Maternal medicine

Question 1

What is the incidence of PE in pregnant women in the UK?
a) 1.5 per 10,000 maternities
b) 1.5 per 10,000 births
c) 1.3 per 10,000 maternities
d) 1.3 per 100,000 maternities
e) 2.0 per 10,000 births

Answer 1

C

Question 2

Regarding PE in pregnancy
a) the risk is higher in the second trimester
b) risk is 9 times higher than in non-pregnant women
c) Heritable thrombophilias account for 15% of PEs in pregnancy
d) Women are 5 times more at risk postpartum than antenatally
e) mortality is lower in obese women

Answer 2

a) risk increases with GA
b) RR in pregnant is 4-5 times higher than non-pregnant
c) account for 20-50%
d) True. RR 5x the antenatal risk
e) false. 60% of deaths between 2003 and 2008 were obese

D

Question 3

Which of the following can cross the placenta?

a)Heparin

b)IgA

c)IgG

d)IgM

e)Insulin

Answer 3

C

Question 4

A 25-year-old women who is 10 weeks pregnant has anti-D antibodies in her booking bloods. What is the reliable method available at this gestation to determine the fetal RhD antigen status?

a-Amniocentesis

b-Fetal blood sampling

c-Maternal blood for cell-free fetal DNA

d-Partner’s blood for rhesus status

e-Ultrasound with middle cerebral artery Doppler

Answer 4

C

Question 5

A RhD antigen-negative woman in her first pregnancy has been involved in a road traffic accident at 29 weeks of gestation without any vaginal bleeding but with trauma to the abdomen. She had received routine antenatal prophylaxis with 1500 units at 28 weeks. What is the most appropriate management?

aAdminister 1500 IU anti-D and take bloods for Kleihauer

b-Administer 1500 IU anti-D

c-Administer 500 IU anti-D and take bloods for Kleihauer

d-Administer 500 IU anti-D

e-Take bloods for Klieihauer

Answer 5

C

Question 6

A woman in her second pregnancy who is RhD antigen negative and has anti-D levels of 4 IU/ml has an antepartum haemorrhage at 24 weeks of gestation. What is the most appropriate management with regards to anti-D?

Administer anti-D 1500 IU intramuscularly

Administer anti-D 250 IU intramuscularly

Administer anti-D 500 IU intramuscularly

Do not administer anti-D

Take Kleihauer to guide the dose of anti-D to give

Answer 6

Do not administer

Question 7

A RhD-negative women has a caesarean section; cell salvage is used intraoperatively. What is the most appropriate management?

Administer anti-D 1500 units intramuscularly prior to reinfusing the blood

Take a cord blood group and if the fetus is found to be RhD negative, administer 1500 units intramuscularly after reinfusion of the blood

Take a cord blood group and if the fetus is found to be RhD negative, administer 500 units intramuscularly after reinfusion of the blood

Take a cord blood group and if the fetus is found to be RhD positive, administer 1500 units intramuscularly after reinfusion of the blood

Take a cord blood group and if the fetus is found to be RhD positive, administer 500 units intramuscularly after reinfusion of the blood

Answer 7

D

Question 8

A women in her fourth pregnancy is known to have anti-K antibodies. She is now at 22 weeks of gestation. What is the best management to investigate if anaemia is present in the fetus?

All of the below

Amniocentesis optical density for bilirubin concentration

Maternal blood titre to quantify antibodies

MCA pulsatility index (PI)

Middle cerebral artery (MCA) peak systolic velocity (PSV)

Answer 8

E

Question 9

You have been asked to review the notes of a 31-year-old nulliparous woman who is now 12 weeks pregnant. She is fit and healthy with a BMI of 24. In the past she had surgical management for a missed miscarriage at 10 weeks of gestation.

The results of her booking bloods have been phoned through to the clinic and are as follows:

blood group: A Rhesus negative
antibody screen: anti-D antibodies present at 3 IU/ml.

Administer anti-D 1500 IU intramuscularly

Administer anti-D 250 IU intramuscularly

Administer anti-D 500 IU intramuscularly

Continue midwifery-led care

Measure serum antibody levels every 2 weeks

Measure serum antibody levels every 4 weeks

No action required

Perform a Kleihauer blood test only

Refer the woman to tertiary fetal medicine unit

Retest for antibodies at 28 weeks

Wait until delivery and test the baby’s blood group

Answer 9

Antibodies every 4 weeks

Question 10

A 23-year-old multiparous woman at 29 weeks of gestation is referred to the antenatal clinic measuring large for dates (symphysio–fundal height = 34 cm).

In her previous pregnancy, she had recurrent antepartum haemorrhage and had a normal delivery at 37 weeks of gestation of a baby girl weighing 2.9 kg.

So far, this pregnancy has progressed as expected with dating and anomaly scans both reporting no anomolies. However, at booking she was noted to have elevated anti-D levels (blood group = AB Rhesus negative). At 16 weeks of gestation, anti-D was 3 IU/ml and at 20 weeks of gestation it was 4 IU/ml. She missed her 24-week blood test due to a family holiday.

She had an ultrasound scan that showed polyhydramnios, fetal ascites and generalised fetal edema.

A serum antibody screen performed last week shows anti-D levels of 18 IU/ml.

Administer anti-D 1500 IU intramuscularly

Administer anti-D 250 IU intramuscularly

Administer anti-D 500 IU intramuscularly

Continue midwifery-led care

Measure serum antibody levels every 2 weeks

Measure serum antibody levels every 4 weeks

No action required

Perform a Kleihauer blood test only

Refer the woman to tertiary fetal medicine unit

Retest for antibodies at 28 weeks

Wait until delivery and test the baby’s blood group

Question 3 (1 point)

Answer 10

refer to FMU

Question 11

A 27-year-old primiparous woman attends for external cephalic version at 38 weeks of pregnancy. Ultrasound confirms a normally grown singleton adopting a flexed breech position, the amniotic fluid index is normal.

