Maternal Medicine Flashcards
What is the prevalence of epilepsy amongst women of childbearing age?
a. 0.1-0.3%
b. 0.5-1%
c. 2-3%
d. 4-5%
e. 6-7%
B - 0.5-1%
Anti-epileptic drugs are known to be taken by women in around 1 in 200 pregnancies overall.
What is the risk of maternal mortality amongst women with epilepsy relative to the general population?
a. Equivalent
b. 2x
c. 3x
d. 10x
e. 20x
D - 10x
The maternal mortality rate for women with epilepsy is of the order of 60 per 100,000 and has not significantly improved over the last decade
You meet a 23 year women with epilepsy in the antenatal clinic. She states that her epilepsy is normally well controlled on lamotrigine with her last seizure over 6 months prior to conception. What proportion of women with epilepsy experience an increase in their seizure frequency during pregnancy?
a. 5%
b. 17%
c. 33%
d. 40%
e. 55%
B - 17%
64% of women with epilepsy remain seizure free in pregnancy.
17% experience an increase in their seizure frequency while 16% experience a decrease.
Around 3.5% of women have a fit in labour.
A 21 year old primigravida with known epilepsy on lamotrigine is seen in the antenatal clinic at booking. Her epilepsy is well controlled and she has been seizure free for 18 months prior to conception. What fetal surveillance is indicated in pregnancy according to RCOG guidelines?
a. SFH measurements with midwife only
b. Uterine artery doppler at 20/40 and serial scans if abnormal
c. Serial scans from 28/40
d. Serial scans from 24/40
e. Single third trimester growth scan at 36/40
C - Serial scans from 28/40
The RCOG recommend that women with epilepsy on anti-epileptic drugs undergo serial growth scans from 28/40.
There is evidence to suggest a 2-fold increased risk of SFGA in such women.
A 38 year old with known epilepsy attends the pre-conceptual counselling clinic. She is currently taking sodium valproate though wishes to conceive in the near future. What is the risk of major congenital malformation amongst women taking sodium valproate in pregnancy?
a. Up to 2%
b. Up to 5%
c. Up to 10%
d. Up to 20%
e. Up to 50%
C - Up to 10%
Valproate has the highest risk of major congenital malformations of any anti-epileptic drug - up to 10%.
Neural tube defects, facial clefts and hypospadias most commonly.
A 24 year old primigravida attends the antenatal clinic at booking. She is known to have poorly controlled epilepsy and is taking lamotrigine, levetiracetam and phenytoin. She wishes to know her risk of a major congenital malformation. What do you advise is the risk of a major congenital malformation in her case?
a. 3-5%
b. 6-8%
c. 9-10%
d. 12-14%
e. 18-20%
B - 6-8%
The risk of a major congenital malformation associated with anti-epileptic drug use is 6-8% for women on polytherapy (10% if includes valproate); comparatively it is 3-5% for women on monotherapy (10% for valproate).
A 27 year old woman is referred to the antenatal clinic at booking on account of a past history of epilepsy. On questioning she reveals that she had a history of seizures in childhood though her last was age 16 and she has been off her anti-epileptic medication for almost 7 years. What schedule of care is most appropriate for this woman in pregnancy?
a. Midwife led care
b. Obstetric led care though no need for additional fetal surveillance
c. Obstetric led care with serial scans from 28 weeks
d. Obstetric led care with fetal echocardiography at 20-24 weeks
e. Obstetric led care with serial scans from 28 weeks and fetal echocardiography at 20-24 weeks
A - Midwife led care
Women who have been seizure free for 10 years or more and off their anti-epileptic drugs for 5 years or more, may be managed as per women without epilepsy.
What is the risk of intrapartum seizures amongst women with epilepsy?
a. 1%
b. 3.5%
c. 10%
d. 15%
e. 33%
B - 3.5%
3.5% of women with epilepsy seize in labour
A woman with known epilepsy is admitted in labour at 5cm. Shortly afterwards she experiences a tonic-clonic seizure. Her blood pressure is normal. Which of the following drugs is considered first line for the management of epileptic seizures in labour?
a. Magnesium Sulphate
b. Phenytoin
c. Lamotrigine
d. Sodium Valproate
e. Lorazepam
E - Lorazepam
Benzodiazepines are first line management of epileptic seizures in labour. Phenytoin may be used in refractory cases.
A 29 year old with known epilepsy is found dead in her home during the second trimester. Following a coroner’s review, sudden unexplained death in pregnancy (SUDEP) is determined to have been the cause. Which of the following anti-epileptic drugs is thought to have the highest association with SUDEP?
a. Sodium valproate
b. Lamotrigine
c. Carbemazepine
d. Diazepam
e. Phenobarbitol
B - Lamotrigine
There are some concerns regarding the incidence of SUDEP amongst women on lamotrigine as rates are higher (2.5 per 1000 patient years) than women on other anti-epileptic drugs (0.5 per 1000 patient years). This may well be related to the higher numbers of women on lamotrigine as well as reduced serum levels with advancing gestation.
What is the normal change in cardiac output seen in pregnancy?
a. Increase by 20%
b. Increase by 40%
c. Increase by 60%
d. Decrease by 20%
e. Decrease by 10%
B - Increase by 40%
This is principally due to an increase in stroke volume though also in part due to a rise in heart rate of approx. 10-20bpm
Source: HB of Obstetric Medicine
What is the normal change in heart rate in pregnancy?
a. Increase by <10bpm
b. Increase by 10-20bpm
c. Increase by 20-30bpm
d. Decrease by <10bpm
e. Decrease by 10-20bpm
B - Increase by 10-20bpm
Source: HB of Obstetric Medicine
What is the most common congenital cardiac defect seen amongst women of reproductive age?
a. Patent ductus arteriosus
b. Coarctation of the aorta
c. Atrial septal defect
d. Hypoplastic left heart syndrome
e. Congenital aortic stenosis
C - Atrial septal defect
These are usually well tolerated in pregnancy. There may be an association with migraine. There is a theoretical risk of paradoxical embolism though this is low.
Blood loss at delivery can increase the left to right shunt leading to a drop in LV output and coronary blood flow.
Source: HB of Obstetric Medicine
A 29 year old woman with Marfan syndrome is reviewed in the antenatal clinic at booking. What is the most significant prognostic consideration amongst patients with Marfan Syndrome in pregnancy?
a. Pectus excavatum
b. Pneumothorax
c. Mitral valve prolapse
d. Mitral regurgutation
e. Aortic root dilatation
E - Aortic root dilatation
Marfan syndrome carries a risk of aortic dissection and rupture. The risk is 10% where the aortic root is >4cm dilated and pregnancy is generally contraindicated above this level.
Women who do continue with pregnancies where the aortic root is >4cm typically require beta-blockade in pregnancy as this has been shown to reduce the rate of complications of further dilatation. Regular echocardiography is required and patients with progressively enlarging or an aortic root >4-4.5cm should be delivered by El. LSCS.
Source: HB of Obstetric Medicine
A woman with a history of a congenital heart defect enquires about the risk of her baby being affected. Overall, what is the risk of congenital heart disease amongst infants born to mothers who themselves have a history of congenital heart defect?
a. No increased risk
b. 1-2%
c. 2-5%
d. 3-8%
e. 9-11%
B - 1-2%
This is well over double the general population risk. The risk is higher for mothers than fathers. Affected women should as such be offered a detailed cardiac scan in the second trimester.
The risk is highest for aortic stenosis (18-20%)
Source: HB of Obstetric Medicine
A 32 year old recent migrant is reviewed in the antenatal clinic at booking. When first seen by her midwife, she disclosed a history of rheumatic fever in infancy. What is the predominant cardiac lesion seen in women with a history of rheumatic fever?
a. Aortic regurgitation
b. Pulmonary atresia
c. Ventriculo-septal defect
d. Mitral stenosis
e. Mitral regurgitation
D - Mitral stenosis
Mitral stenosis accounts for over 90% of rheumatic heart disease seen in women in pregnancy
Source: HB of Obstetric Medicine
A woman with a strong family history of hypertrophic cardiomyopathy attends the pre-conceptual counselling clinic. She has recently undergone echocardiography which is suggestive of mild hypertrophic cardiomyopathy. What class of drugs are the mainstay of therapy for hypertrophic cardiomyopathy in pregnancy?
a. Calcium channel blockers
b. Alpha-blockers
c. Beta-blockers
d. Diuretics
e. ACE-inhibitors
C - Beta-blockers
70% of HCM is familial with autosomal dominant inheritance. It is generally well tolerated in pregnancy owing to an increase in LV cavity size. Women who develop symptoms should be started on beta-blockers in pregnancy.
Source: HB of Obstetric Medicine
A 46 year old Para 4 woman undergoes an echocardiogram in a DCDA twin pregnancy at 34 weeks of gestation for suspected peripartum cardiomyopathy after she presents with worsening shortness of breath, peripheral oedema and palpitations. What threshold of LV ejection fraction is used for the diagnosis of peripartum cardiomyopathy?
a. <90%
b. <75%
c. <60%
d. <45%
e. <30%
D - <45%
Peripartum cardiomyopathy requires an LV ejection fraction of <45% for confirmation of diagnosis.
In addition to cardiac considerations, thromboprophylaxis is important for these women as up to 40% will develop systemic embolisation and 5% will stroke.
Source: HB of Obstetric Medicine
A 35 year old patient with a mechanical heart valve has been anticoagulated with low-molecular weight heparin throughout her pregnancy. She has attended delivery suite with spontaneous labour at 36/40 and her CTG is pathological. She requires urgent delivery. What drug may be used to reverse heparin if required in such a situation?
a. Vitamin K
b. Beriplex (prothrombin complex)
c. Cryoprecipitate
d. Protamine sulphate
e. Fresh frozen plasma
D - Protamine sulphate
Heparin may be reversed with protamine sulphate in an emergency. Warfarin is reversed with FFP and Vitamin K.
Source: HB of Obstetric Medicine
What is the maternal death rate associated with acute myocardial infarction in pregnancy?
a. 1-2%
b. 5-7%
c. 11-15%
d. 18.5-21%
e. 25-30%
B - 5-7%
The incidence of MI in pregnancy is increasing - likely related in part, to advancing maternal age. It occurs most commonly in the third trimester and perpartum.
Management is as per the non-pregnant patient with anti-coagulants, beta blockers and nitrates.
Source: HB of Obstetric Medicine
A 36 year old patient with Ehlers-Danlos syndrome presents at 35 weeks of gestation with acute severe chest pain which radiates to the back and jaw. Blood pressure is noted to be elevated in the right arm at 160/110mmHg though when measured in the left is normal at 110/60mmHg. What is the most likely diagnosis here?
a. Pulmonary embolism
b. Acute myocardial infarction
c. Amniotic fluid embolism
d. Aortic dissection
e. Pulmonary oedema
D - Aortic dissection
Differential blood pressure in each arm is highly suggestive of thoracic aortic dissection which is more common in women with Ehlers-Danlos (type IV - vascular), Turners and Marfan’s syndromes.
A chest radiograph would be expected to show a classic mediastinal widening appearance.
Management is surgical - careful but quick control of blood pressure, delivery by Caesarean section and cardiac surgery to replace the aortic root.
Source: HB of Obstetric Medicine
What is the drug of choice for treating fetal tachyarrhythmias antenatally?
a. Bisoprolol
b. Verapamil
c. Sotalol
d. Flecanide
e. No treatment of known benefit
D - Flecanide
Source: HB of Obstetric Medicine
What is the lifetime prevalence of breast cancer in women in the UK?
a. 1 in 5
b. 1 in 9
c. 1 in 15
d. 1 in 17
e. 1 in 23
B - 1 in 9
Breast cancer is the most common cancer in women with a lifetime risk of 1 in 9 in the UK population. It is the leading cause of death in women aged between 35 and 54.
What percentage of new breast cancer diagnoses are made in women aged <45?
a. 5%
b. 10%
c. 15%
d. 20%
e. 25%
C - 15%
15% of all new breast cancer diagnoses are made in women aged under 45 – equivalent to around 5000 women per year in the UK of reproductive age, 10-20% of which are either associated with pregnancy or occur within 12 months of delivery. Up to 10% of women under 45 who develop breast cancer subsequently fall pregnancy.
What is the preferred mode of screening for metastases of breast cancer diagnosed in pregnancy?
a. PET CT
b. MRI with gadolinium contrast
c. DEXA bone scan
d. USS Liver and CXR
e. CT with contrast
D - USS Liver and CXR
When breast cancer is confirmed, screening for metastases in pregnancy is only indicated if there is a high clinical suspicion and should comprise a chest x-ray and liver ultrasound. Gadolinium contrast MRI is not recommended unless a specific need exists – while data on its safety is limited, no adverse effects of gadolinium have been reported on the fetus. DEXA and CT are avoided owing to the effect of irradiation on the fetus. There is no role for tumours markers in pregnancy.
A patient who is diagnosed with breast cancer in the second trimester requires adjunctive chemotherapy. What is the preferred anti-emetic regimen in chemotherapy- induced sickness?
a. Metoclopramide monotherapy
b. Cyclizine and domperidone
c. Ondansetron and domperidone
d. Ondansetron and dexamethasone
e. Dexamethasone monotherapy
D - Ondansetron and Dexamethasone
Standard chemotherapy anti-emetic regimens should be used in pregnancy – 5HT3-serotonin receptor antagonists (ondansetron) and dexamethasone are most effective.
A woman is restarted on chemotherapy postnatally following a diagnosis of breast cancer in the third trimester. What is the best advice to give mothers on chemotherapy who wish to breastfeed?
a. Breast feeding is safe on chemotherapy – no precautions required
b. Avoid feeding for 24 hours after chemo
c. Avoid feeding for 36 hours after chemo
d. Express and discard 20ml of milk after chemo
e. Avoid breastfeeding entirely while on chemo
E - Avoid breastfeeding entirely while on chemo
Breastfeeding while on chemotherapy is not advised as the drugs cross into milk and may cause neonatal leucopoenia. An interval of 14 days after the last chemotherapy session is advised prior to commencing feeding to enable drug clearance from milk.
In planning elective birth in women on chemotherapy for breast cancer, ideally what interval should have elapsed since the last chemo session prior to delivery?
a. 24-48 hours
b. 6-7 days
c. 1-2 weeks
d. 2-3 weeks
e. >4 weeks
D - 2-3 weeks
Most women affected by breast cancer in pregnancy should deliver at term and aim for normal vaginal delivery. Where possible, birth should be deferred until 2-3 weeks from the last chemotherapy session to allow bone marrow recovery and minimise problems of neutropenia.
You see a 39 year old nulliparous patient in a pre-conceptual counselling clinic with a history of oestrogen-sensitive breast cancer on long term tamoxifen treatment who wishes to discuss her future fertility plans. She has been on tamoxifen for 2 years since initial diagnosis. How long are such patients generally advised to continue on tamoxifen?
a. 3 years
b. 5 years
c. 7 years
d. 10 years
e. Lifelong
B - 5 years
Women with estrogen-receptor positive breast tumours should be advised that tamoxifen treatment is recommended for 5 years. There is a general consensus that women should defer pregnancy for a minimum of 2 years after breast cancer, though this must be weighed against the risk of infertility with the passage of time in certain women. Liaison with the patient’s oncologist and consideration of the specifics of her cancer can be useful in guiding individualised management recommendations.
You see a 39 year old nulliparous patient in a pre-conceptual counselling clinic with a history of oestrogen-sensitive breast cancer on long term tamoxifen treatment who wishes to discuss her future fertility plans. She is anxious however declining rates of fertility with increasing maternal age and states that she is willing to ‘take the risk’ associated with early cessation in tamoxifen therapy to try for a baby. How long would you suggest waiting after stopping tamoxifen before attempting to conceive?
a. No wait necessary
b. 3 months
c. 6 months
d. 9 months
e. 12 months
B - 3 months
Tamoxifen has a relatively long half-life (5-7 days on average – for most drugs half-life is a matter of hours). For this reason, postponing pregnancy for a minimum of 3 months after stopping tamoxifen is advised.
