medical problems Flashcards
- A black multigravid woman who underwent a CS for failure to progress after an induction for PET complicated by endometritis, comes to see you 5/52 post partum with fatigue/dyspnoea/orthopnoea. O/E HR 110, BP 140/95, pretibial oedema, RUQ tenderness, fine crackles at both bases, CXR cardiomegaly, temp 36.7. What is Dx?
a) Post partum cardiomyopathy
b) Mitral stenosis
c) Pulmonary hypertension
d) Bacterial endocarditis
a) Post partum cardiomyopathy
- Red degeneration of a fibroid:
a) Causes an elevation of the ESR
b) Causes leucopaenia
c) Only occurs in pregnancy
d) Occurs due to embolisation of the feeding vessels
a) Causes an elevation of the ESR
- A woman is pregnant after bromocriptine treatment of a pituitary macroademoma. Management during pregnancy should include:
a) Continue bromocriptine
b) Visual field assessment
c) Xray sella turcica
d) Neurosurgery
b) Visual field assessment
- A multiparous woman presents 8 weeks post partum complaining of tiredness, palpitations and tremor. She has been losing weight and is unable to sleep. Pulse is 100 bpm, BP 160/90. The most likely diagnosis is:
a) HIV
b) Anxiety
c) Drug abuse
d) Thyrotoxicosis
d) Thyrotoxicosis
- Which is the most incorrect statement regarding the management of ITP?
a) LUSCS is of no benefit to fetus with known severe thrombocytopaenia
b) Fetal risk increases if the mother has a past history of splenectomy
c) Fetal scalp sampling shouldn’t be used because of the risk of bleeding
d) Maternal steroids should be given if the platelet count drops below 100
e) Fetal risk can be determined by maternal antibody titre
e) Fetal risk can be determined by maternal antibody titre
- What woman has the best reproductive future?
a) PG Eclamptic fit with DIC, BP normal at 6/52
b) Multi with severe preeclampsia, BP normal at 3 months
c) Preeclampsia with diastolic BP 100mmHg at 3 months
d) Woman with essential hypertension
e) Woman with chronic renal failure, currently stable
d) Woman with essential hypertension
1st ANC visit, 22yo primip, mother is NIDDM. No glycosuria. You advise the patient:
a) No chance that she will get diabetes
b) Need GTT in 2nd trimester
c) Start prophylactic insulin
d) If doesn’t get glycosuria in pregnancy, no risk of diabetes
e) Monitor her by doing fasting BSL in pregnancy
b) Need GTT in 2nd trimester
What percentage of patients are negative for HpA1a antigen?
a) 0.0002%
b) 0.02%
c) 0.2%
d) 2%
e) 20%
d) 2%
- Which of the following is most normal in a normal pregnancy?
a) MCV 105
b) WCC 12
c) Platelets 100,000
d) Reticulocytes 15%
b) WCC 12
Regarding Bell’s Palsy:
a) It is caused by compression of the facial nerve in the pterygopallatine fossa
b) It responds to NSAID’s
c) It causes a sensory nerve deficit
d) It is most common in late pregnancy
d) It is most common in late pregnancy
Acute peripheral facial nerve palsy of unknown cause
Paralysis of the facial nerve, typically involving all three peripheral branches, resulting in asymmetric facial expression and unilateral weakness of eye closure. There is a two- to fourfold increase in prevalence during pregnancy, especially in the third trimester or in the first postpartum week
Perineural edema, hypercoagulability causing thrombosis of the vasa nervosum, and relative immunosuppression in pregnancy have been proposed as potential etiologic factors appears to be an association with preeclampsia
The mainstay of pharmacologic therapy for Bell’s palsy is early short-term oral glucocorticoid treatment
no additional benefit for antiviral therapy
- Mother has anti Ro detected. What is the risk of congenital complete heart block in the fetus?
a) <5%
b) 10%
c) 20%
d) 30%
e) 40%
a) <5%
- The CLASP trial demonstrated that aspirin 60mg daily could:
a) Reduce severe early onset IUGR associated with PET
b) Reduce IUGR
c) Both
d) Neither
d) Neither
CLASP: Reduce the likelihood of PTD in women at risk of early onset severe PET.