Her BMI is 26 and blood group is O-negative. She received routine antenatal anti-D prophylaxis (1500 IU intramuscularly) at 28 weeks of gestation.

Question 3 options:

Administer anti-D 1500 IU intramuscularly

Administer anti-D 250 IU intramuscularly

Administer anti-D 500 IU intramuscularly

Continue midwifery-led care

Measure serum antibody levels every 2 weeks

Measure serum antibody levels every 4 weeks

No action required

Perform a Kleihauer blood test only

Refer the woman to tertiary fetal medicine unit

Retest for antibodies at 28 weeks

Wait until delivery and test the baby’s blood group

Answer 11

500IU

Question 12

A 22-year-old primparous woman who is 34 weeks pregnant presents at the antenatal clinic. She is RhD negative with a RhD-positive fetus on cell-free fetal DNA. She attended hospital 1 week ago with an antepartum haemorrhage but did not receive anti-D.

Administer anti-D 1500 IU intramuscularly

Administer anti-D 250 IU intramuscularly

Administer anti-D 500 IU intramuscularly

Continue midwifery-led care

Measure serum antibody levels every 2 weeks

Measure serum antibody levels every 4 weeks

No action required

Perform a Kleihauer blood test only

Refer the woman to tertiary fetal medicine unit

Retest for antibodies at 28 weeks

Wait until delivery and test the baby’s blood group

Answer 12

500IU

Question 13

A 34-year-old RhD-negative women is at 22 weeks of gestation in her second pregnancy and just completed an intrauterine platelet transfusion for alloimmunisation to platelets

Administer anti-D 1500 IU intramuscularly

Administer anti-D 250 IU intramuscularly

Administer anti-D 500 IU intramuscularly

Continue midwifery-led care

Measure serum antibody levels every 2 weeks

Measure serum antibody levels every 4 weeks

No action required

Perform a Kleihauer blood test only

Refer the woman to tertiary fetal medicine unit

Retest for antibodies at 28 weeks

Wait until delivery and test the baby’s blood group

Answer 13

500IU

Question 14

A 31-year-old nulliparous women who is 16 weeks pregnant. At her booking bloods she was found to be O RhD negative with anti-c antibodies. The anti-c level is reported as 5 IU/ml.

Administer anti-D 1500 IU intramuscularly

Administer anti-D 250 IU intramuscularly

Administer anti-D 500 IU intramuscularly

Continue midwifery-led care

Measure serum antibody levels every 2 weeks

Measure serum antibody levels every 4 weeks

No action required

Perform a Kleihauer blood test only

Refer the woman to tertiary fetal medicine unit

Retest for antibodies at 28 weeks

Wait until delivery and test the baby’s blood group

Answer 14

measure every 4 weeks (below 7.5)

Question 15

How much higher is the overall prevalence of PE in pregnancy in comparison to antenatally?
a) 2x
b) 4x
c) 5x
d) 7x
e) 10x

Answer 15

• overall prevalence 10x higher
• Incidence 1.3/10,000 mternities or 1-2/1000
• RIsk is 20x higher in the puerperium in comparison to non-pregnant; 5x higher than in antenatal

E

Question 16

About LMWH
a) Anit-Xa levels are recommended in women with a previous DVT in pregnancy
b) It increases PPH risk in vaginal deliveries by 1.5X
c) Recurrence risk of PE on LMWH is 1.15%
d) LMWH induces less osteoporosis than UFH
e) A twice daily treatment dose is more effective than once daily

Answer 16

• Anti-Xa levels should be considered in: weight <50kg or >90kg; renal impairment or recurrent VTE only
• It does not increase PPH in VD. In comparison to UFH, it decreases haemorrhage, recurrence, extension and mortality
• CORRECT. It is lower than with UFH
• There is no evidence for one or the other

D

Question 17

A 30- year-old nulliparous woman attended the obstetric medicine clinic for pre-pregnancy counselling. She was diagnosed with mitral stenosis eight years ago and had insertion of mechanical heart valve at mitral position two years ago. She is on lifelong anti-coagulation with warfarin (4 mg/day).

What is the most effective anticoagulation regimen during pregnancy to prevent valve thrombosis?

Continue warfarin throughout pregnancy with INR monitoring every four weeks

Continue warfarin throughout pregnancy with INR monitoring twice weekly

Continue warfarin throughout pregnancy with INR monitoring weekly or every two weeks

Therapeutic LMWH between positive pregnancy test - 20 weeks followed by warfarin

Therapeutic LMWH throughout pregnancy

Answer 17

Continue warfarin throughout pregnancy with INR monitoring weekly or eve

Question 18

ou have been asked to prescribe the therapeutic dose of LMWH for a 25-year-old woman who gave birth vaginally 6 hours ago. She had a DVT 6 weeks ago. Her labour was induced at 40 weeks because of recurrent episodes of reduced fetal movement. She needed syntocinon for slow progress in first stage and used Entonox, diamorphine and epidural for analgesia.

When is the safest time to restart her on LMWH after removing the epidural catheter (there is no concerns with bleeding)?

2 hours

3 hours

4 hours

6 hours

8 hours

Answer 18

LMWH should not be given for 4 hours after the use of spinal anaesthesia or after the epidural catheter has been removed, and the epidural catheter should not be removed within 12 hours of the most recent injection.

4 hours

Question 19

A woman, aged 41, gives birth to her first baby by emergency caesarean section complicated by 1.2 litre PPH. She makes a straightforward recovery. Her booking weight was 98 kg with BMI 35. She is a smoker of 10 cigarettes a day. She has no personal or family history of VTE or thrombophilia. What dose and duration of enoxaparin should she be advised to take?