A patient is seen in the antenatal clinic at booking in her first pregnancy. Six years earlier she was diagnosed with breast cancer and was managed with a combination of surgery and doxorubicin chemotherapy. What investigation should be performed routinely in pregnancy in such patients?
a. Spirometry
b. 24 hour ECG
c. Mammography
d. USS liver
e. Echocardiography
E - Echocardiography
There is a dose dependent association between anthracycline chemotherapy agents (doxorubicin) and left-ventricular dysfunction which may be exacerbated by pregnancy. In severe cases, this can even lead to cardiomyopathy. As such, all patients previously treated with anthracyclines should undergo an echocardiography to assess LV function in pregnancy
You review a patient on the post-natal ward with a history of oestrogen sensitive breast cancer, treated by unilateral mastectomy, who wishes to discuss her options for infant feeding. She has been advised by her oncologist to restart her pre-pregnancy tamoxifen following delivery. She would like to feed from the unaffected breast if this was possible. What advice do you give her?
a. Breastfeeding not advised in patients with previous breast ca.
b. Breastfeeding from unaffected breast safe; tamoxifen safe while breastfeeding
c. Breastfeeding from unaffected breast safe; avoid tamoxifen while breastfeeding
d. Breastfeeding from unaffected breast safe; tamoxifen safe though measure levels
e. Breastfeeding from unaffected breast safe, limit dose of tamoxifen to 20mg on alternate days
C - Breastfeeding from unaffected breast safe; avoid tamoxifen while breastfeeding
There is no evidence to suggest breastfeeding increases recurrence risk of breast cancer. While surgery in itself may not inhibit lactation in the affected breast, radiation causes fibrosis which may well do – feeding from the contralateral, unaffected breast is usually possible and safe however. It is unknown whether or not tamoxifen is transmitted in breast milk, thus feeding on tamoxifen is not recommended.
What is the normal daily dose of tamoxifen in women with previously treated oestrogen-sensitive breast cancer?
a. 5mg
b. 10mg
c. 20mg
d. 40mg
e. 100mg
C - 20mg
The standard dose for tamoxifen in women with previous breast cancer is 20mg OD. This is the same dose as when used for most other indications.
A patient who is currently 28 weeks into her first pregnancy is referred to the breast clinic after she notices a lump in her right breast. What is the preferred first line investigation for making a diagnosis in pregnancy?
a. USS
b. Gadolinium-enhanced MRI
c. Mammography with fetal shielding
d. Fine needle aspiration biopsy for cytology
e. CT with contrast
A - USS
Ultrasound is the first line imaging modality in women with suspected breast cancer in pregnancy. If cancer is confirmed, mammography with fetal shielding may be necessary to assess the extent of disease and involvement of the contralateral breast.
What percentage of pregnancies in the UK are complicated by obstetric cholestasis?
a. 0.1%
b. 0.7%
c. 2.5%
d. 3.5%
e. 5%
B - 0.7%
In British obstetric practice, 0.7% of pregnancies (roughly 1 in 140) are affected by obstetric cholestasis though the condition has a varied prevalence amongst ethnic groups – rates in Indian/Pakistani women are approximately twice that of British Caucasians, while rates of 2.4% are seen in Chilean women and up to 5% in Auricanian-Indians of South America.
A patient is seen in the ANC complaining of intense itching of the palms and soles which is worse at night. Blood is collected for LFTs and Bile acids which both fall within normal pregnancy ranges. How often should such testing be repeated assuming there is no improvement in symptoms with conservative measures?
a. 1-2 weekly
b. 3 weekly
c. Monthly
d. No sooner than 8 weeks from initial testing
e. No further testing necessary
A - 1-2 weekly
Pruritus is a common symptom in pregnancy affecting up to 23%. Based on a prevalence of ~0.7% for obstetric cholestasis, this would suggest that only around 1 in 30 women with pruritus could be expected to have OC. Some women may have pruritus of OC for some time (days or weeks) prior to the onset of derangement in their liver function tests. Women with persistent pruritus despite initial normal liver function should have their LFTS repeated every 1-2 weeks.
The majority of women with itching in pregnancy do not have obstetric cholestasis. Approximately what percentage of pregnancy women report itching?
a. 80%
b. 65%
c. 40%
d. 25%
e. 10%
D - 25%
23% of women are thought to report itching at some point in pregnancy, only ~3% of whom have OC.
How often following a diagnosis of obstetric cholestasis should pregnant women have their liver function checked?
a. Fortnightly
b. Monthly
c. Weekly
d. Twice weekly
e. Alternate days
C - Weekly
Following a diagnosis of OC, women should have their LFTs measured weekly until delivery along with a general review, urine and BP measurement. The rise in transaminases may range from just above normal to several hundreds. A rapid rise should prompt consideration of alterative diagnoses as – while such a pattern may occasionally be seen in OC – it is not typical. Similarly if LFTs return to normal antenatally, OC is unlikely to be the root cause.
What is the minimum period of time which should elapse prior to liver function being checked following delivery in women with obstetric cholestasis?
a. 7 days
b. 10 days
c. 2 weeks
d. 6 weeks
e. 12 weeks
B - 10 days
Postnatally, liver function testing in women with obstetric cholestasis should be deferred for at least 10 days - postnatal resolution is essential to confirm the diagnosis. Even in normal pregnancy, a transient rise in LFTs may be seen in the first 10 days. In OC pregnancies LFTs should ideally be performed beyond this time.
Which of the following is not known to be increased in mothers with Obstetric Cholestasis?
a. PPH
b. Caesarean delivery
c. Meconium passage
d. Prematurity
e. IUGR
E - IUGR
There appears to be a small increased risk of both PPH and caesarean section in women with obstetric cholestasis though both may be multifactorial. The risk of stillbirth has yet to be fully determined but any increased risk, if present, if likely to be small. Premature birth is increased in OC pregnancies though a good deal of this is thought to be iatrogenic and the spontaneous preterm rate raised only minimally. There is a well described increased incidence of meconium passage. There is no known association between obstetric cholestasis and fetal growth restriction.
There is debate concerning the optimum timing of delivery in pregnancies affected by obstetric cholestasis with theoretically increased risks of perinatal morbidity balanced against those of early intervention. What percentage of babies delivered by El. CS at 37/40 will require admission to SCBU?
a. 1-2%
b. 4-6%
c. 7-11%
d. 12-15%
e. 18-20%
C - 7-11%
There is a widely adopted practice in obstetric cholestasis of offering elective delivery at 37 weeks though this is not evidence based and as such the potential consequences of iatrogenic early delivery must be considered – the risk of admission to SCBU with elective caesarean is 7-11% at 37/40; 6% at 38/40 and falls to 1.5% at 39/40.
What percentage of infants delivered by El. CS at 38 and 39 weeks will require admission to SCBU respectively?
38/40 39/40
a. 6% 1.5%
b. 3% 0.5%
c. 10% 2.5%
d. 12% 4%
e. 15% 3%
A - 6% at 38/40; 1.5% at 39/40
There is a widely adopted practice in obstetric cholestasis of offering elective delivery at 37 weeks though this is not evidence based and as such the potential consequences of iatrogenic early delivery must be considered – the risk of admission to SCBU with elective caesarean is 7-11% at 37/40; 6% at 38/40 and falls to 1.5% at 39/40.
Which of the following is known to improve neonatal outcomes in pregnancies affected by OC?
a. UCDA
b. Chlorphenamine
c. Cholestyramine
d. A-adenosyl Methionine
e. None of the above
E - None of the above
As it stands, no known drug therapy has been proven to improve fetal nor neonatal outcomes in mothers affected by OC in pregnancy. As such, any proposed therapy should be discussed with this in mind. Ursodeoxycholic acid has been shown to improve pruritus and LFTs though robust data on protection against stillbirth or indeed its safety is lacking.
Which coagulation screen abnormality should prompt use of maternal Vitamin K antenatally?
a. Prolonged PT
b. Prolonged APTT
c. Low platelets
d. Low fibrinogen
e. Reduced APTT
A - Prolned PT
Women with OC should have an informed discussion regarding Vitamin K. Where prothrombin time is prolonged, Vitamin K given at a daily dose of 5-10mg is advised though even where PT is normal there may be a role for its use, providing mothers are counselled regarding the small theoretical risk. Women with OC may be vitamin K deficient as – being a fat soluble vitamin depending on bile for its absorption – uptake from the GI tract can be reduced. There are historical fears regarding a possible risk of haemolytic anaemia (and thus kernicterus and hyperbilirubinaemia) in infants exposed through maternal use. Vitamin K is required for the synthesis of several important clotting factors including II, VII, IX and X thus deficiency carries potential severe consequences. Infants should be offered postnatal Vitamin K in the usual way at birth regardless of maternal use.
What daily dose of Vitamin K (menadiol sodium phosphate) is recommended for at risk mothers in the antenatal period?
a. 5-10mg orally
b. 20-40mg orally
c. 50-100mg orally
d. 5-10micrograms IM
e. 50-100mg IM
A - 5-10mg orally
Women with OC should have an informed discussion regarding Vitamin K. Where prothrombin time is prolonged, Vitamin K given at a daily dose of 5-10mg is advised though even where PT is normal there may be a role for its use, providing mothers are counselled regarding the small theoretical risk. Women with OC may be vitamin K deficient as – being a fat soluble vitamin depending on bile for its absorption – uptake from the GI tract can be reduced. There are historical fears regarding a possible risk of haemolytic anaemia (and thus kernicterus and hyperbilirubinaemia) in infants exposed through maternal use. Vitamin K is required for the synthesis of several important clotting factors including II, VII, IX and X thus deficiency carries potential severe consequences. Infants should be offered postnatal Vitamin K in the usual way at birth regardless of maternal use.
What is the recurrence rate of obstetric cholestasis in future pregnancies?
a. Up to 20%
b. Up to 40%
c. Up to 70%
d. Up to 90%
e. Up to 95%
D - Up to 90%
Women with obstetric cholestasis should be reassured that there are no long term sequelae for mothers and babies though a rather considerable recurrence rate ranging from 45% to as high as 90%.
What contraceptive preparation should generally be avoided in mothers affected by obstetric cholestasis in pregnancy?
a. Injection
b. Combined Pill
c. Implant
d. Levonorgestrel IUS
e. Progesterone-only Pill
B - Combined pill
The RCOG guideline suggests women with a history of OC avoid estrogen-containing contraceptives postnatally. The FSRH guidelines list a history of pregnancy–related cholestasis as a UKMEC 2 for the combined pill, advising that it may increase the risk of cholestasis associated with use of the pill itself (a history of non-obstetric cholestasis is UKMEC 3 for CHC)
Amongst women from which continent is the risk of obstetric cholestasis highest?
a. Europe
b. Oceania
c. Africa
d. Asia
e. South America
E - South America
Obstetric cholestasis has a varied prevalence amongst ethnic groups – rates in Indian/Pakistani women are approximately twice that of British Caucasians, while rates of 2.4% are seen in Chilean women and up to 5% in Auricanian-Indians of South America.
What is the most common strain of malarial infection seen in the UK?
a. Falciparum
b. Vivax
c. Ovale
d. Malariae
e. Knowlesi
A - Falciparum
Falciparum malaria is both the most common strain of the disease seen in UK practice (>75% of cases – mostly from West Africa) as well as that which causes the vast majority of malaria deaths worldwide. In travellers returning from the Indian subcontinent, Vivax is more likely and causes a relapsing type.
What strain of malarial infection is responsible for most deaths worldwide?
a. Falciparum
b. Vivax
c. Ovale
d. Malariae
e. Knowlesi
A - Falciparum
Falciparum malaria is both the most common strain of the disease seen in UK practice (>75% of cases – mostly from West Africa) as well as that which causes the vast majority of malaria deaths worldwide. In travellers returning from the Indian subcontinent, Vivax is more likely and causes a relapsing type.
What is the most common strain of malarial infection seen in returning travellers from the Indian subcontinent to the UK?
a. Falciparum
b. Vivax
c. Ovale
d. Malariae
e. Knowlesi
B - Vivax
Falciparum malaria is both the most common strain of the disease seen in UK practice (>75% of cases – mostly from West Africa) as well as that which causes the vast majority of malaria deaths worldwide. In travellers returning from the Indian subcontinent, Vivax is more likely and causes a relapsing type.
In endemic areas, how much more likely are pregnant women to contract and die from malarial infection compared with non-pregnant women?
a. Equivalent risk to non-pregnant population
b. 2x
c. 3x
d. 5x
e. 10x
B - 2x
Pregnant women in malaria-endemic areas are twice as likely to be bitten, twice as likely to contract and twice as likely to die from malaria than their non-pregnant counterparts. The clinical manifestations of the disease in pregnancy is largely based on ‘premunition’ – the degree of naturally acquired host immunity to the condition.
You see a patient in the antenatal clinic who explains that she is planning a trip to Tanzania to visit family for one month. She wishes to discuss anti-malarial prophylaxis. What is the risk of transmission associated with a one-month stay in Sub-Saharan African without chemoprophylaxis?
a. 1:5
b. 1:10
c. 1:50
d. 1:100
e. 1:500
C - 1 in 50
The uptake of chemoprophylaxis amongst women residing in the UK who later present with malaria is low. The risk of transmission is generally quoted for a one-month stay without chemoprophylaxis and varies enormously from one area to another – highest in endemic parts of Oceania and lowest in America and the Caribbean:
Oceania (Papua New Guinea, Solomon Islands and Vanuatu) 1 in 20 Sub-Saharan Africa 1 in 50 Indian Subcontinent and SE Asia 1 in 500 South America 1 in 2500 Central America/Caribbean 1 in 10,000
You see a patient in the antenatal clinic who explains that she is planning a trip to India to visit family for one month. She wishes to discuss anti-malarial prophylaxis. What is the risk of transmission associated with a one-month stay in the Indian subcontinent without chemoprophylaxis?
a. 1:5
b. 1:10
c. 1:50
d. 1:100
e. 1:500
E - 1 in 500
The uptake of chemoprophylaxis amongst women residing in the UK who later present with malaria is low. The risk of transmission is generally quoted for a one-month stay without chemoprophylaxis and varies enormously from one area to another – highest in endemic parts of Oceania and lowest in America and the Caribbean:
Oceania (Papua New Guinea, Solomon Islands and Vanuatu) 1 in 20 Sub-Saharan Africa 1 in 50 Indian Subcontinent and SE Asia 1 in 500 South America 1 in 2500 Central America/Caribbean 1 in 10,000
A patient is planning a trip to Ghana for a funeral of a close family member during the third trimester of her second pregnancy. Despite awareness of malarial risks, she is unwilling to cancel the trip. Which drug would you recommend for chemoprophylaxis?
a. Chloraquine
b. Mefloquine
c. Atovaquone
d. Artesunate
e. Proguanil
B - Mefloquine
Mefloquine, at a dose of 5mg/kg once weekly, is the recommended drug of choice for malarial chemoprophylaxis in the second and third trimesters. The majority of observational and clinical data suggests the drug is not associated with an increased risk of stillbirth nor congenital malformation at this dose. Available evidence does not support an association with embryotoxicity in the first trimester and thus use may be justified at this time in areas at high risk of falciparum infection. Contraindications to mefloquine include: current or previous depression; neuropsychiatric disorders, epilepsy or hypersensitivity to quinine. The alternative in such patients would be ‘Malarone’ – a combination of atovaquone and proguanil however there is insufficient data on its safety in pregnancy and cases should always be discussed with a malarial specialist prior to prescription in pregnancy.
What is the recommended regimen of emergency ‘standby’ treatment of suspected malaria in patients from the UK?
a. Artesunate
b. Quinine and Clindamycin
c. Quinine
d. Artesunate and Clindamycin
e. Chloraquine and Clindamycin
B - Quinine and clindamycin
The only recommended ‘standby’ treatment for pregnant women from the UK is quinine (600mg and clindamycin 450mg, both TDS, both for 7 days). This should be started in the event of a flu-like illness and temperature >38C in an area with no immediate access to medical care. If there is vomiting within 30 minutes, repeat the full dose; if within 30-60 minutes, repeat a half dose. Mefloquine should then be commenced 1 week after the last treatment dose.
A primigravida at 32/40 develops fever of 39.5C and a flu-like illness while visiting family in Nigeria. Following medical review she is commenced on emergency standby treatment though vomits the first dose 45 minutes after ingestion and is unsure whether or not to repeat the dose. What would you advise in such a scenario?
a. No repeat dose required
b. Repeat half dose and continue next dose at usual time
c. Repeat full dose and continue next dose at usual time
d. Repeat full dose and delay next dose by 12 hours
e. Repeat full dose and omit next dose
B - Repeat half dose and continue next dose at the usual time
The only recommended ‘standby’ treatment for pregnant women from the UK is quinine (600mg and clindamycin 450mg, both TDS, both for 7 days). This should be started in the event of a flu-like illness and temperature >38C in an area with no immediate access to medical care. If there is vomiting within 30 minutes, repeat the full dose; if within 30-60 minutes, repeat a half dose. Mefloquine should then be commenced 1 week after the last treatment dose.
What is the mortality rate associated with malaria infection in the UK?
a. 0.5-1%
b. 2-3%
c. 4-5%
d. 9-10%
e. >10%
A - 0.5-1%
There are approximately 1500 cases of malaria diagnosed in the UK each year with 5-15 deaths (equivalent to a 0.5-1% mortality rate).