In our multicentre study 9364 women were randomly assigned 60 mg aspirin daily or matching placebo. 74% were entered for prophylaxis of pre-eclampsia, 12% for prophylaxis of IUGR, 12% for treatment of pre-eclampsia, and 3% for treatment of IUGR. Overall, the use of aspirin was associated with a reduction of only 12% in the incidence of proteinuric pre-eclampsia, which was not significant. Nor was there any significant effect on the incidence of IUGR or of stillbirth and neonatal death. Aspirin did, however, significantly reduce the likelihood of preterm delivery (19.7% aspirin vs 22.2% control; absolute reduction of 2.5 [SD 0.9] per 100 women treated; 2p = 0.003). There was a significant trend (p = 0.004) towards progressively greater reductions in proteinuric pre-eclampsia the more preterm the delivery. Aspirin was not associated with a significant increase in placental haemorrhages or in bleeding
- Your 16/40 patient has a Mantoux reaction of 16mm. She is asymptomatic and CXR is normal. What is the best management?
a) Vaccinate with BCG
b) Reassure and review postnatally
c) Isoniazid 300mg daily for 6 months
d) Isoniazid 300mg daily for 12 months
e) Rifampicin 100 mg daily for 12 months
b) Reassure and review postnatally
If a skin test has been performed in the absence of an indication for prompt LTBI management and is positive, a chest radiograph should be performed. Delaying therapy is appropriate for patients with positive TST in the absence of a major risk factor for progression to active disease, ie, recent infection or immunosuppression. Therapy may be initiated three months after delivery to minimize concern for hepatitis in the postpartum period. If treatment for LTBI is deferred until after delivery, repeat evaluation for active disease, including chest x-ray, should be performed to confirm that active tuberculosis did not develop in the intervening time between diagnosis and treatment.
The regimen of choice for treatment of LTBI is isoniazid (5 mg/kg up to 300 mg daily) for nine months (table 2). This should be combined with pyridoxine supplementation (25 mg daily) [9].
A six month regimen of daily isoniazid also provides protection but is less desirable
Another choice for treatment of LTBI is rifampin (daily for four months) (table 2) [9]. Rifampin should be used for patients who are intolerant of INH or who are presumed to have infection with INH-resistant, rifampin-sensitive strains of TB.
- 16 yo primip with HIV on Western blot test and 28 weeks pregnant. Risk of transmission to the fetus is:
a) 0%
b) 10%
c) 30%
d) 60%
e) 80%
c) 30%
With multiple retroviral therapy – transmission rate < 2%
With no treatment –
HIV transmission rates were:
●20 percent among 396 women who did not receive antiretroviral drugs
●10 percent for 710 women taking zidovudine alone
●4 percent for 186 women receiving dual antiretroviral drug regimens
●1 percent for those taking three-drug combination antiretroviral drug regimens
- In pregnancy compared to the non-pregnant state:
a) Thyroxine remains the same
b) Free T3 increases
c) Total T3 increases
d) Thyroid binding globulin decreases
c) Total T3 increases
- Serum TBG concentrations rise almost two-fold because oestrogen increases TBG production
- Total serum T4 and T3 concentrations increase. Serum free T4 and T3 concentrations increase slightly, usually within the normal range, and serum TSH concentrations are appropriately reduced
- At routine cardiovascular examination in pregnancy, which of the following may be normal:
a) Diastolic murmur
b) 3rd heart sound
c) Ejection click
d) Renal bruit
b) 3rd heart sound
- *Which of these are true in pregnancy?
a) Normal pregnant requirement of iron in 9mg/day
b) Normal non-pregnant requirement of iron is 4 mg/day
c) Cord ferritin is higher than maternal ferritin
d) 10% of iron is absorbed from non-haem sources
c) Cord ferritin is higher than maternal ferritin
- You see a patient with bipolar disease on Lithium 900mg /day. The risks to the fetus include:
a) CNS abnormalities
b) Cardiac abnormalities
c) Renal anomalies
d) Post-maturity
b) Cardiac abnormalities ( Ebstein barr anomaly)
Normal dose 0.5 – 1gm daily with divided doses
Teratogenicity
o First trimester risk of Ebstein’s anomaly 0.05-0.1%
o Risks of other morphologic and behavioural teratogenicity less clear
o Risk of fetal toxicity cannot be detected by maternal serum lithium level
o Neonatal lithium toxicity can include transient hypothyroidism and tranient nephrogenic diabetes
- Which of the following is associated with intrahepatic cholestasis of pregnancy?