40 mg SC, once a day, for 10 days

40 mg SC, once a day, for 6 weeks

60 mg SC, once a day, for 10 days

60 mg SC, once a day, for 3 months

60 mg SC, once a day, for 6 weeks

Answer 19

All women should have a risk assessment for VTE carried out at booking, during any admission or change in circumstances during pregnancy and postnatally. This woman has several risk factors for VTE, namely emergency caesarean section, PPH, age, raised BMI and smoking status. She requires an increased daily dose of low molecular weight heparin due to her booking weight. She requires an extended course of LMWH due to the number of risk factors. Each trust will have a scoring system for VTE to enable accurate scoring of VTE risk.

60 mg SC, once a day, for 6 weeks

Question 20

A woman with BMI 42, aged 36, with 3 previous normal births, has a straightforward pool birth in midwifery led care. When should she receive her first prophylactic dose of postnatal low molecular weight heparin?

12 hours after birth

2 hours after birth

4 hours after birth

6 pm that evening

As soon as possible

Answer 20

As this woman has had a straightforward birth, with no use of regional analgesia, she is able to receive her first dose of LMWH straight after delivery. Use of LMWH following regional analgesia should be guided by discussion with anaesthetic colleagues.

As soon as possible

Question 21

A 34 year old had an emergency caesarean section for failure to progress with an epidural top up. Estimate blood loss was 600ml. She is transferred to recovery with the epidural catheter in situ for post operative analgesia. There have been delays in transferring women to the post-natal ward. Shortly before transferring to the post-natal ward you are told that the patient has already received prophylactic LMWH which was given 4 hours after her caesarean section. What would you advise regarding the removal of the epidural catheter?

Remove the epidural catheter immediately and transfer to the post-natal ward

Remove the catheter 4 hours after the caesarean section

Remove the catheter 12 hours after the caesarean section

Remove the catheter 12 hours after the last dose of LMWH

Remove the catheter 8 hours after the last dose of LMWH

Answer 21

At least 12 hours should pass after the prophylactic dose of LWMH and the introduction or removal of and epidural or spinal catheter.

Remove the catheter 12 hours after the last dose of LMWH

Question 22

A 26-year-old woman is 24 weeks pregnant in her second pregnancy. She is admitted with a swollen right leg. A provisional diagnosis of DVT is made and is awaiting duplex ultrasound of the leg. She needs to be commenced on anticoagulation.

Anti-Xa activity

Chest X-ray

FBC, coagulation screen, liver and renal function test

Ultrasound should be repeated on day 3 and day 7

Ventilation perfusion scan/CTPA

Answer 22

FBC, coagulation screen, liver and renal function test

Question 23

A 31-year-old woman is 6 days postnatal. She had a emergency caesarean section for fetal distress. She is admitted with shortness of breath, chest pain and haemoptysis. Her chest X-ray is normal.

Anti-Xa activity

Chest X-ray

FBC, coagulation screen, liver and renal function test

Ultrasound should be repeated on day 3 and day 7

Ventilation perfusion scan/CTPA

Answer 23

V/Q / CTPA

Question 24

A 32-year-old woman is 26 weeks pregnant in her first pregnancy and is admitted with a swollen and painful left leg. On examination the left calf is red and measures 3 cm more than the right calf. The compression duplex ultrasound of the leg is negative.

Anti-Xa activity

Chest X-ray

FBC, coagulation screen, liver and renal function test

Ultrasound should be repeated on day 3 and day 7

Ventilation perfusion scan/CTPA

Answer 24

Repeat D3 and D7

Question 25

A 21-year-old woman at 1 day post normal delivery developed acute shortness of breath, tachypnoea, tachycardia, hypotension and chest pain. A CT angiogram pulmonary reported a massive pulmonary embolism occluding the right pulmonary trunk with very little blood supply to the right lung. This patient underwent an open embolectomy of the pulmonary artery. At discharge, what would you advise?

Caesarean section under general anaesthetic

Caesarean section under spinal anaesthetic

Consider aspirin and prophylactic LMWH during antenatal period

Consider prophylactic LMWH for 10 days after delivery

Prophylactic high-dose LMWH during antenatal period and 6 weeks postpartum

Thrombophilia testing is recommended

Answer 25

Thrombophilia testing

Question 26

A 31-year-old primigravida presents with a known antithrombin deficiency and a history of previous thromboembolic event. She attends the antenatal clinic at 10 weeks gestation for booking. How should she be managed?

Caesarean section under general anaesthetic

Caesarean section under spinal anaesthetic

Consider aspirin and prophylactic LMWH during antenatal period

Consider prophylactic LMWH for 10 days after delivery

Prophylactic high-dose LMWH during antenatal period and 6 weeks postpartum

Thrombophilia testing is recommended

Answer 26

Prophylactic high-dose LMWH during antenatal period and 6 weeks postpart

Question 27

A 28-year-old P0+4 has a history of recurrent spontaneous early miscarriages. Her older sister had thromboses during pregnancy. She attends the early pregnancy unit with amenorrhoea of 6 weeks’ duration with vaginal spotting. What would be the next step in her management?

Caesarean section under general anaesthetic

Caesarean section under spinal anaesthetic

Consider aspirin and prophylactic LMWH during antenatal period

Consider prophylactic LMWH for 10 days after delivery

Prophylactic high-dose LMWH during antenatal period and 6 weeks postpartum

Thrombophilia testing is recommended

Answer 27

The answer is peak anti-Xa activity should be assessed 3 hours post low-molecular-weight heparin (LMWH) administration. Routine measurement of peak anti-Xa activity for patients on LMWH for treatment of acute VTE in pregnancy or postpartum is not recommended except in women at extremes of body weight (>90 kg) or with other complicating factors (for example, with renal impairment or recurrent VTE) putting them at high risk.