- What is the ‘hallmark’ complication of falciparum malaria infection in pregnancy, not seen in vivax, ovale or malariae?
a. IUGR
b. Neonatal jaundice
c. Brachycephaly
d. Placental parasitaemia
e. Thrombocytopenia
D - Placental parasitaemia
The hallmark of falciparum malarial infection in pregnancy is the sequestration of parasites in the placenta which can evade host defence mechanisms such as splenic processing and filtration. This is not known to occur in the ‘benign’ malarias. Parasitaemia itself can lead to fetal growth restriction and low birthweight as well as maternal and fetal anaemia.
Malarial infection is generally confirmed by blood film. How many films are required to effectively exclude malaria in patient’s with suspected infection?
a. One
b. Two, one week apart
c. Two, 24 hours apart
d. Three, 24 hours apart
e. Four, 12 hours apart
D - Three, 24 hours apart
Malaria may be diagnosed both by microscopy and rapid-diagnostic tests. Microscopy – allowing both species identification and estimation of parasitaemia – is considered the gold standard. Rapid detection tests may miss low-parasitaemia which is more likely in pregnancy women. They are also relatively insensitive in Vivax malaria. In any event, a positive rapid detection test should always be followed by microscopy. In a febrile patient with suspected malaria, 3 negative blood smears 12-24 hours apart effectively rule out the diagnosis of malaria.
What is the mortality associated with severe malarial infection in pregnancy?
a. 5%
b. 10%
c. 25%
d. 33%
e. 50%
E - 50%
Mortality rates in severe pregnancy are high – up to 50% (compared with 15-20% in the non-pregnant population). Non-falciparum species are rarely fatal though caution should nonetheless be observed. Mortality in uncomplicated malaria is very low – 0.1%.
A primigravida, recently returned from a trip to visit family in Ghana is admitted with a 3 day history of fever, myalgia, vomiting and diarrhoea. Temperature on admission is elevated at 38C. On clinical examination you note her to be jaundiced and there is splenomegaly evident on abdominal palpation. A blood film confirms falciparum malarial infection with 3% parasitaemia. A full blood count reveals anaemia – Hb 76g/L – and thrombocytopenia – Platelets 45. What is first line treatment for severe falciparum malaria in pregnancy?
a. IV Quinine
b. IV Artesunate
c. Oral Clindamycin
d. Oral Chloraquine
e. Oral Mefloquine
B - IV Artesunate
In patients treated for severe falciparum malaria in pregnancy, what is the recommended ‘step-down’ treatment when well?
a. Oral chloraquine + oral quinine
b. Oral artesunate
c. Oral artesunate and oral clindamycin
d. Oral chloraquine
e. Oral clindamycin
C - Oral artesunate and oral clindamycin
Above what level of parasitaemia should patients be treated per the ‘severe’ malaria protocol irrespective of other clinical signs and/or symptoms?
a. 2%
b. 5%
c. 10%
d. 25%
e. 50%
A - 2%
Regardless of clinical presentation, signs or symptoms, patients with parasitaemia greater than 2% should be treated as ‘severe’ malaria.
A primigravida develops uncomplicated malaria during the second trimester and is commenced on Quinine therapy. What is the most common side effect of quinine therapy?
a. Hypoglycaemia
b. Hypocalcaemia
c. Hypomagnesaemia
d. Hyponatraemia
e. Hypokalaemia
A - Hypoglycaemia
The most common and important side effect of quinine therapy is hypoglycaemia, which is secondary to hyperinsulinaemia. While this is commonly asymptomatic, it may be associated with fetal bradycardia.
What is the most common cause of direct maternal death?
a. Haemorrhage
b. Eclampsia
c. Thromboembolism
d. Amniotic fluid embolism
e. Cardiac disease
C - Thromboembolism
Venous thromboembolism (1.39 per 100,000) and cardiac disease (2.39 per 100,000) were the most common direct and indirect causes of maternal death respectively in the most recent (2014-2016) MBBRACE report, and indeed this has been the case for some time.
What is the most common cause of death overall in pregnancy?
a. Haemorrhage
b. Cardiac disease
c. Thromboembolism
d. Suicide
e. Malignancy
B - Cardiac disease
Venous thromboembolism (1.39 per 100,000) and cardiac disease (2.39 per 100,000) were the most common direct and indirect causes of maternal death respectively in the most recent (2014-2016) MBBRACE report, and indeed this has been the case for some time.
What increase in total plasma volume occurs in pregnancy?
a. 10%
b. 25%
c. 33%
d. 50%
e. 75%
D - 50%
Plasma volume increases by up to 50% in pregnancy, resulting in both dilutional anaemia and a reduced oxygen carrying capacity of the blood. Pulse increases by 15-20 beats per minute though together these changes increase cardiac output by only 40%. Arterial blood pressure drops by 10-15mmHg
By how much (in beats/minute) does heart rate typically change in pregnancy?
a. Fall 5-10 bpm
b. Fall 15-20 bpm
c. No change
d. Rise 15-20 bpm
e. Rise 5-10 bpm
D - Rise 15-20 bpm
Plasma volume increases by up to 50% in pregnancy, resulting in both dilutional anaemia and a reduced oxygen carrying capacity of the blood. Pulse increases by 15-20 beats per minute though together these changes increase cardiac output by only 40%. Arterial blood pressure drops by 10-15mmHg
What proportion of cardiac output does the uterus receive at term?
a. 1/20
b. 1/10
c. 1/5
d. 1/4
e. 1/3
B - 1/10
The uterus receives 10% of total cardiac output at term.
- What is the optimum degree of left-lateral tilt to improve maternal resuscitation in pregnancy?
a. 9 degrees
b. 12 degrees
c. 15 degrees
d. 20 degrees
e. 25 degrees
C - 15 degrees
A left lateral tilt of 15 degrees on a firm surface will relieve aorto-caval compression in most pregnant women and still permit effective chest compressions.
How long after diagnosis of maternal cardiac arrest, should Perimortem caesarean section be undertaken if there is no return of spontaneous circulation?
a. Immediately
b. 2 minutes
c. 4 minutes
d. 5 minutes
e. 6 minutes
C - 4 minutes
If there is no response to correctly performed CPR within 4 minutes of a maternal collapse or if resuscitation is continued beyond this in women >20/40, delivery should be achieved within 5 minutes of the collapse in order to assist resuscitation. Delivery of the fetus/placenta reduces oxygen consumption, improves venous return and cardiac output, facilitates cardiac compressions and renders ventilation easier. Prior to 20/40 there is no proven benefit from delivery of the fetus.
In management of the acutely unwell septic patient in pregnancy, what is the target central venous pressure in patients who are NOT on mechanical ventilation?
a. 6mmHg
b. 8mmHg
c. 12mmHg
d. 15mmHg
e. 20mmHg
B - 8mmHg
In the event of severe hypotension despite initial fluid resuscitation, the aim should be to achieve a CVP >8mmHg with aggressive fluid replacement (or >12mmHg in women on mechanical ventilation).
A patient is admitted in pre-term labour and commenced on Magnesium Sulphate for fetal neuroprotection. Some hours later you are called to review as the midwives are concerned her breathing has become laboured and she is increasingly drowsy. You note the absence of deep tendon reflexes on examination and suspect magnesium toxicity. What is the treatment for magnesium toxicity?
a. 10 units of rapid acting insulin in 500ml of 10% dextrose
b. 20% Intralipid infusion
c. 200mcg Flumazenil
d. 150mg/kg N-acetylcysteine
e. 10ml 10% Calcium Gluconate
E 10ml 10% Calcium Gluconate
The antidote to magnesium sulphate is 10ml of 10% calcium gluconate given slow IV.
What is the recommended dose of 20% Intralipid Emulision in treatment of suspected local anaesthetic toxicity?
a. 1.5ml/kg loading; 0.5ml/kg/hour
b. 1.5ml/kg loading; 0.5ml/kg/minute
c. 1.5ml/kg loading; 0.25ml/kg/minute
d. 2.5ml/kg loading; 0.25ml/kg/minute
e. 2.5ml/kg loading; 0.25ml/kg/hour
C - 1.5ml/kg loading; 0.25ml/kg/minute
So-called ‘lipid-rescue’ is the treatment of choice for suspected local anaesthetic toxicity. This consists of an IV bolus of 20% Intralipid at a dose of 1.5ml/kg over 1 minute (can be repeated a further 2 times at five minute intervals) following by an infusion of 0.25ml/kg/min, increased to 0.5ml/kg/min after 5 minutes.
A patient in early labour is given Benzylpenicillin for intrapartum Group B Strep prophylaxis. Shortly after commencing the first dose, she develops stridor, facial oedema and is struggling to maintain her own airway. What is first line management in suspected anaphylaxis in pregnancy?
a. 200mg Hydrocortisone IV
b. 10mg Chlorphenamine IV
c. 250mcg adrenaline IV
d. 500mcg adrenaline IM
e. 250mcg adrenaline IM
D - 500mcg adrenaline IM
500 micrograms of IM adrenaline (0.5ml of 1:1000) is the definitive treatment for suspected anaphylaxis as described here. This can be repeated after 5 minutes if there is no effect. In experienced hands it may be given IV as a 50 microgram bolus (0.5ml of 1:10,000). Chlorphenamine 10mg and hydrocortisone 200mg (both IM or IV) form adjuvant treatment.
By how much does cardiac output change in pregnancy?
a. Increases 20%
b. Increases 40%
c. Increases 60%
d. Decreases 10%
e. Decreases 20%
B - Increases 40%
Plasma volume increases by up to 50% in pregnancy, resulting in both dilutional anaemia and a reduced oxygen carrying capacity of the blood. Pulse increases by 15-20 beats per minute though together these changes increase cardiac output by only 40%. Arterial blood pressure drops by 10-15mmHg.
A primigravida, originally from Nigeria is referred to the ANC for review as she is known to be have Sickle Cell Trait (HbSA). She asks what implications this may have on her pregnancy. Which of the following is increased in patients with Sickle Cell Trait in pregnancy?
a. Anaemia
b. IUGR
c. VTE
d. UTI
e. Arthralgia
D - UTI
Patients with sickle cell trait – one copy of HbS and one normal HbA – are asymptomatic. They require little, if any, additional attention in pregnancy from a maternal point of view. Interestingly the only complication noted is an increased incidence of microscopic haematuria and UTI.
How many babies are born each year in the UK with sickle cell disease?
a. <50
b. 100-500
c. 500-1000
d. 1000-5000
e. >5000
B - 100-500
Sickle cell disease is the most common inherited condition worldwide around 300,000 affected children born each year. There are thought to be around 12-15,000 people in the UK with sickle cell and around 100-200 pregnancies in affected women each year. 300 babies are born on average in the UK every year with the condition.
What is the average life expectancy of patients born in the UK nowadays with sickle cell disease?
a. Late teens
b. Mid-20s
c. Mid-40s
d. Mid-50s
e. No change in life expectancy
D - Mid-50s
SCD has previously been associated with a high early mortality rate though the majority of children born in the UK today with SCD live past reproductive age and average life expectancy is well into the mid-50s.
Patient’s with sickle cell disease are advised to undergo regular echocardiography. Where not performed in the previous year, an echo is advised pre-conceptually in such patients. What complication does an echo seek to exclude in such patients?
a. Iron overload
b. Pulmonary hypertension
c. Aortic stenosis
d. Infective endocarditis
e. Left ventricular hypertrophy
B - Pulmonary hypertension
Where opportunity for pre-conceptual screening arises, patients with SCD should undergo an echocardiogram to screen for pulmonary hypertension. Incidence of pulmonary hypertension is increased in patients with SCD and there is a significant association with increased mortality. A tricuspid jet velocity of >2.5m/second is associated with a high risk of PH. Where not performed in the last year, this should be done antenatally if possible.
What regimen of folic acid supplementation is advised in women with sickle cell disease both in and out of pregnancy?
Pregnant Non-pregnant
a. 400mcg OD No supplementation required
b. 5mg No supplementation required
c. 400mcg 400mcg
d. 5mg 400mcg
e. 5mg 1mg
E - 5mg in pregnancy; 1mg outwith
Women with SCD are advised to take 1mg folic acid every day outwith pregnancy owing to the increased risk of folate deficiency in haemolytic anaemia. In pregnancy, this should be increased to 5mg to guard against neural tube defects in the first trimester and protect against the increased demands for folate during the second and third.
A patient is seen in the pre-conceptual counselling clinic to discuss her sickle cell disease. She is currently taking hydroxycarbamide (hydroxyurea) to reduce the incidence of painful crises and wishes to know if it is safe to continue this as she plans a pregnancy. What advice do you give?
a. Stop at conception, may restart in 2nd trimester
b. Stop at conception, restart postnatally
c. Stop 6 months pre-conception, restart in 3rd trimester
d. Stop 3 months pre-conception, restart postnatally
e. No need to stop, may use throughout pregnancy
D - Stop 3 months pre-conceptually; restart postnatally
Hydroxyurea (hydroxycarbamide) is a drug known to decrease the incidence of painful crises and acute chest syndrome in patients with SCD. It is known however, to be teratogenic in animal studies – thus advice currently is that women on Hydroxyurea use effective contraception and stop the drug 3 month pre-conceptually. This said there are reports of women continuing through pregnancy on the drug without any adverse effects which may help in counselling women who become pregnant while taking – in such a setting, it should be stopped and detailed ultrasound performed by a fetal medicine specialist looking for abnormality, though is not an indication for TOP in isolation.
Aside from folic acid, what other medical treatment is recommended for all with sickle cell as a matter of routine in pregnancy?
a. Aspirin, Iron and LMWH
b. Aspirin, Iron and Antibiotics
c. Antibiotics and Iron
d. Antibiotics and aspirin
e. Antibiotics, Aspirin and LMWH
D - Antibiotics and aspirin
Patients with SCD are hypo-splenic and at an increased risk of infection, especially from encapsulated bacteria – N. Meningitidis; Strep. Pneumoniae and H. Influenzae. There is clear evidence of benefit to this end from penicillin antibiotic prophylaxis in children (though data is lacking on adults/pregnancy) and guidance suggests this should be given to all patients in and out of pregnancy. Penicillin is first line, erythromycin second if allergic. The flu, hepatitis B and meningococcal vaccines should also be up to date as well as pneumococcal ever 5 years. In addition, women with SCD should be considered for aspirin for PET prophylaxis at the usual dose (consider SCD a mild risk factor). Heparin should be given at prophylactic dose during any inpatient admissions.
Between what weeks of pregnancy can NSAIDs safely be used for pain relief?
a. 12 weeks onwards
b. 12-28 weeks
c. 28 weeks onwards
d. Safe throughout
e. Avoid altogether
B - 12-28 weeks
NSAIDs may be used as effective pain relief for women with a painful sickle cell crisis though are only suitable for use between 12 and 28 weeks of pregnancy.
In addition to routine dating and fetal anomaly scans, what additional scanning schedule is advocated in women with sickle cell disease?
a. Early viability and 4-weekly biometry from 24/40
b. Early viability and 4 weekly biometry from 28/40
c. Early viability and 3 weekly biometry from 28/40
d. One-off scan at 34/40
e. Serial biometry from 24/40
A - early viability and 4-weekly biometry from 24/40
In addition to routine scans, women with SCD should be offered an early viability scan at 7-9 weeks and serial fetal biometry on a 4-weekly basis from 24/40. A number of studies have pointed to an increased risk of fetal growth restriction and pre-eclampsia.
Routine antenatal transfusion is not recommended for all women with sickle cell disease, though certain conditions do typically necessitate transfusion. Which of the following situations is NOT in itself an indication for consideration of routine transfusion?
a. Painful crises
b. Acute chest syndrome
c. Twin pregnancy
d. Acute stroke
e. Hb <60
A - Painful crises
Routine prophylactic transfusion for women with SCD in pregnancy was a historic norm as it was associated with decreased perinatal morbidity and mortality compared with historic controls. It has since been argued however that the appreciable risks of transfusion (alloimmunisation [seen in up to 36%], reactions, iron overload, infection etc.) may outweigh this and as such, routine transfusion is no longer recommended. There are a few instances however in which transfusion IS considered best practice:
• Where Hb <6 or falls > 2 units from baseline
• Acute chest syndrome
• Acute stroke
• Twin pregnancy
• Women with previous serious medical, obstetric or fetal complications
• Women on a pre-pregnancy transfusion regimen for prevention of secondary stroke or severe complications – this should be continued through pregnancy
What proportion of women with sickle cell disease have alloimmunisation?
a. Up to 10%
b. Up to 20%
c. Up to 30%
d. Up to 40%
e. Up to 50%
D - Up to 40%
Routine prophylactic transfusion for women with SCD in pregnancy was a historic norm as it was associated with decreased perinatal morbidity and mortality compared with historic controls. It has since been argued however that the appreciable risks of transfusion (alloimmunisation [seen in up to 36%], reactions, iron overload, infection etc.) may outweigh this and as such, routine transfusion is no longer recommended. There are a few instances however in which transfusion IS considered best practice:
• Where Hb <6 or falls > 2 units from baseline
• Acute chest syndrome
• Acute stroke
• Twin pregnancy
• Women with previous serious medical, obstetric or fetal complications
• Women on a pre-pregnancy transfusion regimen for prevention of secondary stroke or severe complications – this should be continued through pregnancy
You meet a 20 year old primigravida in the ANC at booking. She was born in Uganda though has lived in the UK since age 12. She is known to suffer from sickle cell disease and wishes to know about how the pregnancy may impact upon her disease. What proportion of women with sickle cell disease will experience a painful crisis in pregnancy?
a. <5%
b. 10-20%
c. 25-50%
d. 50-75%
e. >80%
C - 25-50%
25-50% of patients with SCD will experience a painful sickling crises in pregnancy and is the most common cause of hospital admission in this cohort. Avoiding precipitants is highly advisable – excessive exercise, cold, dehydration and stress. Women who do not settle with simple analgesia, are febrile, have atypical pain or chest symptoms should be referred to hospital. Fluid intake should be encouraged with a target of 60ml/kg/24 hours (4.2L for a 70kg woman).
