MISCELLANEOUS FACTS FROM PASSMED

Question 1

What are the commonly prescribed drugs that should be avoided in breastfeeding women?

Answer 1

Antibiotics:

• Ciprofloxacin
• Tetracycline
• Chloramphenicol
• Sulphonamides
• Nitrofurantoin

Psychiatric drugs:

• Lithium
• Benzodiazepines
• Clozapine

Aspirin

Carbimazole

Sulphonylureas

Cytotoxic drugs

Amiodarone

Question 2

A 32-year-old 1 week post-partum female presents to her local emergency department with a few days history of vaginal bleeding: initially bright red blood which has now changed in colour to become brown. She is changing her sanitary pads once every 3 hours and is worried that the caesarean section birth has caused damage to her womb. On examination she is visibly distressed but afebrile. She is normotensive with a heart rate of 95 beats per minute and a respiratory rate of 19 breaths per minute. Abdominal examination does not cause pain and reveals a caesarean section scar which is pink and not tender. What is the most appropriate management at this stage?

Reassure, advise and discharge

Insert two large bore cannula and send blood for cross matching

Start immediate IV broad spectrum antibiotics

Refer for exploratory laparoscopy

Admit for IV fluids and observations

Answer 2

Reassure, advise and discharge

This patient is describing lochia, the bleeding that presents for the first 2 weeks (can be up to 6 weeks) following giving birth, whether this is by vaginal birth or caesarian section. Due to the higher risk of post-partum haemorrhage in caesarian section however, a detailed history and examination should take place in this case for any concerning features.

Lochia typically takes the course of fresh bleeding, which undergoes colour changes before finally stopping. The patient can be reassured and advice should be given to her regarding lochia. Specifically, she should be told that if this begins to smell badly, its volume increases or it doesn’t stop, she should seek medical help. In this case the volume is not excessive and there are no concerning features to the lochia or abnormal observations.

Question 3

A 29-year-old woman presents with right iliac fossa pain. She has a past medical history of an ectopic 8 months previously with right sided salpingectomy. She had an ultrasound scan 3 days previously which demonstrated a viable intrauterine pregnancy. Clinically she is Rovsing sign positive with raised inflammatory markers. What is the most likely diagnosis?

Adnexal torsion

Appendicitis

Ectopic

Mesenteric adenitis

Ovarian torsion

Answer 3

Rovsing sign = Appendicitis

Question 4

A 29 year-old woman visits her general practitioner to discuss smoking cessation, having just discovered that she is ten weeks pregnant. She has tried to give up several times in the past using motivational interviewing sessions but was unsuccessful. She wants to know if there are any medications that might help her. Which of the following could be prescribed for this purpose?

Varenicline

Chlordiazepoxide

Bupropion

Nicotine replacement patch

Amitriptyline

Answer 4

Nicotine replacement patch

Question 5

Which one of the following statements regarding cervical ectropion is incorrect?

Describes an increased area of columnar epithelium

May result in post-coital bleeding

Is less common in women who use the combined oral contraceptive pill

May result in excessive vaginal discharge

Is more common during pregnancy

Answer 5

Is less common in women who use the combined oral contraceptive pill

On the ectocervix there is a transformation zone where the stratified squamous epithelium meets the columnar epithelium of the cervical canal. Elevated oestrogen levels (ovulatory phase, pregnancy, combined oral contraceptive pill use) result in larger area of columnar epithelium being present on the ectocervix

This may result in vaginal discharge and post-coital bleeding

Ablative treatment (for example ‘cold coagulation’) is only used for troublesome symptoms

Question 6

Which one of the following is not a recognised adverse effect of the combined oral contraceptive pill?

Increased risk of ovarian cancer

Increased risk of deep vein thrombosis

Increased risk of breast cancer

Increased risk of ischaemic heart disease

Increased risk of cervical cancer

Answer 6

Increased risk of ovarian cancer

Question 7

A 26 year old woman is found to be hypertensive with a blood pressure of 155/110 mmHg during labour for her first baby at 39 weeks. Urinalysis shows +++ protein. Which of these is the most appropriate way to manage her hypertension?

Administer lisinopril with target diastolic blood pressure 80-100 mmHg

Administer aspirin and intramuscular steroids

Administer intravenous nifedipine with target diastolic blood pressure

Answer 7

Administer intravenous labetalol with target diastolic blood pressure 80-100 mmHg

Question 8

A woman who is 36 weeks pregnant is reviewed. This is her first pregnancy. Her baby is known to currently lie in a breech presentation. What is the most appropriate management?

Reassure mother baby will most likely turn to a cephalic presentation prior to delivery

Refer for external cephalic version

Admit for induction of labour and trial of vaginal delivery

Refer for radiological pelvimetry

Admit for caesarean section

Answer 8

Refer for external cephalic version

If less than 36 weeks you can reassure and reassess at 36 weeks. Once you hit 36 weeks, ECV should be attempted

Question 9

Which of these is a possible indication for induction of labour?