a) RUQ pain
b) High risk of recurrence in future pregnancies
c) Bilirubin levels >10 ( rarely exceeds 6 )
d) Excessive use of antacids
b) High risk of recurrence in future pregnancies
- Number of women who experience transient post-partum blues:
a) 5%
b) 10%
c) 25%
d) 50%
e) 90%
d) 50%
- UTD: 40-80% of women develop transient symptoms D2 to D3
- RCOG: Up to 85% of women
- The most common cause of hyperthryoidism in pregnancy is:
a) Toxic multinodular goitre
b) Graves disease
c) Toxic shock syndrome
d) Iatrogenic
b) Graves disease
- Which change is considered normal/physiological in preg (correct option)
a) Raised Alk phos
b) Decreased albumin
c) Increased urea
a) Raised Alk phos
b) Decreased albumin
- ITP, correct option:
a) Caesarean section is not helpful in known severe fetal thrombocytopenia
b) FBS should not be attempted due to risk of bleeding from puncture site
c) Splenectomy decreases the likelihood of correlation between maternal and fetal platelet counts
d) Maternal antiplatelet ab levels correlate with incidence of neonatal platelet levels
b) FBS should not be attempted due to risk of bleeding from puncture site
- How many women die every day world wide because of a pregnancy related problem?
a) 100
b) 700
c) 1400
d) 3600
b) 700
WHO: 830 every day
A woman with bipolar affective disorder on lithium presents at 11/40. Serum lithium is 1.0 (0.9-1.4). She should be told:
a) Lithium is suspected of causing heart defects
b) To cease lithium now will reduce risk to the baby
c) To reduce dose will reduce risk to baby
d) She should have CVS
e) Should have amniocentesis at 16/40
a) Lithium is suspected of causing heart defects
- What is the most likely type of cardiovascular malformation found in the fetus if the mother has congenital heart disease?
a) Congenital heart disease only
b) Congenital heart disease and arterial disease
c) Congenital heart disease and arterial and venous disease
d) Congenital heart disease and venous diseases
e) Congenital arterial and venous diseases
a) Congenital heart disease only
- Most likely cause of perinatal mortality with diabetes?
a) Fetal hypoglycaemia
b) Congenital abnormality
c) APH
d) Fetal hyperinsulinaemia
e) PIH
b) Congenital abnormality
- All the following are associated with increasing maternal age EXCEPT:
a) 45 XO
b) trisomy 21
c) 47 XXY
d) trisomy 13
e) trisomy 18
a) 45 XO
- Which congenital coagulation disorder improves in pregnancy?
a) anti-thrombin 3 deficiency
b) vWB disease
c) protein C deficiency
d) protein S deficiency
e) haemophilia
b) vWB disease (vWB factor increases in pregnancy )
a) anti-thrombin 3 deficiency – steady state
c) protein C deficiency – increase in resistance
d) protein S deficiency – worse
e) haemophilia ( factor 8 levels increase in pregnancy, but not factor 9)
Which of the following test is most useful in diagnosing haemoglobinopathy?
a) HbEPG
b) Bone marrow
c) DNA analysis
d) Red cell index
e) Blood film
a) HbEPG
HbEPG = Hemoglobin electrophoresis which should be performed in all women who have:
• An MCV <80 fL in the absence of iron deficiency or
• A family, ethnic, or medical history at higher risk for hemoglobinopathy
Hemoglobin electrophoresis will identify the presence of abnormal and excess or deficient quantities of globin chains.