What fluid intake regimen should be the target in women with an acute sickle cell crisis in pregnancy?
a. 25ml/kg/24 hours
b. 10ml/kg/hour
c. 60ml/kg/24 hours
d. 33ml/kg/24 hours
e. 2.5ml/kg/hour
C - 60ml/kg/24 hours
25-50% of patients with SCD will experience a painful sickling crises in pregnancy and is the most common cause of hospital admission in this cohort. Avoiding precipitants is highly advisable – excessive exercise, cold, dehydration and stress. Women who do not settle with simple analgesia, are febrile, have atypical pain or chest symptoms should be referred to hospital. Fluid intake should be encouraged with a target of 60ml/kg/24 hours (4.2L for a 70kg woman).
Acute chest syndrome, a complication of sickle cell disease seen in up 20% of women during pregnancy, closely resembles which other cardio-respiratory condition such that both should typically be treated simultaneously until a diagnosis can be accurately made?
a. Myocarditis
b. Pulmonary oedema/right heart failure
c. Myocardial infarction
d. Interstitial pneumonitis
e. Pneumonia
E - Pneumonia
Acute chest syndrome is the second most common complication of SCD seen in pregnant women, occurring in up to 20% of pregnancies. This condition is characterised by respiratory symptoms – tachypnoea, chest pain, cough, SOB – which may mimic pneumonia. To further confuse matters, the presence of a new infiltrate may be seen on CXR. As such, it is advised that patients be treated for both and given antibiotics in addition to oxygen and top-up blood transfusion. If there is any suspicion of PE – treatment dose heparin until excluded is appropriate.
A Para 1 with sickle cell disease and history of emergency caesarean section for failure to progress in her first pregnancy, comes to the ANC at 36 weeks following a growth scan, wishing to discuss options for delivery. The fetus is normally grown and she is very keen to avoid a caesarean section if possible. What management plan for delivery would you recommend?
a. Await spontaneous onset of labour
b. IOL at 37/40
c. IOL at 38/40
d. LSCS at 39/40
e. LSCS at 38/40
C - IOL at 38/40
SCD is not an indication in itself for caesarean delivery, nor a contraindication in itself to attempting VBAC, though the recommendation is that patients be delivered electively from 38 weeks either via LSCS or IOL. Blood should be cross-matched for delivery in the presence of atypical antibodies – otherwise a group and save will suffice.
A primigravida presents in spontaneous labour at 37/40. She is known to have sickle cell disease. Labour is progressing well though she is struggling increasingly with the pain of contractions and is requesting pain relief. Which of the following analgesic options is NOT an appropriate option for patients with sickle cell disease?
a. Epidural
b. Entonox
c. Pethidine
d. Oramorph
e. Paracetamol
C - Pethidine
Patients with SCD can have almost all means of analgesia available to other women in labour with the exception of pethidine owing to its known association with seizures.
A patient with sickle cell disease is admitted for induction of labour at 37+5/40 following an otherwise uncomplicated pregnancy. Several hours after commencing oxytocin, her oxygen saturations drop abruptly to 92%. What is the most appropriate immediate management?
a. Stop the oxytocin infusion
b. Administer oxygen and check arterial blood gas
c. Administer oxygen and IV antibiotics
d. Cat. 1 caesarean section
e. Cat. 2 caesarean section
B - Administer oxygen and check ABG
The demand for oxygen in sickle cell disease is increased during the intrapartum period and use of pulse oximetry to detect hypoxia in the mother should be employed during labour. Arterial blood gas should be performed and oxygen therapy commenced where oxygen saturations fall to 94% or less.
Which of the following is NOT a common finding in patients with beta-thalassaemia?
a. Cardiac failure
b. Diabetes mellitus
c. Alloimmunisation
d. Respiratory failure
e. Subfertility
D - Respiratory Failure
The basic defect in thalassaemia is reduced globin chain synthesis meaning resultant red cells have inadequate haemoglobin content. Pathophysiology is characterised by extravascular haemolysis due to release into the peripheral circulation of damaged red cells and erythroid precursors due to ineffective erythropoiesis. As a result patients require multiple transfusions per year which may lead to iron overload and resultant organ damage. The condition affects multiple organ systems including the pancreas (diabetes common secondary to insulin resistance and iron-induced islet cell deficiency); thyroid; heart (iron related cardiomyopathy); liver (cirrhosis) and bone (osteoporosis). Patients with thalassaemia tend to suffer from subfertility also. There is no association with lung disease.
A patient with known beta-thalassaemia major and insulin-dependent diabetes attends the pre-conception clinic to discuss implications of her disease on the pregnancy she is planning with her husband who does not have thalassaemia. Which of the following investigations is NOT indicated routinely in patients with beta-thalassaemia prior to embarking on pregnancy?
a. Lung function testing
b. DEXA scan
c. Cardiac MRI
d. Echocardiography
e. Serum frustosamine levels
A - Lung function testing
In view of the multiple co-morbidities which may be found in thalassaemia, pre-conceptual planning and counselling is of the utmost importance. It is recommended that prior to embarking upon a pregnancy, patients undergo screening for end-organ damage including both echocardiography and cardiac MRI as well as bone density scanning, diabetes testing (using serum fructosamine concentrations) and thyroid function testing.
What is the target pre-transfusion Hb in patients with thalassaemia major in pregnancy?
a. 70g/L
b. 85g/L
c. 90g/L
d. 100g/L
e. 110g/L
D - 100g/L
The majority of women with thalassaemia major are already established on a transfusion regimen pre-pregnancy which may continue. Patients with thalassaemia require transfusion on a regular basis and should aim for a pre-transfusion Hb of 100g/L. Initially 2-3 units should be transfused with an additional top up the following week until Hb reaches 120g/L. Hb should be re-checked 2 weeks later and a further 2 units transfused if <100g/L.
A 33 year old primigravida attends the ANC at 12/40 on account of her thalassaemia major. All necessary pre-pregnancy investigations were arranged and returned satisfactory results though platelets were elevated at 678 on a recent full blood count. She wishes to know if there is any medication in additional to her existing 5mg folic acid, which she should be taking during pregnancy. What do you advise?
a. Treatment dose LMWH and 75mg aspirin
b. Prophylactic dose LMWH and 75mg aspirin
c. 75mg aspirin alone
d. Prophylactic dose LMWH alone
e. Treatment dose LMWH and 150mg aspirin
C - 75mg aspirin alone
Women with thalassaemia who have either previously undergone a splenectomy or have a current platelet count >600, should be commenced on low-dose aspirin (75mg OD). Women with both risk factors should commence both aspirin as well as low-molecular weight heparin.
A 21 year old Para 1 attends the ANC at 12/40 on account of her thalassaemia major and history of splenectomy. All necessary pre-pregnancy investigations were arranged and returned satisfactory results. She wishes to know if there is any medication in additional to her existing 5mg folic acid, which she should be taking during pregnancy. What do you advise?
a. Treatment dose LMWH and 75mg aspirin
b. Prophylactic dose LMWH and 75mg aspirin
c. 75mg aspirin alone
d. Prophylactic dose LMWH alone
e. Treatment dose LMWH and 150mg aspirin
C - 75mg aspirin alone
Women with thalassaemia who have either previously undergone a splenectomy or have a current platelet count >600, should be commenced on low-dose aspirin (75mg OD). Women with both risk factors should commence both aspirin as well as low-molecular weight heparin.
A 23 year old primigravida attends the ANC at 13/40 on account of her thalassaemia major and previous splenectomy. All necessary pre-pregnancy investigations were arranged and returned satisfactory results though platelets were elevated at 610 on a recent full blood count. She wishes to know if there is any medication in additional to her existing 5mg folic acid, which she should be taking during pregnancy. What do you advise?
a. Treatment dose LMWH and 75mg aspirin
b. Prophylactic dose LMWH and 75mg aspirin
c. 75mg aspirin alone
d. Prophylactic dose LMWH alone
e. Treatment dose LMWH and 150mg aspirin
B - Prophylactic dose LMWH and 75mg aspirin
Women with thalassaemia who have either previously undergone a splenectomy or have a current platelet count >600, should be commenced on low-dose aspirin (75mg OD). Women with both risk factors should commence both aspirin as well as low-molecular weight heparin.
A primigravida with known thalassaemia major is admitted to delivery suit in early labour at 38/40. She is hoping for a vaginal delivery. A full blood count taken upon admission has returned the following results:
WCC 13.4
Hb 98
Plat 538
Based on these results, what management do you advise?
a. Delivery by LSCS Cat 2, administer 2 grams desferrioxamine
b. Delivery by LSCS Cat 2, administer 2 grams desferrioxamine and transfuse 2 units RBCs
c. Vaginal delivery, transfuse 2 units RBCs
d. Vaginal delivery, administer 2 grams desferrioxamine
e. Vaginal delivery, administer 2 grams desferrioxamine, cross-match 2 units RBCs
E - Vaginal delivery, administer 2 grams desferrioxamine, cross-match 2 units RBCs
Thalassaemia is not in itself an indication for delivery by caesarean section though patients should be adequately prepared for labour. High levels of circulating toxic non-transferrin bound iron may pre-dispose to cardiac dysrhythmias during labour. As such, chelation with desferrioxamine 2g over 24 hours should be given for the duration of labour. Patients in whom Hb is found to be <100g/L upon admission to labour ward should have 2 units of RBCs cross-matched.
Amongst patients with beta-thalassaemia major, who are transfusion dependent but not on a chelating agent, what is the risk associated with high serum levels of non-transferrin bound iron in labour?
a. VTE
b. Respiratory failure
c. Cardiac Arrhythmia
d. Hepatic failure
e. Impaired blood glucose control
C - Cardiac arrhythmias
Thalassaemia is not in itself an indication for delivery by caesarean section though patients should be adequately prepared for labour. High levels of circulating toxic non-transferrin bound iron may pre-dispose to cardiac dysrhythmias during labour. As such, chelation with desferrioxamine 2g over 24 hours should be given for the duration of labour. Patients in whom Hb is found to be <100g/L upon admission to labour ward should have 2 units of RBCs cross-matched.
How many transfusions per year distinguishes beta-thalassaemia major from intermedia?
a. 3
b. 7
c. 10
d. 15
e. 18
B - 7
Thalassaemia major describes women who require in excess of 7 transfusions per year, while intermedia refers to women requiring less than 7. Women who are heterozygotes - i.e. minor – do not require transfusion though may suffer from some degree of mild-moderate anaemia.
Measurement of HbA1C in women with thalassaemia is unreliable owing to the dilutional effect of multiple transfusions and fructosamine should be used instead. What level is advised in women with established DM prior to falling pregnant?
a. <50
b. <100
c. <200
d. <300
e. <500
D - <300
HbA1C is unreliable in women with thalassaemia as repeated transfusions dilute levels resulting in underestimation. Serum fructosamine is preferred for monitoring. The pre-pregnancy target is <300nmol/L for 3 months which is equivalent to an HbA1C of <43.
What is the recommended target weight of liver iron pre-pregnancy?
a. <5mg/g
b. <7mg/g
c. <11mg/g
d. <23mg/g
e. <35mg/g
B - <7mg/g
Women embarking on pregnancy should be assessed for liver iron concentration – ideally liver iron should be <7mg/g (dry weight).
What proportion of women with beta-thalassaemia are affected by alloimmunity?
a. 1/10
b. 1/8
c. 1/6
d. 1/2
e. 3/4
C - 1/6
16.5% (or 1/6) of women with thalassaemia have some degree of alloimmunisation pre-pregnancy owing to recurrent transfusions.
A women known to be a carrier for beta-thalassaemia presents for counselling pre-conceptually. Her partner has been tested and does not carry the gene for beta-thalassaemia itself, though does appear to carry another haemoglobin variant. Which of the following, when combined with beta-thalassaemia does NOT risk a serious haemoglobinopathy in the offspring?
a. HbS
b. Hb Lepore
c. HbO Arab
d. Hb Constant Spring
e. HbC
E - HbC
Other haemoglobinopathies in the partner of a women affected by beta-thalassaemia may carry significant implications for her offspring as follows:
Risk of serious haemoglobinopathy: HbS HbE Delat-beta thalassaemia Hb Lepore HbO Arab Hb Constant Spring
Risk of mild-moderate disorder only:
HbC
Other variant Hb
What is the recommended pathway for antenatal scanning in women with beta-thalassaemia?
a. Routine pathway
b. Dating, Anomaly, Serial from 24/40
c. Viability, Dating, Anomaly, Serial from 28/40
d. Viability, Dating, Anomaly, Serial from 24/40
e. Viability, Dating, Anomaly, Serial only if indicated
D - Viability, Dating, Anomaly, Serial from 24/40
In terms of the antenatal ultrasound schedule for women with thalassaemia, they should undergo an early viability scan at 7-9 weeks, routine dating and anomaly followed by serial growth scanning from 24/40 on a 4-weekly basis. The risk of early pregnancy loss is higher in such women and severe maternal anaemia which often co-exists predisposes to fetal growth restriction.
By how much is the maternal death rate increased in women with epilepsy compared to non-epileptic women in pregnancy?
a. 2 fold
b. 5 fold
c. 10 fold
d. 15 fold
e. 20 fold
C - 10 fold
Epilepsy is amongst the most common neurological conditions in pregnancy with a prevalence of 1 in 100-200. The risk of death in women with epilepsy (WWE) is increased ten-fold compared with women without the condition.
How long must adult women remain seizure free and off anti-epileptic medication before they can be considered to no longer have epilepsy (and thus be managed as low risk in pregnancy)?
a. 5 years (3 off medication)
b. 5 years (4 off medication)
c. 10 years (5 off medication)
d. 10 years (8 off medication)
e. 15 years (10 off medication)
C - 10 years (5 off medication)
Women who have remained seizure free for at least 10 years – with the last 5 of those off anti-epileptic drugs – may be considered to no longer have epilepsy.
What seizure type is associated with the highest risk of sudden unexplained death in epileptics in pregnancy (SUDEP)?
a. Absence seizures
b. Focal seizures
c. Complex partial
d. Myclonic
e. Tonic-clonic
E - Tonic clonic
Unsurprisingly of all seizure sub-types, tonic-clonic seizures carry the highest risk of sudden, unexplained death in epilepsy in pregnancy (SUDEP). SUDEP is defined as ‘sudden, unexpected, witness or un-witnessed non-traumatic and non-drowning death in patients with epilepsy with or without evidence of a seizure and excluding status epilepticus in which post-mortem does not reveal an anatomic or toxicological cause of death’
A patient with no significant past medical history presents at 32/40 following a tonic clonic seizure at home, witness by her husband. On arrival she is drowsy and reports feeling ‘just awful’ when she suddenly begins to fit again. What pharmacological management do you initiate first line?
a. Diazepam
b. Lamotrigine
c. Leviteracetam
d. Magnesium Sulphate
e. Phenytoin
D - Magnesium Sulphate
This patient has no documented medical history and is presenting for what we must assume is her first ever seizure, in pregnancy. The most common cause of fitting in such an instance is eclampsia rather than epilepsy and as such, magnesium sulphate is the most appropriate treatment here. This should be the case in any instance of diagnostic uncertainty.
What is the incidence of congenital malformation in infants born to mothers on sodium valproate in pregnancy?
a. 2%
b. 5%
c. 10%
d. 20%
e. 33%
C - 10%
The risk of congenital abnormality is highest amongst women taking sodium valproate at ~10.7 per 100 (or 10-11%). The most commonly seen abnormalities in patients on valproate are neural tube defects, facial clefts and hypospadias.
