relate to a woman who presents to her local Accident and Emergency Department with severe acute abdominal pain requesting urgent medical assistance. Choose the single most appropriate investigation necessary for the diagnosis and management of this patient. Each answer may be used once, more than once or not at all. ``` A: Arterial blood gas analyses B: Blood cultures C: Blood sugar D: Ca125 E: Cervical swab for microscopy and Gram stain F: Chest X-ray G: C-reactive protein H: CT scan of abdomen I: Erect abdominal X-ray J: Full blood count K: Liver function tests L: Mid-stream urine for microscopy M: Pelvic ultrasound scan N: Serum amylase and lipase O: Serum lactate P: Transabdominal ultrasound scan Q: Ultrasound scan of kidneys, ureters and bladder R: Urea, electrolytes and creatinine S: Urine pregnancy test ```

The correct answer is transabdominal ultrasound scan. The key to answering these questions correctly is in the instructions: "choose the single most appropriate investigation necessary for the diagnosis and management of this patient".

A healthy 22-year-old, P0+1, has a 48-hour history of increasingly severe lower abdominal pain localising to the right side. She has lost her appetite and generally feels unwell; she was well prior to the onset of the pain. She smokes 10–15 cigarettes a day and suffers with mild asthma and uses inhalers when necessary; she has noticed a more productive cough and some breathlessness. Her LMP was 3 weeks ago; periods are regular: 3–4/28 days. She uses the progesterone implant for contraception, which was inserted after an uncomplicated termination of pregnancy. On examination: she looks pale and dehydrated; the abdomen is very tender in the lower half particularly on the right side with no peritonism; no masses. Vaginal examination: there is some vague tenderness otherwise unremarkable. Observations are as follows: Pulse rate (bpm) 120 Temperature (ºC) 38.4 Blood pressure (mmHg) 120/70 Urine analysis Protein trace Nitrites trace Ketones + Respiratory rate (breaths/min) 19 O2 Saturation on air (%) 90 The following clinical scenarios relate to a woman who presents to her local Accident and Emergency Department with severe acute abdominal pain requesting urgent medical assistance. Choose the single most appropriate investigation necessary for the diagnosis and management of this patient. Each answer may be used once, more than once or not at all. ``` A: Arterial blood gas analyses B: Blood cultures C: Blood sugar D: Ca125 E: Cervical swab for microscopy and Gram stain F: Chest X-ray G: C-reactive protein H: CT scan of abdomen I: Erect abdominal X-ray J: Full blood count K: Liver function tests L: Mid-stream urine for microscopy M: Pelvic ultrasound scan N: Serum amylase and lipase O: Serum lactate P: Transabdominal ultrasound scan Q: Ultrasound scan of kidneys, ureters and bladder R: Urea, electrolytes and creatinine S: Urine pregnancy test ```

The correct answer is chest X-ray. Right lower lobe pneumonia may present with acute abdominal pain and a proper examination of the respiratory system will provide the provisional diagnosis.

A 19-year-old, P0+1, has a 72-hour history of increasingly severe lower abdominal pain localising to the right side. She has lost her appetite and generally feels unwell; she was well prior to the onset of the pain. She smokes 10 cigarettes a day. Her LMP was 3 weeks ago; periods are regular: 3–4/28 days with some break-through bleeding from time to time. She has used the progesterone implant for contraception for 2 years, which was inserted after a termination of pregnancy that was complicated by a postoperative uterine infection. On examination: she looks pale and dehydrated; the abdomen is very tender in the lower half, particularly on the right side with a suggestion of some peritonism; no masses. Vaginal examination: there is some dark brown vaginal discharge; no masses; normal sized uterus and cervical excitation tenderness. Observations are as follows: Pulse rate (bpm) 105 Temperature (ºC) 37.9 Blood pressure (mmHg) 120/70 Urine analysis Protein trace Blood + Ketones ++ Respiratory rate (breaths/min) 12 O2 saturation on air (%) 99 The following clinical scenarios relate to a woman who presents to her local Accident and Emergency Department with severe acute abdominal pain requesting urgent medical assistance. Choose the single most appropriate investigation necessary for the diagnosis and management of this patient. Each answer may be used once, more than once or not at all. ``` A: Arterial blood gas analyses B: Blood cultures C: Blood sugar D: Ca125 E: Cervical swab for microscopy and Gram stain F: Chest X-ray G: C-reactive protein H: CT scan of abdomen I: Erect abdominal X-ray J: Full blood count K: Liver function tests L: Mid-stream urine for microscopy M: Pelvic ultrasound scan N: Serum amylase and lipase O: Serum lactate P: Transabdominal ultrasound scan Q: Ultrasound scan of kidneys, ureters and bladder R: Urea, electrolytes and creatinine S: Urine pregnancy test ```