The other options are incorrect as:

• if ultrasound is negative and there is a low level of clinical suspicion, anticoagulant treatment can be discontinued. If ultrasound is negative and a high level of clinical suspicion exists, anticoagulant treatment should be discontinued but the ultrasound should be repeated on days 3 and 7 
• D-dimers should not be used for the diagnosis of VTE in pregnancy
• performing a routine thrombophilia screen in pregnancy is not recommended
• the risk of heparin-induced thrombocytopenia is substantially lower with LMWH. Indeed, current guidelines recommend against monitoring platelet count where LMWH is used and where there is no previous exposure to unfractionated heparin. It is only necessary to check the platelet count if the woman has had prior exposure to unfractionated heparin. In a systematic review of 2777 pregnancies, there were no cases of heparin-induced thrombocytopenia. Prolonged unfractionated heparin use during pregnancy may result in osteoporosis and fractures but this risk is very low with LMWH.

Consider aspiring + LMWH antenatal

Question 28

A 32-year-old woman with a BMI of 42 had a normal vaginal delivery.

Caesarean section under general anaesthetic

Caesarean section under spinal anaesthetic

Consider aspirin and prophylactic LMWH during antenatal period

Consider prophylactic LMWH for 10 days after delivery

Prophylactic high-dose LMWH during antenatal period and 6 weeks postpartum

Thrombophilia testing is recommended

Answer 28

10 days PN

Question 29

A 26-year-old gravida 2, para 1 is on prophylactic LMWH for protein S deficiency. She had developed deep vein thrombosis in her last pregnancy 3 years ago. She self administers LMWH at midday every day. She attends the maternity assessment unit at 36+3 weeks at 4 p.m. with painful contractions and is found to be 1 cm dilated. At 5 p.m. the obstetric team decide to deliver her by caesarean section for suspicious cardiotocograph (CTG).

Caesarean section under general anaesthetic

Caesarean section under spinal anaesthetic

Consider aspirin and prophylactic LMWH during antenatal period

Consider prophylactic LMWH for 10 days after delivery

Prophylactic high-dose LMWH during antenatal period and 6 weeks postpartum

Thrombophilia testing is recommended

Answer 29

A

Question 30

A 31-year-old woman is 9 weeks pregnant in her third pregnancy and admitted to hospital because of hyperemesis gravidarum. She has a BMI of 26.

Mobilisation and avoidance of dehydration

Prophylactic LMWH during antenatal period and for 6 weeks postnatal period

Prophylactic LMWH for 6 weeks postnatal period

Prophylactic LMWH for 7 days postnatal period

Prophylactic LMWH for the duration of stay in the hospital

Thrombophilia testing is recommended

Answer 30

LMWH during admission

Question 31

A 38-year-old woman is 31 weeks pregnant in her second pregnancy. She has a BMI of 33 and is admitted in hospital with acute pyelonephritis and is being treated with intravenous antibiotics.

Mobilisation and avoidance of dehydration

Prophylactic LMWH during antenatal period and for 6 weeks postnatal period

Prophylactic LMWH for 6 weeks postnatal period

Prophylactic LMWH for 7 days postnatal period

Prophylactic LMWH for the duration of stay in the hospital

Thrombophilia testing is recommended

Answer 31

LMWH during admission

Question 32

A 29-year-old woman is 9 weeks pregnant in her third pregnancy. She has a BMI of 27 and is a non-smoker. She had DVT following the fracture of her tibia 6 years ago. There is no family history of thromboembolism.

Mobilisation and avoidance of dehydration

Prophylactic LMWH during antenatal period and for 6 weeks postnatal period

Prophylactic LMWH for 6 weeks postnatal period

Prophylactic LMWH for 7 days postnatal period

Prophylactic LMWH for the duration of stay in the hospital

Thrombophilia testing is recommended

Answer 32

C???

Question 33

A 31-year-old woman is 11 weeks pregnant in her second pregnancy. Her first pregnancy was uneventful. She is known to have protein C deficiency but has never had thrombosis in the past. There is no family history of thromboembolism.

Mobilisation and avoidance of dehydration

Prophylactic LMWH during antenatal period and for 6 weeks postnatal period

Prophylactic LMWH for 6 weeks postnatal period

Prophylactic LMWH for 7 days postnatal period

Prophylactic LMWH for the duration of stay in the hospital

Thrombophilia testing is recommended

Answer 33

B????

Question 34

A 21-year-old woman sustained DVT while on the oral contraceptive pill. During investigations she was found to have factor V Leiden mutation. Her mother had DVT several years ago. She is currently 12 weeks pregnant in her first pregnancy.

Mobilisation and avoidance of dehydration

Prophylactic LMWH during antenatal period and for 6 weeks postnatal period

Prophylactic LMWH for 6 weeks postnatal period

Prophylactic LMWH for 7 days postnatal period

Prophylactic LMWH for the duration of stay in the hospital

Thrombophilia testing is recommended

Answer 34

B

Question 35

A 25-year-old primigravid woman presents at 24 weeks of gestation with unilateral leg pain and swelling. She has a BMI of 45 kg/m2 and has been immobile due to severe pelvic girdle pain. You suspect a deep vein thrombosis. Which of the following options is correct?

A negative compression duplex ultrasound excludes the diagnosis

A positive D dimer confirms DVT

A thrombophilia screen should be requested at presentation

Low-molecular-weight heparin never causes heparin-induced thrombocytopenia

Peak anti-Xa activity should be assessed 3 hours post low-molecular-weight heparin administration

Answer 35

E

Question 36

A 35-year-old pregnant woman with a history of a history of previous recurrent venous thromboembolism (VTE) associated with antiphospholipid syndrome presents at 8 weeks of gestation with hyperemesis gravidarum. The woman is admitted to hospital for rehydration and antiemetics. You prescribe prophylactic low-molecular-weight heparin as prophylaxis against VTE. When counselling the woman about investigations, which of the following should you inform her?

Chest x-ray usually shows signs of a PE

CT pulmonary angiogram (CTPA) increases the lilfetime risk of maternal breast cancer by <10%

If leg Doppler studies are not suggestive of DVT and the clinical picture suggests a PE, further imaging is necessary

The perfusion component of a ventilation/perfusion (V/Q) test can be omitted to limit the radiation exposure to the fetus

V/Q scan increases the risk of childhood cancer to one in 1 000 000

Answer 36

The answer is if leg Doppler studies are not suggestive of DVT and the clinical picture suggests a PE, further imaging is necessary.