Which of the following defects is NOT classically associated with sodium valproate use in pregnancy?
a. Cleft lip
b. Spina bifida
c. Hypospadias
d. Micrognathia
e. Anencephaly
D - Micrognathia
The risk of congenital abnormality is highest amongst women taking sodium valproate at ~10.7 per 100 (or 10-11%). The most commonly seen abnormalities in patients on valproate are neural tube defects, facial clefts and hypospadias.
Congenital abnormalities in which body system are most typically associated with phenytoin use in pregnancy?
a. Cardiac
b. Neural tube
c. Renal
d. Hepatic
e. Respiratory
A - Cardiac
Phenytoin (and phenobarbital) use in pregnancy is associated chiefly with cardiac defects and facial cleft.
A rise in which serum biomarker is known to be associated with neural tube defects?
a. Beta-hCG
b. AFP
c. Inhibin
d. Bradykinin
e. PAPP-A
B - AFP
Biochemical screening with maternal serum AFP combined with ultrasonography increases the detection rate of NTDs to 94-100%.
A primigravida is referred for anaesthetic assessment during the antenatal period to discuss her options for pain relief during labour and delivery. Which of the following is contraindicated for pain relief in labour in women with epilepsy?
a. Entonox
b. Pethidine
c. Oramorph
d. Epidural
e. Remifentanyl PCA
B - Pethidine
Most forms of analgesia are perfectly safe for use in labour amongst women with epilepsy and indeed pain relief should be regarded as a priority amongst such women. The only exception is pethidine which should be used with caution in WWE (diamorphine is preferable) – pethidine is metabolised to norpethidine which is known to epileptogenic when given in high doses.
What is the primary mechanism of fetal hypoxia and acidosis during a maternal seizure in pregnancy or labour?
a. Cerebral redistribution of uterine blood flow
b. Traumatic injury to maternal abdomen
c. Maternal hypoxia
d. Uterine hypertonicity
e. Increased vascular permeability secondary to vasoactive peptide release
C - Maternal Hypoxia
Seizures in labour may lead to maternal hypoxia (secondary to apnoea during the seizure itself) as well as fetal hypoxia and acidosis secondary to sustained uterine hypertonus. This may relieved in part (especially if seizures on-going) by the administration of a tocolytic.
What is the first-line drug of choice in terminating epileptic seizures in women with epilepsy in labour?
a. Phenobarbitone
b. Leviteracitem
c. Lorazepam
d. Magnesium sulphate
e. Lamotrigine
C - Lorazepam
There are no studies examining the optimum management of epileptic seizures in labour thus regimens used outwith pregnancy are generally employed – lorazepam (0.1mg/kg) or diazepam IV in those with IV access or 10-20mg diazepam rectally in those without (can be repeated 15 minutes later). Where seizures remain uncontrolled, phenytoin is the next drug which should be used (loading 10-15mg/kg).
What percentage of women with epilepsy will have a seizure during labour?
a. 1-2%
b. 4-5%
c. 10%
d. 15%
e. 20%
A - 1-2%
Tonic clonic seizures occur in ~1-2% of women with epilepsy in labour and within 24 hours of delivery in a further 1-2%
When is the highest period of risk for seizures around childbearing in women with epilepsy?
a. First trimester
b. Second Trimester
c. Third Trimester
d. Labour
e. Postnatal
E - Postnatal
The immediate postpartum period appears to be the highest risk period for seizures owing in large part to the increased stress, sleep deprivation, missed medication and anxiety which characterises this time.
A patient with epilepsy on medication is reviewed on the post-natal ward round and enquires about suitable methods of postpartum contraception. You consider that certain preparations may not be suitable for women on enzyme inducing AEDs. Which of the following drugs is an enzyme inducer?
a. Sodium valproate
b. Phenytoin
c. Lamotrigine
d. Leviteracetam
e. Clobezam
B - Phenytoin
The enzyme inducing AEDs are as follows: carbamazepine, phenytoin, phenobarbital, primidone and oxcarbezine. Women should be counselled that the efficacy of oral contraceptives (combined and progesterone only), transdermal patches, vaginal ring and progesterone only implants may be affected by these. All contraceptive methods may be prescribed for those not on enzyme-inducing drugs.
A patient on carbamazepine and phenobarbital for epilepsy, though with no other medical history of note, seeks post-natal contraceptive advice. Which of the following options is appropriate for such a patient?
a. Progesterone only pill
b. Progesterone-implant
c. Transdermal patch
d. Combined pill
e. Progesterone injection
E - Progesterone injection
The enzyme inducing AEDs are as follows: carbamazepine, phenytoin, phenobarbital, primidone and oxcarbezine. Women should be counselled that the efficacy of oral contraceptives (combined and progesterone only), transdermal patches, vaginal ring and progesterone only implants may be affected by these. All contraceptive methods may be prescribed for those not on enzyme-inducing drugs.
What proportion of women with epilepsy report a family history of the condition?
a. 1/10
b. 1/5
c. 1/3
d. 1/2
e. 2/3
C - 1/3
30% of women with epilepsy report a positive family history of the condition
What proportion of women see a change in their seizure frequency in pregnancy?
a. 1/4
b. 1/3
c. 1/2
d. 2/3
e. 3/4
B - 1/3
Seizure frequency for the vast majority of women with epilepsy does not change in pregnancy (65%) – amongst the remaining third who do experience a change, approximately half report an increase and the other half a decrease. Women who have been seizure free for many years are unlikely to fit in pregnancy unless they change or stop their medication.
A women with well controlled epilepsy is seen in the antenatal clinic at booking. She wishes to know what the risk of the child having epilepsy is. What is the risk of epilepsy in the child when one parent has epilepsy?
a. Background risk (<1%)
b. 5%
c. 10%
d. 15%
e. 25%
B - 5%
The risk of the child developing epilepsy is increased if either parent has epilepsy (4-5%) and increased considerably if both parents have epilepsy (15-20%). If a sibling is affected, the risk is 10%.
What is the prevalence of diabetes (all subtypes) amongst the obstetric population in the UK?
a. <1%
b. 3%
c. 5%
d. 10%
e. 15%
C - 5%
A patient attends the diabetic clinic for review following a new diagnosis of GDM. She is anxious to know about the potential impact this might have on her pregnancy. Which of the following risks is NOT known to be increased in diabetic, when compared with non-diabetic pregnancies?
a. Birth injury
b. Preterm labour
c. Miscarriage
d. PPH
e. Pre-eclampsia
D - PPH
A patient with type 1 diabetes attends the pre-conceptual counselling clinic to discuss optimising her diabetes before embarking on her first pregnancy. Above which BMI should patients be advised on weight loss prior to pregnancy?
a. 25
b. 27
c. 30
d. 32
e. 35
B - 27
What is the recommended HbA1C target for diabetic patients planning pregnancy?
a. <48
b. <55
c. <60
d. <72
e. <86
A - 48
Above which HbA1C threshold should patients be advised against pregnancy?
a. >48
b. >55
c. >78
d. >86
e. >100
D - 86
A patient with Type 2, non-insulin dependent diabetes attends for pre-conceptual counselling. She is currently taking metformin 500mg TDS as well as 40mg gliclazide in the morning with breakfast. What advice do you give respect to her medications and pregnancy?
a. Stop metformin pre-pregnancy, continue gliclazide, restart metformin in the second trimester
b. Stop gliclazide pre-pregnancy, continue metformin, consider starting insulin
c. Stop both and switch to insulin pre-pregnancy
d. Reduce metformin to 500mg OD, continue gliclazide
e. Continue both at current dose
B - Stop gliclazide pre-pregnancy, continue metformin, consider starting insulin
How often should diabetic patients undergo retinal screening around pregnancy?
a. Within 6 months of conception and 6 monthly thereafter
b. Within 12 months of conception and yearly thereafter
c. Within 6 months of conception and yearly thereafter
d. Within 3 months of conception and 6 monthly thereafter
e. Within 12 months of conception and 2 yearly thereafter
C - Within 6 months of conception and yearly thereafter
A patient with type 1 diabetes attends the pre-conceptual counselling clinic for review. Results of recent renal screening are reviewed as part of the discussion which follows. What eGFR threshold should prompt urgent renal referral and advice to avoid pregnancy in diabetic patients with secondary renal impairment?
a. <90
b. <75
c. <45
d. <30
e. <20
C - <45
- Which of the following patients does NOT require a routine glucose tolerance test in the third trimester of pregnancy?
a. Para 1; BMI 24; last baby weighed 4.25kg at birth
b. Para 2; BMI 21; recently moved to the UK from India
c. Primigravida; BMI 18; her father is a type 2 diabetic
d. Para 4; BMI 19; cousin is type 1 diabetic; last baby weighed 4.9kg at birth
e. Para 1; BMI 18; had GDM in last pregnancy though managed via diet alone
A - Para 1; BMI 24; last baby weighed 4.25kg at birth
What are the diagnostic thresholds for diagnosing GDM based on a 75mg oral glucose tolerance test?
Fasting 2hours
a. >4.5 >6.7
b. >5.6 >7.8
c. >6.7 >8.9
d. >7.0 >11.0
e. >7.5 >10.1
B - Fasting >5.6; 2-hour >7.8
A patient attends the diabetic antenatal clinic for review after she undergoes a glucose tolerance test at 28/40 following 2 episodes of 1+ glycosuria. Otherwise until now her pregnancy has been low risk and a growth scan today was entirely normal. The results of her GTT were as follows:
Fasting: 6.1 2 hour: 7.5
What initial management plan is appropriate here?
a. Dietary advice and exercise
b. Metformin
c. Glibenclamide
d. Long acting insulin before bed
e. Rapid acting insulin with meals
A - Dietary advice and exercise
A patient attends the diabetic antenatal clinic for review after she undergoes a glucose tolerance test at 28/40 following 2 episodes of 1+ glycosuria. The results of her GTT were as follows:
Fasting: 7.4 2 hour: 7.7
What initial management plan is appropriate here?
a. Dietary advice and exercise
b. Metformin OD
c. Metformin BD
d. Insulin
e. Glibenclamide
D - Insulin
A patient attends the diabetic antenatal clinic for review after she undergoes a glucose tolerance test at 28/40 after a growth scan detects fetal macrosomia and polyhydramnios. The results of her GTT were as follows:
Fasting: 6.4 2 hour: 7.1
What initial management plan is appropriate here?
a. Dietary advice and exercise
b. Metformin
c. Metformin and Glibenclamide
d. Insulin
e. Glibenclamide
D - Insulin
A patient is given advice on diet and exercise following a GTT for BMI which demonstrates mild impairment of fasting glucose. She is commenced on BM monitoring though when she returns to clinic for review 2 weeks later, her readings remain abnormal. What is the next step in her management?
a. Trial of long acting insulin before bed
b. Trial of long acting insulin before bed + rapid acting insulin with meals
c. Metformin
d. Glibenclamide
e. Metformin + long acting insulin
C - Metformin
A patient attends the GDM clinic for review. Despite efforts with dietary changes, exercise and BD metformin, her glucose control remains erratic and insulin is recommended. She declines however as she is needle-phobic. What management do you advise?
a. Referral to mental health services for review of needle phobia
b. Referral to community dietician for more intensive input
c. Increase metformin to TDS
d. Consider Glibenclamide
e. Arrange insulin pump
D - Consider glibenclamide
What is the optimum target fasting blood glucose in pregnancy?
a. <7.0
b. <6.2
c. <5.6
d. <5.3
e. <4.8
D - <5.3
What is the optimum target blood glucose 2 hours after a meal in pregnancy?
a. <9.0
b. <8.5
c. <7.8
d. <6.4
e. <5.6
D - <6.4
What is the optimum target blood glucose 1 hour after a meal in pregnancy?
a. <8.2
b. <7.8
c. <6.7
d. <5.6
e. <5.1
B - <7.8
When should pre-existing diabetic patients undergo retinal assessment in pregnancy?
a. At booking and again at 28/40
b. At booking only
c. At 28/40 only
d. 12 months from previous screening should this fall during pregnancy
e. 6 months from previous screening irrespective of gestation
A - At booking and again at 28/40
A patient with type 1 diabetes undergoes renal function testing at 20/40 after persistent proteinuria is noted. This is suggestive of significant renal impairment and a 24 hour protein collection is arranged which collects 5.7 grams in 24 hours. What therapy should be considered here?
a. Aspirin
b. LMWH
c. Loop diuretic
d. Labetalol
e. Albumin solution
B - LMWH
By what gestation should women with pre-pregnancy diabetes deliver – following induction of labour if necessary – assuming no other concerns are present?
a. 37/40
b. 38/40
c. 39/40
d. 40/40
e. 41/40
C - 39/40
By what gestation should women with uncomplicated gestational diabetes deliver – following induction of labour if necessary – assuming no other concerns are present?
a. 37/40
b. 38/40
c. 39/40
d. 40/40
e. 41/40
E - 41/40
Which of the following should be avoided in women with diabetes in pregnancy?
a. Steroids for fetal lung maturity
b. Methyldopa for hypertensive disorders
c. Terbutaline for uterine hyperstimulation
d. Nifedipine for tocolysis
e. Ranitidine for pre-op gastric emptying
C - Terbutaline for uterine hyperstimulation
A patient with type 1 diabetes is admitted for induction of labour. Polyhydramnios is noted on her most recent scan, and following amniotomy, a cord prolapse is suspected. She is taken for an immediate Cat. 1 caesarean delivery under general anaesthetic. How often should blood glucose be monitored in women who have a general anaesthetic in labour?
a. 15 minutes
b. 30 minutes
c. Hourly
d. 2 hourly
e. As per usual schedule
B - 30 minutes
Outwith what blood glucose thresholds should IV insulin dextrose infusion be considered for women with gestational diabetes in labour?
a. <4 or >7
b. <3.5 or >7.5
c. <4 or >8
d. <3 or >8
e. <3 or >7.6
A - <4 or >7
A mother with type 1 diabetes is keen to breastfeed. How soon after birth should the first feed ideally occur?
a. Within 30 minutes
b. Within 1 hour
c. Within 90 minutes
d. With 2 hours
e. Within 3 hours
A - Within 30 minutes
What target pre-feed capillary blood glucose should be used in babies born to diabetic mothers?
a. >2
b. >3
c. >4
d. >4.5
e. >5
A - >2
A primigravida with gestational diabetes undergoes an emergency caesarean section for failure to progress in labour and is reviewed on the postnatal ward round the following morning. She wishes to know what she should do in respect of her diabetic therapy. She has been taking long acting insulin before bed and metformin TDS. What advice do you give her?
a. Stop insulin now, continue metformin until 6 week check
b. Continue all therapy until 6 week check including BM monitoring
c. Stop metformin now, gradually reduce insulin dose over next 7 days
d. Stop all therapy now – no further testing indicated
e. Stop all therapy now – fasting plasma glucose at 6 week check
E - Stop all therapy now – fasting plasma glucose at 6 week check
A 42 year old patient with gestational diabetes has a straightforward vaginal birth and uneventful post-natal recovery. She attends her GP for her 6 week check and a fasting blood glucose is arranged which return a result of 7.1. What is the implication of this result?
a. This result is normal – no further action is required
b. Advise the patient she likely has ‘pre-diabetes’ and refer to community dietician
c. Advise the patient she may be a type 1 diabetic and arrange formal testing
d. Advise the patient she may be a type 2 diabetic and arrange formal testing
e. Advise the patient to commence metformin 500mg BD and repeat the test in 6 weeks
D - Advise the patient she may be a type 2 diabetic and arrange formal testing
A 29 year old patient with gestational diabetes attends for her 6 week check following an otherwise uncomplicated pregnancy, labour and delivery. A fasting blood glucose is arranged which returns a result of 5.8. What further testing is indicated in this patient?
a. Oral glucose tolerance test now
b. Annual HbA1C
c. Annual oral glucose tolerance test
d. Repeat fasting blood glucose in 6 weeks
e. No further testing indicated
B - Annual HbA1C
Based on the information given, which of the following women would NOT require low dose aspirin in pregnancy for hypertensive disease prophylaxis?
a. 42 year old, Para 3, BMI 25, known factor V leiden homozygote
b. 27 year old Para 1, BMI 36, DCDA twin pregnancy
c. 19 year old, Para 1, BMI 22, Type 1 diabetic
d. 28 year old, Primigravida, BMI 24, sister had pre-eclampsia and was delivered at 28/40
e. 33 year old, Para 1, BMI 21, has antiphospholipid syndrome
A - 42 year old, Para 3, BMI 25, known factor V leiden homozygote
A primigravida with known chronic hypertension attends the antenatal clinic to discuss management of her blood pressure in pregnancy. She was switched from ramipril to labetalol at booking and is otherwise well. What blood pressure targets should be used in pregnancy?
a. <160/100mmHg
b. <150/100mmHg
c. <140/90mmHg
d. <130/80mmHg
e. <120/80mmHg
B - <150/100mmHg
A primigravida is referred for assessment by her community midwife after her blood pressure was checked at a routine AN visit at 32/40 gestation and found to be elevated at 158/105mmHg. She has no symptoms and urine dipstick testing is negative for protein. All other readings thus far in pregnancy, including booking have been within normal limits. How would you classify this clinically?
a. Mild gestational hypertension
b. Moderate gestational hypertension
c. Severe gestational hypertension
d. Moderate chronic hypertension
e. Severe chronic hypertension
B - Moderate gestation hypertension
A Para 1 is seen in the antenatal clinic at 7/40 after an early viability scan. On review of her history you note that in her first pregnancy she suffered from gestational hypertension and was induced at 37/40. Accordingly you suggest she take aspirin in this pregnancy. When do you advise her to start and stop aspirin?
a. Start immediately, stop at 36 weeks
b. Start immediately, stop at delivery
c. Start at 12/40, stop at 36/40
d. Start at 12/40, stop at delivery
e. Start at 16/40, stop at 36/40
D - Start at 12/40, stop at delivery
Based on the information given, which of the following women would NOT require antenatal aspirin for pre-eclampsia prophylaxis in pregnancy?
a. 29 year old primigravida. Booking BMI 38. Medical history: mild asthma controlled with inhalers, PCOS
b. 27 year old Para 3. Booking BMI 23. Medical history: Type 1 diabetes, mild depressive disorder.
c. 42 year old primigravida. Booking BMI 24. Medical history: n.a.d.
d. 32 year old Para 1. Booking BMI 34. Medical history: DVT following orthopaedic procedure 5 years ago. Last pregnancy with a different partner 11 years ago.
e. 31 year old Para 2. Booking BMI 19. Medical history n.a.d. Mild gestational hypertension in first pregnancy though no recurrence with second child. Cannot recall receiving aspirin in either pregnancy.