For example, hemoglobin A2 >3.5 percent with MCV <80 fL suggests the diagnosis of beta thalassemia;
a normal hemoglobin A2 with MCV <80 fL suggests alpha thalassemia;
- Most likely to cause maternal mortality
a) Mitral stenosis
b) Diabetes
c) PIH
d) Pulmonary stenosis
a) Mitral stenosis
- Zinc deficiency causes:
a) Anaemia
b) IUGR
c) Prem labour
b) IUGR
Severe Zinc deficiency associated with IUGR, another study suggest increase in birth weight. Meta analysis showed no association with IUGR but assoc with PTL in women of low income.
Possible answers for next 3 question
a) Nil
b) 1-2%
c) 2-4%
d) 5-10%
e) 25%
f) 50%
g) 100%
- Pregnant woman’s brother has schizophrenia. Risk of schizophrenia in child?
- Pregnant woman’s husband has schizophrenia. Risk of schizophrenia in child?
- Your patient attends for menopausal advice, mentions her son has schizophrenia as has his partner and they are thinking of starting a family. Risk of child?
- c) 2- 8% ( babys uncle)
- d) 6-16% (father of baby)
- both parents 36%
- Management of isolated thyroid nodule at 10/40?
a) FNAC
b) Expectant Mx
c) Administer thyroxine to shrink it
d) Radioactive Iodine uptake scan
a) FNAC
- Commonest cause of hypothryoidism during pregnancy?
a) Congenital
b) Autoimmune
c) Drugs
d) Previous surgery
e) Previous irradiation
b) Autoimmune
- Post partum thyroiditis women usually experience transient?
a) Hypothyroidism
b) Hyperthyroidism
b) Hyperthyroidism
- At 12/12, patients with post partum thyroiditis are usually?
a) Hypothyroid
b) Euthyroid
c) Hyperthyroid
b) Euthyroid
- Post partum thyroiditis is usually?
a) Graves
b) Hashimoto’s
c) De Quervian’s
b) Hashimoto’s
- Usually found in trophoblast associated hyperthyroidism?
a) Increase free T3 and T4
b) Increase total T3 and T4
c) Low measurable TSH
d) All of the above
d) All of the above
- Intrahepatic cholestasis associated with all except:
a) Neonatal jaundice
b) Pruritis with onset of jaundice
c) 3rd trimester
d) Increase premature delivery
a) Neonatal jaundice
Fetal risks are mec stained liquor, fetal distress, stillbirth incidence > 37 wks 1.2/100, rds, preterm birth ( iatrogenic, spontaneous )
- Prognosis for future pregnancy is best for:
a) Primip – eclampsia and DIC at 6 weeks postpartum normal BP
b) Multi with HT controlled in pregnancy, still hypertensive
c) Multi with severe PE with normal BP at 6/52
d) Congenital cardiac disease, stable but past history of CCF
e) Stable chronic renal failure
b) Multi with HT controlled in pregnancy, still hypertensive
- Which of the following parameters are reduced in the 3rd trimester when iron supplements have been given?
a) Total WCC
b) Serum ferritin
c) Red cell mass
d) Plasma volume
e) ESR
??
a) Total WCC – false increases normally
b) Serum ferritin – increase
c) Red cell mass – increase normally until 32 weeks
d) Plasma volume – increase until 32 weeks
e) ESR – increases
- In RCT the proven benefits of screening for GDM are
a) Decreased PNM
b) Decreased shoulder dystocia
c) Decreased neonatal jaundice
d) All of the above
e) None of the above
a) Decreased PNM
Options for next 4 questions
a) heparin only
b) warfarin only
c) heparin and warfarin
d) none of the above
- Which one crosses the placenta
- Which one is monitored by bleeding time?
- Which one causes stripling of the epiphysis?
- Which one causes lysis of the thromboses?
- b
- . d
- b
- d
- Which chromosomal abnormality doesn’t increase in frequency with increased maternal age?
a) trisomy 21
b) trisomy 18
c) Turners XO
d) XXY
c) Turners XO
- An IV drug user on heroin first presents at 28/40 and is commenced on methadone 40mg daily. She is seeing you at 31/40. What should ongoing Mx plan be?
a) Continue methadone at current dose until delivery
b) Wean from now on, using promethazine to treat withdrawal symptoms
c) Continue methadone but introduce low dose naloxone at 38/40
d) Continue methadone until labour then cease and use promethazine in labour
e) Continue methadone but give IV naloxone infusion in labour
a) Continue methadone at current dose until delivery
- Regarding mitral stenosis?