The correct answer is pelvic ultrasound scan. See explanation to question 1.

``` A healthy 38-year-old P3 has a 5-hour history of sudden-onset severe right-sided lower abdominal pain that came on after sexual intercourse. Her LMP was 24 days ago; periods are regular: 3–4/28 days; she has been sterilised. She has a past history of recurrent urinary tract infections, which is under investigation by a urologist. On examination: she looks pale and distressed; the abdomen is very tender in the lower half, particularly over the bladder and on the right side with rebound peritonism; no masses. Vaginal examination: normal sized uterus, no masses and cervical excitation tenderness is elicited. Observations are as follows: Pulse rate (bpm) 115 Temperature (ºC) 36.0 Blood pressure (mmHg) 140/60 Urine analysis Protein trace Blood trace Respiratory rate (breaths/min) 18 O2 saturation on air (%) 96 ``` The following clinical scenarios relate to a woman who presents to her local Accident and Emergency Department with severe acute abdominal pain requesting urgent medical assistance. Choose the single most appropriate investigation necessary for the diagnosis and management of this patient. Each answer may be used once, more than once or not at all. ``` A: Arterial blood gas analyses B: Blood cultures C: Blood sugar D: Ca125 E: Cervical swab for microscopy and Gram stain F: Chest X-ray G: C-reactive protein H: CT scan of abdomen I: Erect abdominal X-ray J: Full blood count K: Liver function tests L: Mid-stream urine for microscopy M: Pelvic ultrasound scan N: Serum amylase and lipase O: Serum lactate P: Transabdominal ultrasound scan Q: Ultrasound scan of kidneys, ureters and bladder R: Urea, electrolytes and creatinine S: Urine pregnancy test ```

The correct answer is full blood count. Clinically, this woman has intra-abdominal haemorrhage and her cardiovascular system is compensating, probably to its limit, so there is no time for a scan and a FBC will confirm the clinical diagnosis and define how much blood has been lost and how much needs to be replaced.

A healthy 38-year-old P3 has a 10-hour history of severe right-sided lower abdominal pain associated with nausea and vomiting, and feels generally unwell. Her LMP was 4 weeks ago and is due soon; periods are regular: 3–4/28 days; she uses the diaphragm with spermicidal cream for contraception. She smokes 10 cigarettes a day and has a past history of irritable bowel syndrome and has been somewhat constipated lately. On examination: she looks unwell and dehydrated; the abdomen is very tender in the lower abdomen, particularly on the right side and loin; no masses. Vaginal examination: normal sized uterus, no masses and no significant pelvic tenderness and faecal loading of the rectum. Observations are as follows: Pulse rate (bpm) 110 Temperature (ºC) 38.1 Blood pressure (mmHg) 140/70 Urine analysis Protein + Blood + Ketones +++ Respiratory rate (breaths/min) 13 O2 saturation on air (%) 98 The following clinical scenarios relate to a woman who presents to her local Accident and Emergency Department with severe acute abdominal pain requesting urgent medical assistance. Choose the single most appropriate investigation necessary for the diagnosis and management of this patient. Each answer may be used once, more than once or not at all. ``` A: Arterial blood gas analyses B: Blood cultures C: Blood sugar D: Ca125 E: Cervical swab for microscopy and Gram stain F: Chest X-ray G: C-reactive protein H: CT scan of abdomen I: Erect abdominal X-ray J: Full blood count K: Liver function tests L: Mid-stream urine for microscopy M: Pelvic ultrasound scan N: Serum amylase and lipase O: Serum lactate P: Transabdominal ultrasound scan Q: Ultrasound scan of kidneys, ureters and bladder R: Urea, electrolytes and creatinine S: Urine pregnancy test ```

The correct answer is mid-stream urine microscopy. See explanation to question 1.

A 21-year-old, P1+1, has a 72-hour history of increasingly severe lower abdominal pain localising to the right side. She has lost her appetite and generally feels unwell; she was well prior to the onset of the pain. Her LMP was 3 weeks ago; periods are regular: 3–4/28 days with some break-through bleeding from time to time. She uses the Mirena® IUS for contraception, which was inserted after a termination of pregnancy 2 months ago. She smokes 10–15 cigarettes a day and has a past history of recurrent urinary tract infections that is currently under investigation by a urologist. On examination: she looks pale and dehydrated; the abdomen is very tender in the lower half, particularly on the right side with a suggestion of some peritonism; no masses. Vaginal examination: there is some dark brown offensive vaginal discharge; normal sized uterus and cervical excitation tenderness and a tender fullness in the pouch of Douglas. Observations are as follows: Pulse rate (bpm) 115 Temperature (ºC) 38.5 Blood pressure (mmHg) 115/55 Urine analysis Protein trace Blood + Ketones ++ Respiratory rate (breaths/min) 15 O2 saturation on air (%) 95 The following clinical scenarios relate to a woman who presents to her local Accident and Emergency Department with severe acute abdominal pain requesting urgent medical assistance. Choose the single most appropriate investigation necessary for the diagnosis and management of this patient. Each answer may be used once, more than once or not at all. ``` A: Arterial blood gas analyses B: Blood cultures C: Blood sugar D: Ca125 E: Cervical swab for microscopy and Gram stain F: Chest X-ray G: C-reactive protein H: CT scan of abdomen I: Erect abdominal X-ray J: Full blood count K: Liver function tests L: Mid-stream urine for microscopy M: Pelvic ultrasound scan N: Serum amylase and lipase O: Serum lactate P: Transabdominal ultrasound scan Q: Ultrasound scan of kidneys, ureters and bladder R: Urea, electrolytes and creatinine S: Urine pregnancy test ```

The correct answer is pelvic ultrasound scan. See explanation to question 1.