D - 32 year old Para 1. Booking BMI 34. Medical history: DVT following orthopaedic procedure 5 years ago. Last pregnancy with a different partner 11 years ago.
Which of the following is considered a ‘major’ risk factor for hypertensive disease in pregnancy and should prompt low-dose aspirin therapy independent of additional factors?
a. First pregnancy
b. Age >40
c. Multiple pregnancy
d. First degree relative with PET
e. Diabetes
E - Diabetes
A patient with chronic pre-pregnancy hypertension is commenced on labetalol at booking. Growth scans show a well grown fetus. Throughout the third trimester, blood pressure has repeatedly been in the range 150-160/90-105mmHg. In the absence of any additional concerns, when is the earliest elective delivery should take place?
a. 34/40
b. 36/40
c. 37/40
d. 39/40
e. 40/40
C - 37/40
A primigravida is reviewed on the post-natal ward round following a normal vaginal delivery. She is a known chronic hypertensive and was on enalapril pre-pregnancy though has been on methyldopa since the early third trimester. She is breastfeeding. When should methyldopa be stopped in patients postnatally?
a. Immediately
b. 48 hours
c. 7 days
d. 14 days
e. 6 weeks
B - 48 hours
What is the definition of ‘significant’ proteinuria on 24 hour urine collection?
a. >30mg
b. >90mg
c. >150mg
d. >200mg
e. >300mg
E - >300mg
A patient attends delivery suite, referred by her community midwife after her blood pressure at 35/40 was noted to be 148/97mmHg during a routine visit. This remains the case when you review her on the ward. Urine dipstick is negative for protein and all bloods are normal. She complains of a mild headache though is otherwise well. What management is appropriate here?
a. Commence antihypertensives, admit to hospital until BP controlled, recheck BP twice weekly on discharge
b. Commence antihypertensives, admit to hospital until BP controlled, recheck BP weekly on discharge
c. Commence antihypertensives, do not admit to hospital, recheck BP twice weekly
d. Do not commence antihypertensives, do not admit to hospital, recheck BP twice weekly
e. Do not commence antihypertensives, do not admit to hospital, recheck BP weekly
E - Do not commence antihypertensives, do not admit to hospital, recheck BP weekly
A patient attends delivery suite, referred by her community midwife after her blood pressure at 33/40 was noted to be 158/105mmHg during a routine visit. This remains the case when you review her on the ward. Urine dipstick is negative for protein and all bloods are normal. She complains of a mild headache though is otherwise well. What management is appropriate here?
a. Commence antihypertensives, admit to hospital until BP controlled, recheck BP twice weekly on discharge
b. Commence antihypertensives, admit to hospital until BP controlled, recheck BP weekly on discharge
c. Commence antihypertensives, do not admit to hospital, recheck BP twice weekly
d. Do not commence antihypertensives, do not admit to hospital, recheck BP twice weekly
e. Do not commence antihypertensives, do not admit to hospital, recheck BP weekly on
C - Commence antihypertensives, do not admit to hospital, recheck BP twice weekly
How often should urine dipstick be tested for proteinuria in patients with severe gestational hypertension following discharge from hospital?
a. Daily
b. Alternate days
c. Twice weekly
d. Weekly
e. Fortnightly
C - Twice weekly
How often should blood pressure be checked in gestational hypertensives following delivery?
a. Daily for first two days, once between days 3 and 5
b. 4 hourly for first 2 days, daily for days 3-7
c. Twice daily for first 2 days; daily for days 3-5
d. Daily until day 7
e. Twice daily until day 5
A - Daily for first two days, once between days 3 and 5
A patient is reviewed in the antenatal clinic following a routine growth scan, where her blood pressure is noted to be elevated at 145/98mmHg on several readings over one hour. Urine is positive for protein and a PCR returns a result of 75. Bloods are normal and she feels systemically well. What management do you propose?
a. Admit to hospital, start antihypertensives and repeat blood pressure hourly
b. Admit to hospital, do not start antihypertensives but repeat blood pressure 4x daily
c. Do not admit to hospital, do not start antihypertensives, repeat blood pressure daily
d. Do not admit to hospital, do not start antihypertensives, repeat blood pressure twice weekly
e. Do not admit to hospital, start antihypertensives, repeat blood pressure twice weekly
B - Admit to hospital, do not start antihypertensives but repeat blood pressure 4x daily
How often should bloods be repeated in patients managed in the community with moderate pre-eclampsia?
a. Weekly
b. Twice weekly
c. Three times weekly
d. Daily
e. No need to repeat bloods unless clinical deterioration/symptomatic
C - Daily
How often should urinary protein quantification be repeated in patients with pre-eclampsia?
a. At each contact
b. Weekly
c. Twice weekly
d. Three times weekly
e. No need to repeat once confirmed
E - No need to repeat once confirmed
What is the loading dose of magnesium sulphate for severe pre-eclampsia?
a. 1.5g
b. 2g
c. 3g
d. 4g
e. 8g
D - 4g
What is the maintenance dose of magnesium sulphate in severe pre-eclampsia?
a. 1 gram/hour
b. 1.5 grams/hour
c. 2 grams/hour
d. 4 grams/hour
e. 5 grams/hour
A - 1 gram/hour
What precaution should be undertaken when treating patients with severe hypertension with IV hydralazine antenatally?
a. Monitor core temperature 15-minutely to detect malignant hyperthermia
b. Pre-load with 500ml crystalloid
c. Monitor pulse for ventricular tachycardia
d. Avoid concurrent opiate analgesia
e. Do not use in patients with regional analgesia
B - Pre-load with 500ml crystalloid
What fluid restriction regimen is recommended in patients with severe pre-eclampsia who have no other on-going loss?
a. 40ml/hour
b. 80ml/hour
c. 125ml/hour
d. 2.5L/day
e. 4L/day
B - 80ml/hour
A patient develops severe pre-eclampsia with HELLP syndrome in her first pregnancy and requires delivery by emergency caesarean section at 27/40. What is her risk of PET in a future pregnancy?
a. 75%
b. 55%
c. 35%
d. 25%
e. 15%
B - 55%
A patient comes to the antenatal clinic for review in her second pregnancy. Her first pregnancy, 3 years ago resulted in delivery at 33/40 after she developed severe PET. What would you advise is her risk of recurrence of PET in this pregnancy?
a. 62%
b. 55%
c. 25%
d. 15%
e. 5%
C - 25%
A 25 year old woman known to have hyperthyroidism is going for radioactive iodine therapy. She has been trying to conceive for the last 6 months. How long should she avoid pregnancy after this treatment?
a. 3 months
b. 6 months
c. 9 months
d. 12 months
e. 18 months
B - 6 months
A 28 year old para 1 delivers an infant at 40 weeks of gestation who is noted to have a skin condition diagnosed as ‘aplasia cutis congenita’. She herself is known to have hyperthyroidism secondary to Graves Disease and has been on medication for this throughout pregnancy. Which of the following medications to known to cause this condition in the infant?
a. Carbimazole
b. Hydrouracil
c. Levothyroxine
d. Methythiouracil
e. Propylthiouracil
A - Carbimazole
Carbimazole and methimazole are associated with aplasia cutis congenita. This is a rare condition and - while propylthiouracil is preferred - these drugs may be used in pregnancy if required.
A 38 year old woman with moderate chronic renal failure comes to the preconception clinic as she wishes to have a baby. She underwent a renal transplant 3 years ago and has been taking prednisolone, mycophenolate and ACE-inhibitors since. You have suggested she stop the mycophenolate and commence an alternative immunosuppressant. Which if the following immunosuppressant drugs is also contraindicated in pregnancy?
a. Azathioprine
b. Cyclosporine
c. Hydroxychloraquine
d. Sirolimus
e. Tacrolimus
D - Sirolimus
Steroids, hydroxychloraquine, azathioprine, ciclosporin and tacrolimus are the immunosuppressants known to be safe in pregnancy.
Others - mycophenolate, sirolimus, cyclophosphamide and chlorambucil are teratogenic and should be avoided.
A 35 year old woman with chronic renal failure undergoes a successful renal transplant. How long after an allograft transplantation should she be advised to defer pregnancy?
a. 6 months
b. 12 months
c. 18 months
d. 24 months
e. 36 months
D - 24 months
A 34 year old primigravida is diagnosed with acute fatty liver of pregnancy. She is stabilised and delivered by caesarean section. She wishes to know her risk of recurrence in a future pregnancy. What do you advise?
a. 5%
b. 10%
c. 15%
d. 20%
e. 25%
E - 25%
More likely where the woman is a heterozygote for LCHAD deficiency (implicated in 19% of cases). Offspring of affected mothers should be screened for the common mutation E474Q.
A 27 year old nulliparous woman with known sickle cell disease is considering pregnancy. You meet her in the Preconceptual clinic and review her vaccination history. She has had haemophilus B, meningitis C, pneumococcal and hepatitis B vaccine previously (all 5 years ago) and influenza vaccine 8 months ago. What vaccine would you recommend her to have now?
a. Haemophilus influenza B
b. Meningitis C
c. Hepatitis B
d. Pneumococcal
e. Influenza
D - Pneumococcal
The pneumococcal vaccine should be given to susceptible patients every 5 years. Hep B, HIB and Men C are given as a one-off. Influenza is given annually.
A 24 year old nulliparous woman at 36 weeks of gestation is diagnosed with idiopathic immune thrombocytopenia. Her most recent platelet count is 70. Which of the following statements is true?
a. She should be treated with immunosuppressants
b. Regional analgesia is contradicated
c. Instrumental delivery is contraindicated
d. Delivery should be by caesarean section at 37 weeks
e. Neonatal thrombocytopenia occurs in 25%
B - Regional analgesia is contraindicated
ITP is a diagnosis of exclusion. There is an association with fetal/neonatal thrombocytopenia in 10% thus ventouse is generally best avoided though forceps may be used with caution. Regional analgesia is safe where platelet count is >80.
A primigravida presents in the late third trimester with headache, new-onset seizures, vomiting and photophobia. Her blood pressure is normal and there is no proteinuria. She undergoes cranial imaging and a cerebral vein thrombosis is diagnosed. What is the approximate incidence of cerebral vein thrombosis in pregnancy?
a. 1 in 100,000
b. 1 in 10,000
c. 1 in 5000
d. 1 in 1000
e. 1 in 500
B - 1 in 10,000
CVT is rare but associated with a high mortality rate. Risk factors are very similar to those for VTE elsewhere and many cases are associated with heritable thrombophilia - all patients should be tested. MRI Venogram is the optimum imaging modality to demonstrate venous thrombosis.
Source: HB of Obstetric Medicine
A 23 year woman in a low-risk pregnancy attends delivery suite complaining of shortness of breath. Examination is normal and her observations are all stable. A chest x-ray is performed and reported as clear. She has no other symptoms. What proportion of women will report breathlessness at some stage in pregnancy?
a. 1/10
b. 1/4
c. 1/3
d. 1/2
e. 3/4
E - 3/4
The sensation of breathlessness in most women if probably a result of increased awareness of physiological hyperventilation causing a subjective feeling of breathlessness. This physiologically breathlessness is often paradoxically present at rest and improves with mild activity.
Nevertheless there are clearly numerous specific causes which warrant exclusion.
Source: HB of Obstetric Medicine
A woman attends the pre-conception counselling clinic for advice prior to embarking on pregnancy. Her mother suffered from cystic fibrosis and she herself has been tested and found to be a carrier for the most common mutation known to cause CF. Her husband has never been tested though has no family history of the condition. What is the incidence of carrier status for cystic fibrosis in the UK caucasian population?
a. 1 in 1000
b. 1 in 500
c. 1 in 250
d. 1 in 100
e. 1 in 25
E - 1 in 25
CF is the most common autosomal recessive disorder in the UK with a carrier incidence of 1 in 25 amongst British caucasians.
Although a specific mutation on chromosome 7 has been identified, only 2/3 of cases have this specific mutation.
A 38 year old primigravida attends for review following her mid-trimester ultrasound scan at 20 weeks of gestation. She has a history of systemic lupus erythematous which causes her chiefly joint and skin symptoms. The sonographer has raised concerns that on scan, the fetal heart rate appeared to be only ~85 beats per minute. What antibody is the most likely cause of the fetal heart rate of 85bpm?
a. Anticardiolipin
b. Anti-dsDNA
c. Anti-nuclear
d. Ribonuclear protein antibodies
e. Sjörgren’s syndrome A antibodies
E - Sjörgren’s syndrome A antibodies
Anti-SSA antibodies - previously known as ‘anti-Ro’ are known to cause congenital heart block. Amongst mothers positive for anti-Ro/La, the risk of CHB is approximately 2%.
Where the woman has a previously affected child the risk of recurrence is higher at 15%
A 32 year old woman attends the antenatal clinic at 12 weeks of gestation. She is known to have systemic lupus erythematous. Her first child, delivered 3 years earlier required a pacemaker after he was born with congenital heart block secondary to the effect of lupus antibodies. She wishes to know what is the risk that this child will be affected by the same problem. What do you advise is the risk of recurrence?
a. 2-3%
b. 5%
c. 15%
d. 20%
e. 50%
C - 15%
The risk of recurrence of congenital heart block is 15%
What percentage of maternal deaths involve women who are obese by the latest CMACE report?
a. 5-10%
b. 11-15%
c. 16-20%
d. 21-25%
e. 26-30%
E - 26-30%
=What is the risk of vertical transmission of HIV to the infant or fetus amongst women who are not on treatment?
a. 0.5%
b. 5%
c. 25%
d. 50%
e. 75%
C - 25%
Approximately how many women in the UK are living with HIV infection?
a. 2000
b. 20,000
c. 100,000
d. 200,000
e. 2 million
B - 20,000
What is the current rate of vertical transmission of HIV in the UK?
a. 0.5%
b. 2.5%
c. 5%
d. 10%
e. 25%
A - 0.5%
A para 2 who is known to be HIV positive on cART books at 11 weeks gestation on cART with a normal CD4 count. When should this be repeated?
a. At 20/40
b. Once in each trimester
c. Fortnightly until 28 weeks and 4 weekly thereafter
d. 4 weekly until 28 weeks and fortnightly thereafter
e. At delivery
E - At delivery
A primigravida who is currently 12 weeks of gestation, tests positive for HIV in her booking bloods. She states that she was previously unaware that she was positive for the virus. Her viral load is currently 50,000 copies per ml. CD4 count is 350. What management plan is appropriate here?
a. Commence cART immediately
b. Commence cART at the beginning of the second trimester
c. Commence cART at the beginning of the third trimester
d. Commence zidovudine monotherapy immediately
e. Commence zidovudine monotherapy at the beginning of the second trimester
B - Commence cART at the beginning of the second trimester
Where viral load is <100,000, cART should be started at the start of the second trimester providing CD4 count is >200. If either viral load is >100,00 or CD4 count <200, cART should be commenced as soon as possible, including in the first trimester if required. All women should be on cART by 24/40. Zidovudine monotherapy is not recommended except in women who decline cART, have a viral load <10,000 and are prepared to deliver by LSCS.