* ***
a) It is the worst cardiac lesion to have in pregnancy – if lesion< 1cm 2 with sx pre pregnancy
b) It is unusual to cause any problems if it is grade 1 or 2 at conception
c) If it produces cardiac failure before 32 weeks valvotomy will often be required despite medical treatment ( sx occur later 2nd trimester and early 3rd trimester at max CO 20-28wks )
d) The most common cause of death is cerebral emboli from atrial thrombus
e) Bacterial endocarditis is more common in pregnancy
a) It is the worst cardiac lesion to have in pregnancy – if lesion< 1cm 2 with sx pre pregnancy
c) If it produces cardiac failure before 32 weeks valvotomy will often be required despite medical treatment ( sx occur later 2nd trimester and early 3rd trimester at max CO 20-28wks )
pulmonary HTN has highest maternal mortality but that is not a cardiac lesion
- Regarding inflammatory bowel disease in pregnancy?
a) Ulcerative colitis is associated with reduced fertility compared to Crohn’s disease
b) It gets worse in pregnancy and the puerperium -
c) Surgery should not be delayed due to pregnancy
d) Sulphasalazine is C/I in pregnancy
c) Surgery should not be delayed due to pregnancy
a) Ulcerative colitis is associated with reduced fertility compared to Crohn’s disease – Crohns associated with reduced fertility
d) Sulphasalazine is C/I in pregnancy – Safe in pregnancy and bf
Crohns:
Reduced fertility with active crohns disease
Quiescent in ¾ of pregnant px & improves in 1/3rd of active disease
Most exacerb of inactive disease in 1st trimester
UC:
Exacerb mild and usually 1st and 2nd trimester
Post partum flare same as non pregnant
Px with prev surgery and active disease do less well. Ileostomy dysfunction can occur in pregn. Most serious complication is intermittent intestinal obstruction, peristomal cracking and bleeding from stretching of abdominal wall.
Successful pregnancies and vaginal deliveries have been reported foll ileoanal anastomosis and ileal pouches.
- Herpes gestationis can be diagnosed if?
a) Similar skin lesions are noted in subsequent pregnancies
b) Similar skin lesions are noted in association with the OCP or menstruation
c) There is peripheral eosinophilia
d) Herpes serology is positive-
e) On histologic examination complement and IgG is seen adjacent to the basement membrane between the dermis and epidermis
e) On histologic examination complement and IgG is seen adjacent to the basement membrane between the dermis and epidermis T
Also called pemphigoid gestationis
- Rare serious condition
- 1 in 10 000 to 1 : 60 000
- Autoimmune possibly related to exposure to fetal antigen
- Onset 9wks to 1 week post partum
- Distribution: periumbilical spread to limbs, palms, and soles
- Pruritis, erythematous plaques & papules, target lesions, annular wheals – can form vesicles and large tense vesicles.
- Resolves in 2nd trimester, improvement at end of pregnancy. Can persist many months post partum.
- Dx – skin bx, complement deposition C3 at basement membrane zone.
- Fetal - ↑ risk of LBW, SB, PTB – 10% neonate can have bullous eruption.
- Rx – steroids, topical or oral, anti histamine.
- Recurrence – future pregn and COC
- Severe post-partum depression is most likely with?
a) Low SES status
b) A poor emotional relationship of the patient with her mother
c) Past history of depression
d) First pregnancy
e) Loss of weight during the pregnancy
c) Past history of depression
- The psychiatric diagnosis which is most likely to have a familial component is?
a) Post-partum depression
b) Post-menopausal depression
c) Anxiety
d) Bipolar disorder
e) None of the above
d) Bipolar disorder
- The disease most likely to cause jaundice when it occurs in pregnancy is?
a) Pancreatitis
b) Cholecystitis
c) Hepatitis
d) Severe pre-eclampsia
e) Cirrhosis
? e
jaundice more common in choledocholithiasis than cholecystitis
14% of hepatitis present with jaundice
In a woman who is found to have Hb 9 g/dl, MCV 70fl, MCHC 28, serum iron 6 and TIBC 109, which is most likely?