``` A healthy 28-year-old, P0+2, has a 7-hour history of sudden-onset severe right-sided lower abdominal pain; her LMP was 6 weeks ago; periods are normally infrequent and irregular: 3–4/35–56 days. She and her partner have a past history of subfertility and are currently receiving clomifene citrate 100 mg for ovulation induction for anovulatory oligomenorrhoea. Her first pregnancy was an early miscarriage; the second was a left tubal pregnancy. On examination: she looks pale and distressed; the abdomen is very tender in the lower half on the right side with rebound peritonism; no masses. Vaginal examination: normal sized uterus, no masses and cervical excitation tenderness is elicited. Observations are as follows: Pulse rate (bpm) 110 Temperature (ºC) 36.0 Blood pressure (mmHg) 120/50 Urine analysis has not passed urine ``` Respiratory rate (breaths/min) 14 O2 saturation on air (%) 96 The following clinical scenarios relate to a woman who presents to her local Accident and Emergency Department with severe acute abdominal pain requesting urgent medical assistance. Choose the single most appropriate investigation necessary for the diagnosis and management of this patient. Each answer may be used once, more than once or not at all. ``` A: Arterial blood gas analyses B: Blood cultures C: Blood sugar D: Ca125 E: Cervical swab for microscopy and Gram stain F: Chest X-ray G: C-reactive protein H: CT scan of abdomen I: Erect abdominal X-ray J: Full blood count K: Liver function tests L: Mid-stream urine for microscopy M: Pelvic ultrasound scan N: Serum amylase and lipase O: Serum lactate P: Transabdominal ultrasound scan Q: Ultrasound scan of kidneys, ureters and bladder R: Urea, electrolytes and creatinine S: Urine pregnancy test ```

The correct answer is urine pregnancy test. See explanation to question 1.

A 45-year-old P3 has a 4-day history of increasingly severe lower abdominal pain associated with nausea and vomiting and feeling generally unwell with anorexia. Two weeks ago she had a vaginal hysterectomy, which was complicated by a symptomatic post-operative anaemia that required a two unit blood transfusion. She was discharged from hospital 1 week ago and has not felt well since and has noticed an increasingly heavy blood-stained vaginal discharge. She smokes 10 cigarettes a day and has a past history of irritable bowel syndrome. She has been somewhat constipated since the operation. On examination: she looks unwell and dehydrated; the abdomen is very tender in the lower abdomen and on the right side there is rebound tenderness; no masses. Vaginal examination: a pelvic fullness was noted with significant pelvic tenderness in the right fornix; faecal loading of the rectum. Observations are as follows: Pulse rate (bpm) 110 Temperature (ºC) 38.3 Blood pressure (mmHg) 140/75 Urine analysis Protein + Blood ++ Ketones + Respiratory rate (breaths/min) 14 O2 saturation on air (%) 98 The following clinical scenarios relate to a woman who presents to her local Accident and Emergency Department with severe acute abdominal pain requesting urgent medical assistance. Choose the single most appropriate investigation necessary for the diagnosis and management of this patient. Each answer may be used once, more than once or not at all. ``` A: Arterial blood gas analyses B: Blood cultures C: Blood sugar D: Ca125 E: Cervical swab for microscopy and Gram stain F: Chest X-ray G: C-reactive protein H: CT scan of abdomen I: Erect abdominal X-ray J: Full blood count K: Liver function tests L: Mid-stream urine for microscopy M: Pelvic ultrasound scan N: Serum amylase and lipase O: Serum lactate P: Transabdominal ultrasound scan Q: Ultrasound scan of kidneys, ureters and bladder R: Urea, electrolytes and creatinine S: Urine pregnancy test ```

The correct answer is CT scan of abdomen. With the faecal loading and the clinical possibility of a pelvic abscess a CT will give more valuable information than an ultrasound scan especially to see if bowel is involved and if a general surgeon needs to be involved with a return to theatre.