A primigravida presents at 35/40 following a growth scan. This has demonstrated normal fetal growth though the fetus is noted to be in a breech presentation. Her viral load is currently undetectable and she informs you that she was hoping for a vaginal birth. What management plan is most appropriate here, considering her wishes, and the wellbeing of her fetus?
a. El. LSCS at 38/40
b. El. LSCS at 39/40
c. Vaginal breech birth
d. ECV from 36/40
e. ECV from 37/40
D - ECV from 36/40
In women with a viral load <50, ECV is appropriate; in primigravidae this should be performed from 36/40
A para 3 with a history of 3 vaginal births is seen in the antenatal clinic at 36 weeks. She is known to be HIV positive and despite cART therapy since 24/40 in this pregnancy, her viral load is 400. She is keen to have a further vaginal birth though states she will ‘do whatever is safest for the baby’. What plan for delivery do you advise?
a. Await spontaneous labour and aim for vaginal birth
b. IOL at 37/40
c. IOL at 38/40
d. El. LSCS at 38/40
e. El. LSCS at 39/40
D - El. LSCS at 38/40
Where the indication for CS is prevention of vertical transmission, this should be done from 38/40. If viral load <50 and CS is for obstetric indication alone, then from 39/40 is appropriate. Women with a viral load of 400 or more should be advised to deliver by LSCS.
A para 3 who has had straightforward vaginal births in the past and who is known to be HIV positive, presents with spontaneous membrane rupture at 35+5 weeks of gestation. She feels normal fetal movements and CTG is normal. She is well in herself and draining clear, inoffensive liquor. She is comfortable and does not report any uterine activity. You review her latest bloods which report an undetectable viral load. What management plan do you initiate with respect to mode and timing of delivery?
a. Commence immediate induction of labour
b. Expectant management with induction of labour in 24 hours if not laboured spontaneously in the interim
c. Expectant management with induction of labour at 36/40 if not laboured spontaneously in the interim
d. Delivery by Cat. 1 LSCS
e. Delivery by Cat. 2 LSCS
A - Commence immediate induction of labour
Women with an undetectable viral load, to some degree may be managed as per the HIV-negative population with respect to decision making around labour and delivery. The exception in in pre-labour membrane rupture in which delivery should be achieved within 24 hours in all over 34/40. Women with a viral load greater than 50 should generally be encouraged to deliver by LSCS though individualised care may be appropriate depending on the circumstances between 50 and 399. Those with a viral load of 400 or more should be delivered by LSCS. In those <34/40, a multi-disciplinary discussion regarding mode and timing of delivery should take place.
A primigravida who is HIV positive has an uneventful labour and spontaneous delivery of a live male infant at 39/40. She has been taking cART since 24 weeks and always had an undetectable viral load throughout pregnancy including upon admission. What should be the plan for post-exposure prophylaxis in the neonate?
a. No prophylaxis required
b. 2 weeks zidovudine monotherapy
c. 4 weeks zidovudine monotherapy
d. 2 weeks combination therapy
e. 4 weeks combination therapy
A - No prophylaxis required
Where mum has been on cART for >10 weeks and has an undetectable viral load at 36/40 as well as twice, 4 weeks apart during pregnancy, the infant is considered to be at ‘very low risk’ of transmission and should receive 2 weeks of zidovudine monotherapy as prophylaxis. If any of these 3 criteria are not met but viral load <50 (or in any infant born <34/40), 4 weeks should be given. Where viral load is >50 or unknown, combination therapy is indicated.
How soon following delivery should the infant be first tested for HIV when born to an HIV positive mother (irrespective of viral load)?
a. Immediately after birth
b. 48 hours
c. 7 days
d. 14 days
e. 6 weeks
B - 48 hours
All infants, irrespective of risk status should be tested within 48 hours of birth and again prior to discharge home. Further testing is dependent on risk status and mode of infant feeding.
Which of the following is a diagnostic marker for diabetic ketoacidosis in pregnancy?
a. Blood glucose >11
b. Bicarbonate <15
c. Venous pH <7.3
d. Blood ketones >3
e. All of the above
E - All of the above
TOG 2017
What is the fetal mortality associated with DKA in pregnancy?
a. Up to 5%
b. Up to 20%
c. Up to 40%
d. Up to 50%
e. Up to 80%
C - Up to 40%
TOG 2017
What is the target HbA1C level pre-pregnancy in diabetic women?
a. <34
b. <48
c. <52
d. <64
e. <84
B - <48
TOG 2017
Above which level should pregnancy be avoided in patients with diabetes?
a. >34
b. >48
c. >65
d. >84
e. >96
D - >84
TOG 2017
A 36-year-old woman with type 1 diabetes on insulin is seen as an emergency at 34 weeks of gestation with severe vomiting, polyuria and blurred vision. She is examined and found to be drowsy, hyperventilating, tachypnoeic and hypotensive. You suspect that she has diabetic ketoacidosis. What test value will help you confirm the diagnosis?
a. Bicarbonate level of less than 10 mmol/l
b. Blood glucose of more than 11mmol/l
c. Blood ketone of more than 2.0 mmol/l
d. Blood pH of less than 7.4
e. Urinalysis that shows ketonuria
B - Blood glucose of more than 11mmol/l
TOG 2017
How long after correction of diabetic ketoacidosis would the fetal heart rate be expected to have been normalised?
a. As soon as the DKA has been corrected
b. 30–60 minutes
c. 1−2 hours
d. 2−4 hours
e. 4−8 hours
E - 4-8 hours
TOG 2017
Which of the following is an example of WHOMEC grade 4 cardiac condition, suggesting pregnancy is contraindicated owing to an unacceptable risk to life?
a. Tricuspid regurgitation
b. Pulmonary hypertension
c. Tissue aortic valve replacement
d. Patent foramen ovale
e. Repaired VSD
B - Pulmonary Hypertension
What endocrine gland is responsible for the secretion of vasopressin?
a. Hypothalamus
b. Anterior pituitary
c. Posterior pituitary
d. Parathyroid gland
e. Adrenal gland
C - Posterior pituitary
Which of the following hormones is structurally similar to vasopressin, such that at large doses it may mimic the physiological action of vasopressin?
a. Luteinising hormone
b. Follicle stimulating hormone
c. Gonadotrophin releasing hormone
d. Oxytocin
e. hCG
D - Oxytocin
What is the normal effect of pregnancy on plasma sodium levels?
a. Increases by 10-15
b. Increases by 4-5
c. No change
d. Decreases by 4-5
e. Decreases by 10-15
D - Decrease by 4-5
A 20 year old primigravida is diagnosed with diabetes insipidus at 20 weeks gestation. What is the most likely biochemical abnormality associated with this condition?
a. Hypernatraemia
b. Hypocalcaemia
c. Hypokalaemia
d. Hypomagnesaemia
e. Metabolic acidosis
A - Hypernatraemia
A 30 year old has been diagnosed with diabetes insipidus. What would help differentiate between the different types of diabetes insipidus this patient may have?
a. Failure to respond to treatment with vasopressin
b. Improvement in response to treatment with vasopressin
c. Timing of diagnosis with gestational diabetes insipidus being diagnosed mainly after the 1st trimester
d. Urine:Plasma osmolality ratio is >2 in gestation DI compared to neurogenic and nephrogenic DI
e. Uine specific gravity of <1.005 in non-gestational DI compared to neurogenic and nephrogenic DI
B - Improvement in response to treatment with vasopressin
What is the incidence of maternal cardiac arrest in pregnancy?
a. 1 in 5000
b. 1 in 7500
c. 1 in 12,500
d. 1 in 25,000
e. 1 in 50,000
C - 1 in 12,500
What is the most common cause of maternal cardiac arrest in pregnancy?
a. Haemorrhage
b. Venous thromboembolism
c. Amniotic fluid embolism
d. Anaesthetic complications
e. Pre-existing cardiac disease
A - Haemorrhage
How soon following cardiac arrest should a perimortem caesarean be commenced assuming there is no return of spontaneous circulation?
a. Immediately
b. 2 minutes
c. 4 minutes
d. 5 minutes
e. 10 minutes
C - 4 minutes
Following intubation in maternal cardiac arrest, what rate of ventilation breaths should be given?
a. 6/min
b. 10/min
c. 14/min
d. 20/min
e. 24/min
B - 10/min
From which gestation (or estimate of gestation if unknown) should perimortem caesarean section be performed?
a. 12/40
b. 16/40
c. 20/40
d. 24/40
e. 28/40
C - 20/40
What is the physiological benefit of perimortem caesarean section on a 26 year old who suffered a cardiac arrest following an RTA?
a. Increased oxygen consumption by the mother
b. Facilitate CPR
c. Allows for a more rapid return of spontaneous circulation
d. Facilitates delivery of the electric shock to the heart
e. Reduces compression on the great vessels
E - Reduces compression on the great vessels
What is the recommended ratio of compressions to ventilation breaths during CPR prior to intubation?
a. 15 to 1
b. 30 to 1
c. 30 to 2
d. 60 to 2
e. 100 to 2
C - 30 to 2
What is the primary treatment modality in phenylketonuria?
a. Steroids
b. Phenylalanine-hydroxylase replacement
c. Phenylalanine dietary supplementation
d. Dietary phenylalanine restriction
e. No treatment required
D - Dietary phenylalanine restriction
Which of the following is NOT a consequence of maternal PKU syndrome?
a. IUGR
b. Hypospadias
c. Congenital heart disease
d. Intellectual impairment
e. Facial dysmorphism
B - Hypospadias
What is the mode of inheritance of phenylketonuria?
a. X-linked recessive
b. X-lined dominant
c. Autosomal recessive
d. Autosomal dominant
e. Y-linked
C - Autosomal recessive
Which of the following contraceptive choices, if any, is contraindicated in women with PKU?
a. Combined pill
b. Depo-Provera
c. Copper-IUD
d. Progesterone-implant
e. No restrictions on contraceptive use
E - No restrictions on contraceptive use
How often should women with PKU have dry blood spot testing for phenylalanine levels in pregnancy?
a. 3x/weekly
b. Weekly
c. Fortnightly
d. Monthly
e. Each trimester
A - 3x/weekly
What is the mode of inheritance of sickle cell disease?
a. X-linked recessive
b. X-lined dominant
c. Autosomal recessive
d. Autosomal dominant
e. Y-linked
C - Autosomal recessive
What is the mode of inheritance of beta-thalassaemia?
a. X-linked recessive
b. X-lined dominant
c. Autosomal recessive
d. Autosomal dominant
e. Y-linked
C - Autosomal recessive
Which of the following statements about Sickle cell disease is true?
a. Heterozygotes have relative resistance to P. Vivax malaria
b. Approximate 500,000 women of reproductive age in the UK are homozygous
c. It is a transfusion dependent haemoglobinopathy
d. It results from a point mutation on the beta globin gene
e. Significant clinical disease occurs in heterozygotes
D - It results from a point mutation on the beta-globin gene
How much iron is contained with a single unit transfusion of red-blood cells?
a. 50mg
b. 200mg
c. 500mg
d. 1 gram
e. 2.5 grams
B - 200mg
What is the principle mechanism of subfertility in patients with beta-thalassaemia major?
a. Hypogonadotrophic hypogonadism
b. Premature ovarian failure
c. Loss of GnRH secretion secondary to hypothalamic failure
d. Iron deposition in endometrial glandular epithelium
e. High incidence of concurrent uterine structural abnormality
A - Hypogonadotrophic hypogonadism
Beta-thalassaemia major is characterised by which underlying pathology?
a. Markedly reduced alpha globin production
b. Markedly reduced beta globin production
c. Point mutation in alpha globin gene
d. Point mutation in beta globin gene
e. Point mutation in both alpha and beta globin genes
B - Markedly reduced beta globin production
How does chelation reduce iron toxicity?
a. By decreasing absorption of iron from the GI tract
b. By increasing excretion of iron from the kidneys
c. By increasing metabolism of iron by the liver
d. By increasing the protein bound iron in circulation
e. By promoting the excretion of plasma non-transferrin-bound iron
E - By promoting the excretion of plasma non-transferrin-bound iron
What is the mode of inheritance of phenylketonuria?
a. Autosomal recessive
b. Autosomal dominant
c. Sex-linked recessive
d. Sex-linked dominant
e. Polygenic
A - Autosomal recessive
How often should women with PKU undergo Phe level testing?
a. 1-2x per week
b. 2-3x per week
c. 3-4x per week
d. 0-1x per week
e. 4-5x per week
B - 2-3x/week
A 25 year old woman is diagnosed with obstetric cholestasis at 32 weeks in her first pregnancy. Her bile acids are noted to be significantly elevated at 45. What is the principal hepatic bile acid receptor?
a. Hepatoprotein G Receptor
b. Biliceptin S Receptor
c. Farnesoid X Receptor
d. Cholecystin Receptor
e. Hepcidin B-protein Receptor
C - Farnesoid X Receptor
The principal hepatic bile acid receptor is farnesoid X receptor - in response to elevated levels of intrahepatic bile acids, it is responsible for the coordinated downregulation of synthesis and upregulation of export.
TOG 2016
Which of the following is NOT a recognised risk factor for obstetric cholestasis?
a. Hepatitis C infection
b. Gallstones
c. IVF
d. Primiparity
e. Family history
D - Primiparity
Numerous risk factors are described for obstetric cholestasis including:
- Asian, Northern European or South American ethnicity
- Multiple pregnancy
- IVF
- Existing liver disease (gallstones, hepatitis)
- Advanced maternal age
A family history is found (especially amongst sisters) in 10-15% of affected women suggesting a genetic component.
While recurrence rates of up to 90% are described in the literature, parity itself is not a described risk.
TOG 2016
What is the incidence of obstetric cholestasis amongst the UK obstetric population?
a. 0.2%
b. 0.7%
c. 1.1%
d. 2.9%
e. 4.5%
B - 0.7%
Obstetric cholestasis complicates 0.7% (~1 in 140) pregnancies in the UK
TOG 2016
A primigravida presents at 34 weeks of gestation complaining of pruritus on the palms and soles which is worse at night. Liver function and bile acid levels are tested and normal results obtained. Assuming her symptoms persist, when should testing be repeated?
a. Twice weekly
b. In 1-2 weeks
c. In 3-4 weeks
d. In 6-8 weeks
e. No indication to repeat testing
B - 1-2 weeks
It is recommended that women with continuing pruritus but normal LFTs and bile acids have these repeated after 1-2 weeks.
TOG 2016
What is the most sensitive marker for the diagnosis of obstetric cholestasis?
a. Gamma glutamyl transferase (GGT)
b. Alanine aminotransferase (ALT)
c. Alkaline phosphatase (ALP)
d. Aspartate aminotransferase (AST)
e. Serum bile acids
E - Serum bile acids
While all of the options given might reasonably be expected to be elevated in a patient with OC, serum bile acids are considered the most sensitive for making the diagnosis.
ALP is elevated in normal pregnancy while AST is not specific to liver pathology (it is also produced by skeletal and cardiac muscle). Gamma GT is frequently normal in OC though may be elevated. Bilirubin is elevated in ~10%.