Bishop’s score of 7

Previous induced labour

Uncomplicated pregnancy at 41 weeks gestation

Fetal growth restriction (FGR)

Breech position

Answer 9

Uncomplicated pregnancy at 41 weeks gestation

Women should be offered induction between 41-42 weeks of an uncomplicated pregnancy to avoid risks of prolonged pregnancy.

Question 10

A 33-year-old primigravida woman of 32 weeks gestation presents to the Emergency Department with premature rupture of membranes. There have been no complications of the pregnancy so far and the woman is normally fit and well. How is she best managed?

Inform her that she should come back if she feels she is getting a temperature

Prescribe her antibiotics and inform her to come back if she feels she is getting a temperature

Admit her for at least 48 hours and prescribe antibiotics

Admit her for at least 48 hours and prescribe antibiotics and steroids

Admit her for at least 48 hours and prescribe steroids only

Answer 10

Admit her for at least 48 hours and prescribe antibiotics and steroids. Currently erythromycin is recommended

Question 11

A 31-year-old female presents to the genitourinary medicine clinic due to four fleshy, protuberant lesions on her vulva which are slightly pigmented. She has recently started a relationship with a new partner. What is the most appropriate initial management?

Oral aciclovir

Topical podophyllum

Topical salicylic acid

Topical aciclovir

Electrocautery

Answer 11

Genital wart treatment:

• if there are multiple, non-keratinised warts: topical podophyllum
• if there is a solitary, keratinised warts: cryotherapy

Cryotherapy is also acceptable as an initial treatment for genital warts

Question 12

A woman complains of severe itching at 34 weeks gestation. The itching started 2 weeks previously and has been preventing her from sleeping. She is itchy all over her body, especially in her hands and feet. She has not noticed any rashes. Her mother reports similar symptoms when she was pregnant with her 2nd child. She is otherwise well. What is the most appropriate action?

Dermatology referral

Give topical steroids

Check uric acid levels

Check renal function

Check liver function tests

Answer 12

Check liver function tests.

It is bile acids that are raised rather than uric acid levels

Question 13

A 31-year-old woman complains of intermittent pain in the left iliac fossa for the past 3 months. The pain is often worse during intercourse. She also reports urinary frequency and feeling bloated. There is no dysuria. What is the most likely diagnosis?

A.	Appendicitis
B.	Ovarian torsion
C.	Subacute bowel obstruction
D.	Endometriosis
E.	Urinary tract infection
F.	Ovarian cyst
G.	Chronic interstitial cystitis
H.	Uterine fibroids
I.	Pelvic inflammatory disease
J.	Ectopic pregnancy

Answer 13

Ovarian cyst

Question 14

A 28-year-old woman who is 10 weeks pregnant comes to see you for her booking appointment. She has heard there are some vaccinations offered in pregnancy and wants more information.

Which of the following combinations of vaccinations are routinely offered to pregnant women in the UK?

Pertussis and pneumococcus

Influenza and rubella

Influenza and pneumococcus

Influenza and pertussis

Pertussis and rubella

Answer 14

Influenza and pertussis

Question 15

A 44-year-old female has a Mirena (intrauterine system) fitted for contraception on day 12 of her cycle. How long will it take before it can be relied upon as a method of contraception?

Immediately

2 days

5 days

7 days

Until first day of next period

Answer 15

Contraceptives - time until effective (if not first day period):

• Instant: IUD
• 2 days: POP
• 7 days: COC, injection, implant, IUS

Question 16

Your next patient in an antenatal clinic is a woman who is 30 weeks pregnant. Which of the following findings during your examination would you be concerned with?

Fundus palapable above the umbilicus but below the xiphisternum

Fundal height growth of 2cm per week

Breech presentation

Able to auscultate the foetal heart

Free head of palpation

Answer 16

Fundal height growth of 2cm per week

Question 17

The chance of a 40-year-old mother giving birth to a child with Down’s syndrome is approximately:

1 in 5

1 in 10

1 in 30

1 in 100

1 in 500

Answer 17

1 in 100

20 years of age – 1 in 1,500

30 years of age – 1 in 800

35 years of age – 1 in 270

40 years of age – 1 in 100

45 years of age – 1 in 50 or greater

One way of remembering this is by starting at 1/1,000 at 30 years and then dividing the denominator by 3 (i.e. 3 times more common) for every extra 5 years of age

Question 18

A 35-year-old obese gravida 3 para 2 has developed a swollen and tender left leg; she is currently at 32 weeks of gestation and started on the appropriate treatment regimen. Due to her weight, the clinician decides to monitor her treatment with a specific blood test. Which blood test is this?

Platelet count

Prothrombin time (PT)

Activated Partial Thromboplastin Time (APTT)

Anti-Xa activity

International Normalised Ratio (INR)

Answer 18

Anti-Xa activity

Routine measurement of peak anti-Xa activity for patients on LMWH for treatment of acute VTE in pregnancy or postpartum is not recommended except in women at extremes of body weight (less than 50 kg and 90 kg or more) or with other complicating factors (for example, with renal impairment or recurrent VTE). Routine platelet count monitoring should not be carried out.