For singleton breech presentation at term: the number of planned caesarean sections needed to be performed to prevent one perinatal death or serious neonatal morbidity during the 6 week period after the birth, when compared with planned vaginal birth Number Needed to Treat (NNT) to prevent one affected case is a commonly used statistic to counsel and inform women about the value of interventions in obstetrics. From the range of numbers listed below, choose the most accurate NNT for the clinical situations. Each answer may be used once, more than once or not at all. ``` A: 1–10 B: 11–50 C: 51–100 D: 101–250 E: 251–500 F: 501–750 G: 751–1500 H: 1501–3000 I: 3001–6000 J: 6001–12 000 ```

The answer is 11–50 (30). If you need more information about how to calculate NNTs you can refer to the Green-top Guideline on that particular topic. Another source of information is to do an internet search using the term "number needed to treat" and browsing through the search results that are relevant to you and your question.

For singleton preterm birth: the use of intramuscular corticosteroids administered to the mother prior to preterm birth to prevent one neonatal death Number Needed to Treat (NNT) to prevent one affected case is a commonly used statistic to counsel and inform women about the value of interventions in obstetrics. From the range of numbers listed below, choose the most accurate NNT for the clinical situations. Each answer may be used once, more than once or not at all. ``` A: 1–10 B: 11–50 C: 51–100 D: 101–250 E: 251–500 F: 501–750 G: 751–1500 H: 1501–3000 I: 3001–6000 J: 6001–12 000 ```

The answer is 11–50 (23). See explanation to question 1.

For neonatal early-onset group B streptococcal (GBS) disease: the number of women receiving intrapartum antibiotics to prevent one case of neonatal death attributable to GBS disease Number Needed to Treat (NNT) to prevent one affected case is a commonly used statistic to counsel and inform women about the value of interventions in obstetrics. From the range of numbers listed below, choose the most accurate NNT for the clinical situations. Each answer may be used once, more than once or not at all. ``` A: 1–10 B: 11–50 C: 51–100 D: 101–250 E: 251–500 F: 501–750 G: 751–1500 H: 1501–3000 I: 3001–6000 J: 6001–12 000 ```

The answer is 3001–6000 (5882). See explanation to question 1.

For women at moderate risk of developing pre-eclampsia: the number of women taking low-dose aspirin to prevent one case of pre-eclampsia in pregnancy Number Needed to Treat (NNT) to prevent one affected case is a commonly used statistic to counsel and inform women about the value of interventions in obstetrics. From the range of numbers listed below, choose the most accurate NNT for the clinical situations. Each answer may be used once, more than once or not at all. ``` A: 1–10 B: 11–50 C: 51–100 D: 101–250 E: 251–500 F: 501–750 G: 751–1500 H: 1501–3000 I: 3001–6000 J: 6001–12 000 ```

The answer is 101–250 (119). See explanation to question 1.

For pregnant women with pre-eclampsia: the number of women receiving magnesium sulfate to prevent one case of seizure Number Needed to Treat (NNT) to prevent one affected case is a commonly used statistic to counsel and inform women about the value of interventions in obstetrics. From the range of numbers listed below, choose the most accurate NNT for the clinical situations. Each answer may be used once, more than once or not at all. ``` A: 1–10 B: 11–50 C: 51–100 D: 101–250 E: 251–500 F: 501–750 G: 751–1500 H: 1501–3000 I: 3001–6000 J: 6001–12 000 ```

The answer is 51–100 (90). See explanation to question 1.

For routine induction of labour at 41 weeks of gestation: the number of women with a singleton uncomplicated pregnancy undergoing a planned induction of labour and/or caesarean section to prevent one perinatal death when compared with women undergoing spontaneous labour Number Needed to Treat (NNT) to prevent one affected case is a commonly used statistic to counsel and inform women about the value of interventions in obstetrics. From the range of numbers listed below, choose the most accurate NNT for the clinical situations. Each answer may be used once, more than once or not at all. ``` A: 1–10 B: 11–50 C: 51–100 D: 101–250 E: 251–500 F: 501–750 G: 751–1500 H: 1501–3000 I: 3001–6000 J: 6001–12 000 ```

The answer is 751–1500 (1000). See explanation to question 1.

Brainscape's Knowledge GenomeTM

EMQ Flashcards

Brainscape's Knowledge Genome^TM