TOG 2016
A woman delivers a healthy baby boy at 38 weeks of gestation following a pregnancy complicated by obstetric cholestasis in the third trimester. After what time period following delivery would liver function tests be expected to have resolved to confirm the diagnosis of obstetric cholestasis?
a. 2-3 days
b. 7 days
c. 14 days
d. 6 weeks
e. 6 months
D - 6 weeks
Resolution of liver function within 6 weeks of delivery is a requisite for confirmation of the diagnosis of OC
TOG 2016
A 33 year old woman presents for antenatal care in her first pregnancy. She explains that she was treated in childhood for leaukaemia with anthracycline chemotherapy. What organ system is anthracycline chemotherapy known to have a detrimental effect on?
a. Hepatic
b. Thyroid
c. Cardiac
d. Respiratory
e. Gastrointestinal
C - Cardiac
Patients with a history of exposure to certain chemotherapy agents may be at an increased risk of certain complications. The most commonly reported are as follows:
- Anthracyclines and taxanes: cardiac dysfunction
- Alkylating agents: GDM
- Bleomycin: respiratory disease
Asymptomatic anthracycline-induced cardiac dysfunction is described in up to 57% of those with a history of exposure. RCOG guidelines advocate echocardiogram screening in such patients antenatally
TOG 2016
A patient is reviewed in the antenatal clinic at booking in her first pregnancy. She has been referred on account of her history of Hodgkin’s lymphoma which was treated with an alkylating chemotherapy agent. What additional test in the antenatal period is of benefit in patients with prior exposure to alkylating agents?
a. Echocardiogram
b. Glucose tolerance test
c. Lung function testing
d. DEXA bone scan
e. Retinal screening
B - Glucose tolerance test
Patients with a history of exposure to certain chemotherapy agents may be at an increased risk of certain complications. The most commonly reported are as follows:
- Anthracyclines and taxanes: cardiac dysfunction
- Alkylating agents: GDM
- Bleomycin: respiratory disease
TOG 2016
A patient is reviewed in the antenatal clinic at booking in her first pregnancy. She has been referred on account of her history of Hodgkin’s lymphoma which was treated with bleomycin chemotherapy. What additional test in the antenatal period is of benefit in patients with prior exposure to bleomycin?
a. Echocardiogram
b. Glucose tolerance test
c. Lung function testing
d. DEXA bone scan
e. Retinal screening
C - Lung function testing
Patients with a history of exposure to certain chemotherapy agents may be at an increased risk of certain complications. The most commonly reported are as follows:
- Anthracyclines and taxanes: cardiac dysfunction
- Alkylating agents: GDM
- Bleomycin: respiratory disease
TOG 2016
A patient with a history of breast cancer 6 months ago attends for pre-pregnancy counselling as she and her partner wish to have another child. How long after treatment for breast cancer are patients advised to defer pregnancy?
a. 3 months
b. 6 months
c. 1 year
d. 2 years
e. 3 years
D - 2 years
TOG 2016
Which of the following is noted to be increased amongst women with a history of cancer treatment prior to pregnancy?
a. Obstetric cholestasis
b. Premature birth
c. Congenital anomaly
d. Pre-eclampsia
e. All of the above
B - Premature birth
Women with a history of malignancy should be reassured that while a small increase in preterm birth is noted, there is no evidence to support an increase in congenital abnormality. Any increases in IUGR or stillbirth are related largely to specific exposure to pelvic radiotherapy in the past and are not universal risks.
TOG 2016
A 33-year-old woman had an induced vaginal delivery at 36 weeks of gestation. The pregnancy was induced on account of severe intrahepatic cholestasis of pregnancy. What recurrence rate will you give this women assuming that the diagnosis is confirmed by a return to normal of her bile acids after delivery?
a. >50%
b. >60%
c. >70%
d. >80%
e. >90%
E - >90%
Intrahepatic cholestasis of pregnancy has a very high recurrence rate. It has been estimated to recur in over 90% of subsequent pregnancies.
TOG StratOG Resource
A 27-year-old woman was diagnosed with intrahepatic cholestasis at 32 weeks of gestation. She had an induced vaginal delivery at 37 weeks of gestation. What plan with regard to monitoring will you recommend for her now?
a. Liver function and bile acid levels 7 days postpartum
b. Liver function and bile acid levels 10 days postpartum
c. Liver function and bile acid levels 21 days postpartum
d. Liver function and bile acid levels 28 days postpartum
e. Liver function and bile acid levels 42 days postpartum
E - Liver function and bile acid levels 42 days postpartum
All women with intrahepatic cholestasis should have their liver function and serum bile acid levels checked at 6 weeks postpartum to ensure resolution. If the liver transaminases or serum bile acids remain elevated at the postnatal check, alternative causes for hepatic dysfunction should be sought and referral to a hepatologist should be considered.
TOG StratOG Resource
A 25-year-old woman who had Hodgkin’s lymphoma as a child treated with chemotherapy only. With respect to her cancer treatment she is at a slightly increased risk of which pregnancy complication?
a. Congenital malformations
b. Miscarriage
c. Preterm delivery
d. Small-for-gestational-age fetus
e. Stillbirth
C- Preterm Delivery
Women who are survivors of childhood cancer and are embarking on pregnancy should be advised about the slightly increased risk of preterm birth. They can be reassured that the risk of congenital malformations is not greater than in the general population. However, for those women with a history of abdomino-pelvic radiation, or who have developed secondary medical conditions, there may be an increased risk of miscarriage, stillbirths and small for gestational age. For these women, growth scans may be appropriate.
TOG StratOG Resource
Which of the following statements concerning the use of biologic drugs in pregnancy is correct?
a. There is a robust evidence base to support a teratogenic effect of the most common biologic drugs in pregnancy
b. Women on biologics should be advised not to breastfeed or defer restarting their biologic therapy postnatally
c. Where the mother has been exposed to anti-TNF drugs in the first trimester, the BCG vaccine should be withheld for 6 months postnatally in the infant
d. Anti-TNF drugs are IgG molecules which cross the placenta with ease
e. Women attending for pre-pregnancy counselling should ideally be advised to cease biologic therapy a minimum of 6 months postnatally
D - Anti-TNF drugs are IgG molecules which cross the placenta with ease
a) There is no evidence that biologic agents are teratogenic, the concern is related to risks of maternal and neonatal infection (as well as theoretical concern regarding fetal immune development)
b) Women on biologics should be encouraged to breastfeed - the drugs are unlikely to survive passage through the infants GI tract to achieve plasma levels of any significance
c) Live vaccinations such as BCG should be withheld when maternal exposure beyond the recommended gestation has occured (usually third trimester) - the risk from first trimester exposure is very low
e) Women should be discouraged from stopping biologic therapy in anticipation of pregnancy owing to the detrimental effect such a period may have on their underlying condition - flares of disease are almost universally more harmful to mother and baby than biologic therapy itself
TOG 2016
An infant is born at term to a primigravida with severe Crohn’s disease managed with infliximab. Despite advice to stop infliximab prior to the third trimester, she proceeds and has infusions right up until delivery. How long after delivery should live vaccinations be withheld in the infant?
a. No need for additional precautions
b. 6 weeks
c. 3 months
d. 6 months
e. 12 months
D - 6 months
Live vaccines (BCG and rotavirus) should be withheld following exposure to biologics in the third trimester. Non-live vaccines are safe and should be given.
TOG 2016
In patients using anti-TNF biologic drugs in pregnancy, when is the risk of transplacental passage to the neonate highest?
a. Before 12 weeks
b. 12-18 weeks
c. 18-24 weeks
d. 24-28 weeks
e. Beyond 28 weeks
E - Beyond 28 weeks
Most biologics are IgG molecules and cross the placenta easily - especially after 28 weeks
TOG 2016
A patient with rheumatoid arthritis on anti-TNF therapy wishes to discuss the safety of her medication prior to pregnancy. Which of the following biologic agents does not cross the placenta as efficiently as others in the class?
a. Certolizumab
b. Etanercept
c. Infliximab
d. Rituximab
e. Adalimubab
A - Certolizumab
This pegylated anti-TNF agent does not easily cross the placenta and may well become the mainstay of biologic therapy in women of childbearing age in the near future
TOG 2016
What are the most common liver masses seen in women of reproductive age?
a. Hepatocellular carcinoma
b. Focal nodular hyperplasia
c. Hepatic adenoma
d. Lymphagniomatosis
e. Haemangioma
E - Haemangioma
Hepatic haemangiomas are the most common liver tumours, seen in up to 20% of healthy individuals
TOG 2016
Which of the following statements regarding hepatic haemangiomas is false?
a. They are present in up to 20% of healthy individuals
b. Pregnancy is associated with accelerated growth
c. They occur more frequently in individuals using combined oral contraceptives
d. They occur most commonly in adolescent males
e. Rupture, causing life threatening haemoperitoneum is a recognised complication
D - They occur most commonly in adolescent males
Hepatic haemangiomas occur most commonly in middle aged women
TOG 2016
What tumour marker may be used in the diagnosis of suspected hepatocellular carcinoma in pregnancy?
a. Carcino-embyronic antigen (CEA)
b. Ca19-9
c. Alpha-feto protein (AFP)
d. Lactate dehydrogenase (LDH)
e. Ca505
C - AFP
There is a suggestion from small series that levels of AFP >1000 may be considered diagnostic even in pregnancy
TOG 2016
A 40-year-old woman who presented with a recurring upper abdominal pain at 24 weeks of gestation was extensively investigated and after ultrasound scan was found to have a tumour in the liver. What is the most common benign hepatic tumour in pregnancy?
a. Focal nodular hyperplasia
b. Haemangioma
c. Hepatic adenomas
d. Hepatic aneurysm
e. Hepatic cell carcinoma
B - Haemangioma
Hepatic haemangiomas are the commonest benign tumours of the liver and are present in 2–20% of healthy individuals. They are more common in middle-aged women although it is uncertain if estrogen has a pathophysiological role.
TOG StratOG Resource
A 30-year-old who is on etanercept (an anti-TNF agent) for severe arthritis has just delivered by an emergency caesarean section. What would be the advice on continuation of her arthritis medication?
a. Delay recommencing for two days (48 hours)
b. Delay recommencing for seven days (1 week)
c. Delay recommencing for 28 days (4 weeks)
d. Delay recommencing until after lactation
e. Recommence as soon as possible
B - Delay recommencing for seven days (1 week)
Women on etanercept can resume their medication almost immediately after delivery. If they have a wound from a caesarean section, an episiotomy or a perineal tear, this should be delayed for a few days until the wound has healed to minimise the risk of wound infection. In most cases, this would be around 5–7 days.
TOG StratOG Resource
A 30-year-old who suffers from systemic lupus erythematosus (SLE), and is currently on the biologic agent belimumab (a monoclonal antibody that inhibits B-cell activating factor), attends for prepregnancy counselling as she wishes to start trying for a baby. She is currently taking 5 mg folic acid daily. What advice should she be given about her SLE medication?
a. Continue medication through to pregnancy and thereafter or switch to an alternative after discussion with Rheumatologist
b. Continue medication until 28 weeks of gestation then stop and recommence soon after delivery
c. Discontinue medication as soon as she is pregnant
d. Discontinue medication for at least 12 weeks before trying
e. Discontinue medication with a positive pregnancy test and recommence after the first trimester
A - Continue medication through to pregnancy and thereafter or switch to an alternative after discussion with Rheumatologist
There is no evidence that biologic agents are teratogenic. Cessation in anticipation of pregnancy is therefore inadvisable due to the long lag time to conception, leading to the risk of flares just before pregnancy. Such flares tend to be harmful to both the mother and the fetus, leading to placental insufficiency complications such as miscarriages, preterm birth, fetal growth restriction and pre-eclampsia. Women on biologic agents are at a greater risk of infections. Offspring exposed to belimumab have normal growth and neurodevelopment. These are no contraindications in breastfeeding
TOG StratOG Resource
The primary function of peripheral natural killer (pNK) cells is to recognise foreign antigens. These cells are characterised by their surface antigens. What is the characteristic surface antigen pattern in pNK cells?
a. CD56dim/CD16-
b. CD56bright/CD16+
c. CD56dim/CD16+
d. CD56bright/CD16-
e. CD56-/CD16+
C - CD56dim/CD16+
Central to the host defense mechanisms, are natural killer cells which play a vital role in the innate immune response. They are subtyped by virtue of their expression of CD56 and CD16 cell surface antigens. Most pNK cells exhibit CD16 but fewer CD56 surface antigens thus they are typically described as CD56dim/CD16+
TOG StratOG Resource
The population of cells in the endometrial stroma varies with the time of the menstrual cycle. What proportion of the leucocyte population of the endometrial stroma during the later secretory phase is made up of uterine natural killer cells?
a. At least 10%
b. At least 20%
c. At least 30%
d. At least 40%
e. At least 50%
C - At least 30%
Uterine natural killer (uNK) cells are the predominant leucocyte population of the endometrium and account for at least 30% of the endometrial stroma during the later secretory phase of the menstrual cycle where they are found surrounding the spiral arteries (but not the veins).
TOG StratOG Resource
A couple are anxious about the risk of their baby being born with an inherited autosomal recessive condition. Their anxiety stems from the fact that their relative recently had a baby with an autosomal recessive condition. They want to know what the most common autosomal recessive condition worldwide is. What do you tell them?
a. α-thalassaemia
b. β-thalassaemia
c. Cystic fibrosis
d. Haemophilia
e. Sickle cell disease
B - β-thalassaemia
The most common autosomal recessive condition worldwide is β-thalassaemia. The most common autosomal recessive condition among Caucasians in Europe is cystic fibrosis. There are currently more than 1000 mutations responsible for cystic fibrosis and the most common is Δ508.
TOG StratOG Resource
A 30-year-old has been diagnosed with acute kidney injury following an obstetric complication. What is the most common cause of acute kidney injury in obstetrics?
a. Antepartum haemorrhage especially placental abruption
b. Drugs such as NSAIDs
c. Postpartum haemorrhage
d. Pre-eclampsia
e. Sepsis
D - Pre-eclampsia
More than one aetiology is responsible for AKI in pregnancy. Data from audit studies indicate that it complicates 1.4% of obstetric admissions in the UK and that the most common cause is pre-eclampsia. Most cases occur in women without pre-existing renal disease and over 40% go unrecognised by the treating clinical team.
TOG StratOG Resource
You are part of the team managing a 24-year-old pregnant woman who developed acute kidney injury at 28 weeks of gestation following a road traffic accident. What will be the pregnancy-specific indication for considering renal replacement in this woman?
a. Fluid overload refractory to medical management
b. Hyperkalaemia
c. Metabolic acidosis
d. Serum urea >17 mmol/l
e. Serum urea >17 mmol/l despite medical treatment
E - Serum urea >17 mmol/l despite medical treatment
The indications for renal replacement therapy in pregnancy mirror those in the nonpregnant population and include metabolic acidosis, hyperkalaemia and fluid overload refractory to medical management. In addition, urea is teratogenic and a serum urea of greater than 17 mmol/l, despite medical management, is a pregnancy-specific indication for renal replacement therapy.
TOG StratOG Resource
What changes in heart rate from lying to an upright position are essential to make a diagnosis of postural tachycardia syndrome (PoTS)?
a. A persistent increase in heart rate of >10 bpm
b. A persistent increase in heart rate of >20 bpm
c. A persistent increase in heart rate of >30 bpm
d. A persistent increase in heart rate of >40 bpm
e. A persistent increase in heart rate of >50 bpm
C - A persistent increase in heart rate of >30 bpm
For a diagnosis of PoTS, there has to be a persistent increase in heart rate of > 30 bpm when changing from lying to upright position in the absence of orthostatic hypotension. In severe cases, the standing heart rate is persistently >120 bpm.
TOG StratOG Resource
A 29-year-old is diagnosed with postural tachycardia syndrome (PoTS) at 20 weeks of gestation. What conservative treatment would be considered for this patient in the first instance?
a. Application of compression stockings
b. Increase caffeine intake
c. Increase fluid intake
d. Increase fluid and salt intake
e. Initiate aerobic exercises
D - Increase fluid and salt intake
The initial mainstay of conservative management for PoTS is increased fluid (2-3 l/day) and salt intake (up to 10–12 g/day), which is aimed at increasing the circulating plasma volume and improving clinical symptoms. Other conservative strategies include physical manoeuvres such as making a fist, bending forward, placing a foot on a chair and pumping calves before standing. Compression stockings have been used effectively but caffeine intake should be limited as it may promote hypovolaemia by increasing diuresis.
TOG StratOG Resource
A patient with a diagnosis of postural tachycardia syndrome presents to the antenatal clinic at booking. What do you advise is the effect of pregnancy on postural tachycardia syndrome in the majority of patients?
a. One third improve, one third deteriorate, one third stay the same
b. Deterioration in most patients
c. Stays the same in most patients
d. Improves in most patients
e. Stays the same in most patients with a considerable deterioration immediately postnatally
D - Improves in most patients
60% of patients with PoTS report improvement in their symptoms in pregnancy; around 15% stay the same and 25% worsen.
TOG 2018
Which of the following investigations is the usual diagnostic modality in the majority of non-pregnant patients with postural tachycardia syndrome?
a. 24 hour tape
b. Echocardiography
c. 24 hour tape with ambulatory blood pressure monitoring
d. Tilt table test
e. Completion of the ‘Orthostatic Pressure Symptoms Score’ (OPSS)
D - Tilt table test
The tilt table test is generally contraindicated in pregnancy. A stand test may be performed instead.
TOG 2018
Rates of which complication of pregnancy are higher amongst patients with postural tachycardia syndrome?
a. Hyperemesis gravidarum
b. Pre-eclampsia
c. Post-partum haemorrhage
d. VTE
e. Cardiomyopathy
A - Hyperemesis gravidarum
Women with PoTS have a higher
rate of severe vomiting or hyperemesis gravidarum in the
first trimester (50–60%) compared with the general
population.
TOG 2018
Which of the following is not a recommended conservative treatment modality for patients with postural tachycardia syndrome?
a. Increased fluid intake
b. ‘Pumping’ calves prior to standing
c. Reduced caffeine consumption
d. Exercise
e. Dietary salt restriction
E - Dietary salt restriction
An increase in salt consumption (10-12g/day) is recommended.
TOG 2018