The other options are incorrect as:

chest x-ray usually shows signs of a PE in only 50% cases, and is normal in the remaining 50%
CT pulmonary angiogram increases the lifetime risk of maternal breast cancer by less than 13.6%
the ventilation component of a ventilation/perfusion (V/Q) test can be omitted to limit the radiation exposure to the fetus
V/Q scan increases the risk of childhood cancer to one in 280 000.

C

Question 37

A 35-year-old pregnant woman with a history of a history of previous recurrent venous thromboembolism (VTE) associated with antiphospholipid syndrome presents at 8 weeks of gestation with hyperemesis gravidarum. The woman is admitted to hospital for rehydration and antiemetics. You prescribe prophylactic low-molecular-weight heparin as prophylaxis against VTE. Which of the following options is the single best answer?

This should be continued antenatally and for 6 weeks postpartum

This should be continued throughout pregnancy and for 7 days following delivery

This should be continued throughout pregnancy until delivery

This should be continued until the woman is discharged from hospital

This should be continued whilst the woman has hyperemesis

Answer 37

The answer is this should be continued antenatally and for 6 weeks postpartum. Women with VTE associated with APS or with recurrent VTE (who will often be on long-term oral anticoagulation) should be offered thromboprophylaxis with higher dose LMWH (either 50%, 75% or full treatment dose) antenatally and for 6 weeks postpartum or until returned to oral anticoagulant therapy after delivery. Persistent aPL in women without previous VTE should be considered as a risk factor for thrombosis such that if she has other risk factors she may be considered for antenatal or postnatal thromboprophylaxis. 

A

Question 38

A 34-year-old low risk primigravida mentions at her routine 16 week antenatal clinic appointment that she and her partner are planning a holiday in Mexico when she is 26 weeks pregnant. Her pregnancy has been uncomplicated to date, her BMI is 24 and she has no significant personal or family history of venous thromboembolism (VTE). What information should she be given about her risk of venous thromboembolism (VTE) with long haul travel and prophylactic measures?

Aspirin 75mg once a day is recommended as VTE prophylaxis in low risk women

Graduated elastic compression stockings worn during the flight will reduce the risk of asymptomatic VTE by 50%

Prophylactic low molecular weight heparin (LMWH) should be administered on the day of travel and for several days afterwards

The absolute incidence of venous thromboembolism is doubled with prolonged air travel

The overall incidence of symptomatic VTE is low at 1/4600 flights in the month following a flight over 4 hours

Answer 38

The true incidence of DVT in pregnancy with long haul travel is unknown, but it is accepted that prolonged air travel results in a small increase in the absolute incidence of VTE by three fold with an 18% higher risk of VTE for each 2 hour increase in flight duration.

For short haul journeys no specific measures are likely to be required. For medium and long haul flights lasting more than 4 hours, it is suggested that all pregnant women wear properly fitted graduated elastic compression stockings. There is evidence that graduated elastic compression stockings will reduce the risk of asymptomatic VTE with a relative risk of 0.1 (95% CI 0.04-0.25)

Aspirin alone is not recommended as VTE prophylaxis as there are more effective methods and there is an association with non-obstetric haemorrhage complications.

Women with additional risk factors (previous DVTs, symptomatic thrombophilia, morbid obesity or medical problems such as nephrotic syndrome should be offered prophylaxis with low molecular weight heparin on the day of travel and for several days thereafter if not already on LMWH.

E

Question 39

A woman, aged 41, gives birth to her first baby by emergency caesarean section complicated by 1.2 litre PPH. She makes a straightforward recovery. Her booking weight was 98kg with BMI 35. She is a smoker of 10 cigarettes a day. She has no personal or family history of VTE or thrombophilia. What dose and duration of enoxaparin should she be advised to take?

40 mg SC, once a day, for 10 days

40 mg SC, once a day, for 6 weeks

60 mg SC, once a day, for 10 days

60 mg SC, once a day, for 3 months

60 mg SC, once a day, for 6 weeks

Answer 39

All women should have a risk assessment for VTE carried out at booking, during any admission or change in circumstances during pregnancy and postnatally. This woman has several risk factors for VTE, namely emergency caesarean section, PPH, age, raised BMI and smoking status. She requires an increased daily dose of low molecular weight heparin due to her booking weight. She requires an extended course of LMWH due to the number of risk factors. Each trust will have a scoring system for VTE to enable accurate scoring of VTE risk.

E

Question 40

A woman with BMI 42, aged 36, with 3 previous normal births, has a straightforward pool birth in midwifery led care. When should she receive her first prophylactic dose of postnatal low molecular weight heparin?

12 hours after birth

2 hours after birth

4 hours after birth

6 pm that evening

As soon as possible

Answer 40

E

Question 41

A 31-year-old woman is 11 weeks pregnant in her second pregnancy. Her first pregnancy was uneventful. She is known to have protein C deficiency but has never had thrombosis in the past. There is no family history of thromboembolism.

Mobilisation and avoidance of dehydration

Prophylactic LMWH during antenatal period and for 6 weeks postnatal period

Prophylactic LMWH for 6 weeks postnatal period

(Prophylactic LMWH for 7 days postnatal period

Trophylactic LMWH for the duration of stay in the hospital

Thrombophilia testing is recommended

Answer 41

This patient has an asymptomatic hereditable thrombophilia, therefore prophylaxis is recommended during the antenatal and extended post natal period.

B

Question 42

You see a 44 year old in antenatal clinic. She had an unprovoked DVT 2 years ago, thrombophilia testing did not yield any acquired or hereditable thrombophilia. She has 2 children. Her eldest is 10 years old and her youngest is 8 years old. She has no allergies. Her dating scan has confirmed a viable singleton pregnancy. Her BMI is 31 and her booking weight it 76kg. Which is the most appropriate for her antenatal VTE management?