a) A microcytic picture on blood film
b) Target cells
c) Reticulocyte count of 10%
d) She should be treated with folic acid
e) High urea levels
a) A microcytic picture on blood film
- Phaeochromocytoma in pregnancy is associated with?
a) Paroxysmal episodes of HT
b) High urinary levels of hydroxy indole acetic acid, HIAA – for carcinoid tumours
c) Obstetric collapse
d) Tumour in adrenal cortex
e) Glucose intolerance
a) Paroxysmal episodes of HT
Catechollamine secreting tumour of the adrenal medulla.
Rare 0.2% of px with hypertension.
Classic triad of sx ( not all necessary or present at the same time )– headache 90% of patients, sustained or paroxysmal HTN, generalised sweating in 60-70% of sx px. ( palpitation, SOB, panic attack type sx )
Ix: 24hr urine catecholamine, plasma fractionated metanephrines, ( TCA can affect result, stop for 2/52, stress induced from major illness can also affect results )
Rx in Pregnancy : Maternal 8% and fetal 17% mortality high. Optimal mx not clearly defined. Medical Rx – alpha adrenergic blockade ( phenoxybenzamine ) followed by beta blocker.
Surgical if < 24/40 , drug crosses placenta and causes perinatal depression and transient hypotension, But drug generally safe.
Medical if > 24 wks – cs + adrenal tumour resection together closer to term, cs preferred less risk of maternal death than vaginal delivery.
- Which of the following is considered normal in the second half of pregnancy?
a) MCV 105 fl
b) WCC 12x10 (9) /l
c) Platelets 100,000
d) Reticulocytes 15% of red blood cell count
b) WCC 12x10 (9) /l
- Which of the following is considered normal in pregnancy?
Renal blood flow serum urea serum creatinine
a) increased increased increased
b) increased decreased increased
c) increased decreased decreased
d) increased increased decreased
e) decreased decreased decreased
c) increased decreased decreased
- Which of the following is least likely to have normal pregnancy outcome?
a) booking BP 140/90
b) maternal age 40 yrs
c) serum urea of 12
c) serum urea of 12
Which of the following in not associated with thrombosis?
a) Activated protein deficiency
b) Protein S deficiency
c) Thrombin 3 deficiency
d) Factor V leiden mutation -
e) Antiphospholipid syndrome -
`````
a) Activated protein deficiency
b) Protein S deficiency - T
c) Thrombin 3 deficiency – ( anticoagulant usually so if deficiency is associate - T
d) Factor V leiden mutation - T
e) Antiphospholipid syndrome - T
Which is not true?
a) Normal non-pregnant, non-menstruating iron intake is 1mg/day
b) Normal non-pregnant, menstruating iron intake is 2mg/day
c) Normal pregnant intake 8mg/day
d) 10% of iron from diet is absorbed in non-pregnant
e) Cord ferritin is higher than maternal ferritin
c) Normal pregnant intake 8mg/day
Normal pregnant intake 2.5mg/day
Max rise with oral or parental iron is 0.8g/dL/wk
- PG at 32/40 presents with vomiting, epigastric pain. LFT’s abnormal, platelets 60. Cervix long and closed. BP normal, no proteinuria. What do you do?
a) US liver
b) Induction
c) Caesarean
d) Watch and wait
c) Caesarean
AFLP high feat/ neonatal and maternal mortality rate . need to check glucose- and replace/ ICU etc
- Which state has the greatest clinical infection of candida?
a) 1st trimester
b) 2nd trimester
c) 3rd trimester
d) Post partum
e) Post menopause
c) 3rd trimester
- Which is most likely to cause pulmonary HT?
a) Eisenmengers
b) MS - severe
a) Eisenmengers
- Advice re alcohol in pregnancy?
a) Only safe thing is not to have any
b) Better to have none but no increase in FAS with one standard drink per day
c) 3 standard drinks per day safe as long as there is no binge drinking
d) A constant low intake best so the fetus is exposed to constant low levels
a) Only safe thing is not to have any