Commence Aspirin

Commence Aspirin and 40mg enoxaparin daily
Correct Answer
Commence 40mg enoxaparin daily
Incorrect Response
Commence 7500 units of dalteparin

Commence 40mg enoxaparin at 28 weeks at prophylactic dose

Answer 42

This patient only has 1 moderate risk factor for pre eclampsia so Aspirin in her case is not indicated. Had her most recent pregnancy been more than 10 years ago or her BMI was over 35 then she would have qualified for Aspirin. Due to her previous VTE, LMWH at prophylactic dose is indicated.

C

Question 43

Regarding heart disease in pregnancy:
A) Affects approximately 10% of pregnancies
B) The most common aetiology in the World is congenital heart disease
C) Has a 5% mortality rate
D) A NTproBNP>128 in the first trimester is predictive of future cardiac events in pregnancy
E) Most audible diastolic murmurs are a normal feature of pregnancy and do not require investigation

Answer 43

A) Affects 1-4%
B) it is in western countries (75-80%). In non-Western, it is rheumatic valve disease
C) Correct
D) It is predictive when above this value at 20 weeks
E) These are always abnormal

C

Question 44

Regarding heart disease in pregnancy:
A) Induction of labour at 40 weeks should be considered in all women
B) MRI is contra-indicated for cardiac assessment in pregnancy
C) One passive hour should be given for descent of fetal head at the second stage of labour
D) Neonatal mortality when maternal cardiac disease is present is close to 20%
E) Ergometrine can be used if no acute blood pressure concerns

Answer 44

A) Correct
B) Recommended when echo is not enough for assessment
C) 2 hours should be given
D) it is 1-4%. It is Close to 20% when maternal surgery is performed
E) should be avoided

Question 45

A 25-year-old woman with a mechanical heart valve is approximately 6 weeks into an unplanned pregnancy. She is currently on 5.5g/day of Warfarin. What would you advise in terms of managing her anticoagulation?
A) Stop Warfarin between 10 and 12 weeks, switch to LMWH and then restart until 36 weeks
B) Stop Warfarin now and continue LMWH until the end of pregnancy
C) Discuss termination of pregnancy
D) Stop Warfarin now, until 12 weeks then restart until 36 weeks.
E) Continue Warfarin until 36 weeks with INR monitoring every 1-2 weeks.

Answer 45

D

Warfarin rules:
- If low dose (<5mg), there is a <2% chance of fetal defect. Therefore, it can continue throughout all tirmesters. It should be stopped and changed to LMWH at 36/40
- If high dose (>5mg/day), then it should be suspended and changed for LMWH between 6-12 weeks. It can then be continued until 3 weeks, after which it should be changed to LMWH again.
- Discussion about pros and cons of changing to LMWH if high dose should be taken
- After 36 weeks, all women should switch to LMWH. They should then switch to UFH 36 hours after birth, then stoop 4-6 hours before until 4-6 hours after.
- Women on UFH should have aPTT monitored.
- Women on LMWH should have anti-Xa monitored weekly
- Women on Warfarin should have INR monitored every 1-2 weeks

Question 46

A woman has been on Warfarin throughout her pregnancy due to a mechanic heart valve. She attends labour ward in preterm labour at 35 weeks’ gestation. She reports that she forgot to take her last dose of Warfarin, which was over 24 hours ago. What management plan would you advise?
A) Advise caesarean section
B) Proceed with labour and start UFH 4-6 hours after delivery.
C) Proceed with labour and start treatment dose of LMWH 4-6 hours after
D) Advise caesarean section and neonatal Vit K
E) Proceed with labour after giving FFP. Start UFH 4-6 hours after.

Answer 46

D

• A CS is usually advised if within 2 weeks of stopping a VKA or whilst VKA as labour increases the risk of ICH in the fetus. The fetus will remain anticoagulated for 8-10 days after, therefore Vit K +/- FFP is advised.
• For women on UFH or LMWH, labour can proceed after protamine sulfate. However, it may need repeat dose or infusion for LMWH.
• We should aim for an INR<=1.5
• Four factor prothrombin concentrate is preferred to FFP

Question 47

Which of these is an indication for caesarean section?
A) An ascending aorta of 41mm in a Woman with Marfan’s syndrome
B) An ASI of 20mm/m2 in a woman with Turner syndrome
C) A woman on Warfarin who had her last dose 25 hours ago
D) A woman on LMWH who had her last dose 24 hours ago
E) A woman with a known PFO

Answer 47

C

Indications for caesarean section are
- Marfan’s: aorta >45mm
- Severe aortic stenosis
- Severe HF
- Severe PH (Eisenmerger’s syndrome)
Consideration about caesarean section should be given to:
- previous aortic dissection
- Marfan’s with aorta between 40 and 45mm –> although in these cases early epidural and limited second stage are a good option
In any woman whose last dose of Warfarin was less than 2 weeks ago, CS is advised to protect the fetus against ICH

Question 48

Which of these is not a conta-indication to pregnancy?
A) Vascular EDS
-B) urner with ASI>25mm/m2
C) Biscupid aortic valve with ascending aorta >50mm
D) Woman with Marfan’s syndrome and ascending aorta >45mm
E) Woman with Marfan’s syndrome, ascending aorta >35mm and family history of aortic dissection

Answer 48

E

• This should be >40mm

Question 49

About PPCM
A) It has a low recurrence rate if happens in the third trimester
B) Future pregnancies are not recommended if ejection fraction does not recover to levels >45%
C) Bromocriptine associated with LMWH is an established treatment
D) Is directly related to maternal BMI
E) Is rare in women <18 years old

Answer 49

C

• Bromocriptine should always be given with LMWH
• A) it always has a high recurence
• B) not recommended if <50-55%
• C: correct
• D) risk factors are: smoking, African, multiparity, PET, age>40, teenage pregnancy, malnutrition, DM
• E) teenage pregnancy is a risk factor

Question 50

About heart disease in pregnancy:
A) MRI imaging should not be performed
B) Mitral stenosis with area <1cm2 should be reparied prior to pregnancy
C) Anti-Xa levels should be repeated every trimester for women on LMWH anticoagulation
D) In women with aortic stenosis, intervention should be done before pregnancy if the ejection fraction is below 40%
E) In women with AF, anticoagulation Warfarin is contra-indicated

Answer 50

B

• A) it can be done, without gadolinium, if echo not enough
• B) True. Consider if <1.5cm2
• C) every week
• D) if EF below 50%
• E) anticoagulation can be done with LMWH or Warfarin depending on gestation

Question 51

A woman presents to the antenatal clinic with palpitations. She describes these as episodes of a fast heartbeat which last about 5–10 minutes and occur roughly once a week. They can come on suddenly at any time. She hasn’t blacked out with them, but feels anxious when they happen. She hasn’t had any heart problems before, but her father has had a heart attack aged 55. There is no other family history of note.

What is the most likely diagnosis?

Anxiety

Atrial fibrillation

Ectopic beats

Supraventricular tachycardia

Ventricular tachycardia

Answer 51

SVT

Features which suggest this is supraventricular tachycardia are fast heartbeat with sudden onset. Anxiety tends to be a more gradual onset. A duration of 5–10 minutes is greater than expected with ectopic beats. In someone with no other cardiac history, recurrent symptomatic ventricular tachycardia without blackouts would be rare. While paroxysmal atrial fibrillation can occur, it is less common than supraventricular tachycardia in a woman with no previous cardiac history.

Question 52

A woman with mitral stenosis and atrial fibrillation asks your advice about contraception. She is anticoagulated because of her atrial fibrillation.

What would you advise?

Combined oral contraceptive pill

Depo-Provera™

Long-acting progesterone implant, e.g. Nexplanon™

Mirena™ IUS

Progesterone-only pill

Answer 52

Mirena

A Mirena™ IUS will provide effective contraception. Women who are anticoagulated often suffer from menorrhagia and a Mirena™ IUS will have the added benefit of stopping this. The combined oral contraceptive pill is inappropriate as it is thrombogenic. Injection of Depo-Provera™ can result in haematoma formation. Nexplanon™ may be appropriate, but can result in problematic irregular bleeding in women who are anticoagulated.

Question 53

A woman from south-east Asia becomes breathless 12 hours after the delivery of her first child. She had an epidural in labour, was kept well-hydrated because of a pyrexia and had syntometrine for third stage. She is coughing up pink frothy sputum.

What is the most likely diagnosis?

Anxiety

Aortic stenosis

Asthma

Flu

Hypertrophic cardiomyopathy

Mitral stenosis

Peripartum cardiomyopathy

Pneumonia

Pre-eclampsia

Answer 53

Mitral stenosis

Pink frothy sputum is a feature of pulmonary oedema. Pulmonary oedema occurs with peripartum cardiomyopathy and mitral stenosis. Either of these answers could be correct. Giving syntometrine results in a sudden increase in venous return, which in the presence of a stenosed mitral valve can precipitate pulmonary oedema. Undiagnosed mitral stenosis is more common in women from countries where rheumatic fever occurs, for example south-east Asia.

Question 54

A 40-year-old African woman with an IVF twin pregnancy at 35 weeks’ gestation is admitted with a cough. Her pulse is 110 bpm. Her respiratory rate is 25 breaths per minute. She refuses to lie down to be examined, saying that she can’t because it makes her more breathless. She has attended frequently during pregnancy because she is very worried about fetal wellbeing. She has ankle oedema and is agitated.

What is the most likely diagnosis?

Anxiety

Aortic stenosis

Asthma

Flu

Hypertrophic cardiomyopathy

Mitral stenosis

Peripartum cardiomyopathy

Pneumonia

Pre-eclampsia

Answer 54

PPCM

This woman has orthopnoea (can’t lie down) which suggests pulmonary oedema. She has risk factors for peripartum cardiomyopathy and signs suggestive of this. Ankle oedema is common in pregnancy, but in conjunction with her breathlessness is suggestive of poor ventricular function and peripartum cardiomyopathy. The case scenario does not give the woman’s blood pressure, but it is unusual for orthopnoea to be a presenting symptom of pre-eclampsia.

Question 55

A woman who is 32 weeks’ pregnant in her first pregnancy with a history of repaired Tetralogy of Fallot as a child presents to antenatal clinic. She is feeling more tired and has recently started to become more breathless when she climbs the stairs at home.

What is the most appropriate plan of management?

Reassure her that these are common symptoms associated with the third trimester

Request a FBC and ferritin

Request an outpatient echo and review in 2 weeks

Admit and aim to deliver in the next 24-48 hours

Admit for bed rest with a plan for earlier delivery

Answer 55

The correct answer is to** admit for bed rest with a plan for early delivery**. This patient is at risk of heart failure in the pregnancy, so given that she has a reduced exercise tolerance, bed rest will help to prolong the pregnancy and reduce the work on the heart. An inpatient echo should be requested as this will guide timing of delivery. Diuretics may be required. Multi-disciplinary input from a tertiary-level maternal medicine network is crucial for such patients.

Question 56

You review a 38-year-old black African woman in triage who is currently 40 weeks into her second pregnancy. She had an uncomplicated vaginal delivery at term 4 years ago.

She presents with breathlessness and palpitations over the last few days. She also mentions that she requires four pillows to sleep at night. She denies any chest pain, cough or syncope. There is no past cardiac or respiratory history of note. On examination:

BMI = 35 kg/m2
pulse = 134 bpm and regular
blood pressure = 130/78 mmHg
respiratory rate = 28 breaths per minute
SpO2 on air = 94%
chest clear
normal first and second heart sounds with gallop rhythm
mild-to-moderate peripheral oedema.
An ECG shows sinus tachycardia and a chest X-ray shows an enlarged heart with pulmonary congestion.

What would be the most appropriate next step in this patient’s management?

Take blood cultures and commence antibiotics

Start low-molecular weight heparin and request a CTPA

Take an arterial blood gas and request an urgent echocardiogram

Start diuretics and plan for immediate delivery

Commence anti-hypertensives and magnesium sulphate

Answer 56

ABG and echo

This patient shows features of acute heart failure. Complete assessment of this includes knowing a lactate and left ventricular function. Differentials include pneumonia and pulmonary embolus. Diuretics may be needed after multi-disciplinary team discussion with a cardiologist.

Question 57

You are asked to review a 22-year-old woman who is known to have mitral stenosis. She is currently at 12 weeks of gestation in her first pregnancy. She has had percutaneous mitral commisurotomy in the past. Currently she is asymptomatic and is not on any medications. There is no other medical or surgical history of note.

On examination:

BMI = 22
Pulse = 60 beats/minute and regular
BP = 110/50 mm Hg
Chest = clear; loud heart sounds with diastolic murmur over mitral area.
A recent echocardiogram showed moderate mitral stenosis with a large left atrium.

What plan would you put in place to optimally manage her pregnancy?

Multidisciplinary team input, avoid bradycardia, monthly or bimonthly echocardiography depending on haemodynamic tolerance, anticoagulation

Multidisciplinary team input, avoid tachycardia, monthly or bimonthly echocardiography depending on haemodynamic tolerance

Multidisciplinary team input, avoid tachycardia, monthly or bimonthly echocardiography depending on haemodynamic tolerance, anticoagulation

Multidisciplinary team input, bed rest, oxygen therapy, monthly or bimonthly echocardiography depending on haemodynamic tolerance, anticoagulation

Multidisciplinary team input, perform planned percutaneous mitral commisurotomy before 20 weeks of gestation, monthly or bimonthly echocardiography depending on haemodynamic tolerance, anticoagulation

Answer 57

The correct answer is multidisciplinary team input, avoid tachycardia, monthly or bimonthly echocardiography depending on haemodynamic tolerance, anticoagulation.

This is a high-risk pregnancy and the woman should be reviewed by the multidisciplinary team (obstetrician, cardiologist, anaesthetist). Bed rest and oxygen therapy is not routinely recommended. When symptoms or pulmonary hypertension (echocardiographically estimated systolic PAP > 50 mmHg) develop, activity should be restricted and β1-selective blockers commenced. Diuretics may be used if symptoms persist, avoiding high doses.

Clinical and echocardiographic follow-up is indicated monthly or bimonthly depending on haemodynamic tolerance. In mild MS, evaluation is recommended every trimester and prior to delivery.

Percutaneous mitral commisurotomy is preferably performed after 20 weeks of gestation. It should only be considered in women with NYHA class III/IV and/or estimated systolic PAP > 50 mmHg at echocardiography despite optimal medical treatment, in the absence of contraindications and if patient characteristics are suitable.

Tachycardia is particularly dangerous in mitral stenosis as it results in pulmonary oedema. Tachycardia → further decrease in diastolic filling of left ventricle → fall in stroke volume → rise in left atrial pressure → pulmonary oedema.

Therapeutic anticoagulation is recommended in the case of paroxysmal or permanent AF, left atrial thrombosis, or prior embolism. It should also be considered in women with moderate or severe MS and spontaneous echocardiographic contrast in the left atrium, large left atrium (≥ 40 ml/m2), low CO, or congestive heart failure, because these women are at very high thrombo-embolic risk.

Question 58

A 20-year-old woman attends the obstetric cardiology clinic with her partner for pre-pregnancy counselling. She has a repaired tetralogy of Fallot (ToF) and is contemplating her first pregnancy. She is asymptomatic and her recent echocardiogram showed mild pulmonary regurgitation.

What advice would you give her regarding her likely pregnancy outcome?

A planned caesarean section at term is recommended

Likely to tolerate pregnancy well

May develop arrhythmias and left heart failure

There is a significant chance of needing admission for bed rest and diuretics

Will require a fetal cardiac scan as the overall risk of the fetus having a congenital heart disease is 25%

Answer 58

The correct answer is likely to tolerate pregnancy well.

The preferred mode of delivery is vaginal in almost all cases. Caesarean section is only indicated for obstetric reasons.
Women with repaired tetralogy of Fallot usually tolerate pregnancy well (WHO risk class II). Cardiac complications during pregnancy have been reported in up to 12% of patients.
Arrhythmias and right heart failure in particular may occur. Moderate to severe pulmonary regurgitation → increase in RV size → RV dysfunction and failure. If RV failure occurs during pregnancy, treatment with diuretics should be started and bed rest advised. Transcatheter valve implantation or early delivery should be considered in those who do not respond to conservative treatment
There is a small chance of needing admission for bed rest and diuretics but this is unlikely in this case as ventricular function was normal on the recent echocardiogram.
The woman will definitely require a fetal cardiac scan but the overall risk of the fetus having a congenital heart disease is 2–5%.
mother with CHD = 6% risk
father with CHD = 2% risk
one previous child with CHD = 2–5%
two previous children with CHD = 10–15%.
The level of risk also depends on the specific lesion and the risk is highest (1–20%) for congenital aortic stenosis.

Question 59

You see a 23-year-old primigravida who is 10 weeks pregnant in the combined obstetric cardiac antenatal clinic. She has Eisenmenger Syndrome due to a complex congenital heart defect repaired as a child.

What would be the most appropriate advice for management?

Bed rest at home with oxygen

Commence sildenafil

Commence low molecular weight heparin

Admit from 28 weeks’ gestation for bed rest

Termination of pregnancy

Answer 59

The correct answer is E. Termination of pregnancy. Pregnancy in Eisenmenger syndrome is associated a 20-50% risk of mortality. Termination of pregnancy should be offered but carries a risk of its own. Miscarriage is common.