Question 19

A 22-year-old female has a Nexplanon inserted. For how long will this provide effective contraception?

12 weeks

12 months

3 years

5 years

7 years

Answer 19

3 years

Question 20

A 22 year old woman is 14 days postpartum. She is formula feeding her baby. She attends her GP requesting emergency contraception as she had unprotected sexual intercourse (UPSI) 2 days ago. Which of the following would you recommend?

Levonorgestrel (Levonelle)

Ulipristal acetate (ellaOne)

No emergency contraception required

Mirena coil

Copper intra-uterine device (Cu-IUD)

Answer 20

No emergency contraception required

Emergency contraception (EC) is not required before day 21 postpartum. The earliest date of ovulation in a non-breastfeeding woman is thought to be day 28 postpartum. Therefore, contraception is required from day 21 onwards, as sperm can survive for up to 7 days. Woman who are exclusively breastfeeding will take longer to ovulate, however contraception should still be advised if pregnancy is not desired.

After day 21 postpartum, progesterone only EC (Levonelle and ellaOne) can be used in both breastfeeding and non-breastfeeding woman.

The Cu-IUD should not be inserted before day 28 postpartum, due to the increased risk of uterine perforation if inserted before this time.

Question 21

A 20-year-old woman comes to your clinic complaining of three missed periods, although home pregnancy tests have been negative (which is confirmed today in clinic). She has noticed her skin has become spottier and she has more hair growing on her face than normal. What one investigation would best diagnose her condition?

MRI brain

Serum testosterone and prolactin

Serum LH/ FSH levels

Fasting blood glucose

Ovarian ultrasound

Answer 21

Ovarian ultrasound

Question 22

A 31-year-old female presents to the antenatal clinic for a booking appointment. Which of the following should be identified as a risk factor for pre-eclampsia?

Her age (31 years old)

1 previous successful pregnancy

Body mass index of 29kg/m^2

History of smoking

Pre-existing renal disease

Answer 22

Pre-existing renal disease

The following are risk factors that should be determined:

Aged 40 years or older
Nulliparity
Pregnancy interval of more than 10 years
Family history of pre-eclampsia
Previous history of pre-eclampsia
Body mass index of 30kg/m^2 or above
Pre-existing vascular disease such as hypertension
Pre-existing renal disease
Multiple pregnancy

Question 23

A 32-year-old female with long standing hypothyroidism is confirmed as pregnant at 8 weeks gestation. She is taking 75 micrograms of levothyroxine and this dose has remain unchanged over the past 18 months. Blood tests show the following:

fT4 11.7 pmol/L
TSH 2.77 mU/L

What is the most appropriate action in relation to this woman’s levothyroxine dose?

Increase to 100 micrograms daily

Maintain at 75 micrograms per day

Reduce to 50 micrograms per day

Change to liothyronine

Reduce to 25 micrograms per day

Answer 23

Increase to 100 micrograms daily

Question 24

An 18-year-old woman is diagnosed with epilepsy and started on carbamazepine. She currently takes the combined oral contraceptive pill for contraception. She tells her GP that she is sexually active and would like to continue to use some form of contraception. She does not want a coil as she has states her friend ‘had a bad experience’. What would be the best form of contraception for her?

Continue on the combined contraceptive pill

Switch to progesterone only pill

Switch to the progesterone implant (Nexplanon)

Switch to the combined contraceptive patch

Switch to progesterone injection (Depo-Provera)

Answer 24

Switch to progesterone injection (Depo-Provera)

Carbamazepine is an enzyme inducer and it can decrease the effectiveness of the combined oral contraceptive pill and progesterone only pill when taken at normal doses. The progesterone implant (Nexplanon) is also not recommended as it has a low dose of progesterone that is released into the bloodstream and this low amount can be effected by enzyme inducing drugs such as Carbamazepine.

The patient has stated that she does not want an intra-uterine method (coil) at this time and so Depo-Provera is the best choice. Depo-Provera can be used as a first-line contraception in younger women as long as other methods have been discussed with the patient and are considered to be contraindicated or unacceptable to the patient.

Question 25

A 39-year-old woman, para 4+1, presents to the antenatal clinic for her booking appointment at 12+2 weeks gestation. Her body mass index is 39 kg/m2. She states that she is a non-smoker. She does not have a past history of blood clots or any other health problems. Her family history does not include any thrombophilia or blood clots. She reports no issues with her pregnancy thus far. She is assessed for her risk of venous thromboembolism. What is the correct management? Low molecular weight heparin from 28 weeks until 6 weeks post-natal Low molecular weight heparin now until 6 weeks post-natal Oral warfarin Oral aspirin No prophylaxis needed

Answer 25

Low molecular weight heparin from 28 weeks until 6 weeks post-natal This woman is at an increased risk of deep vein thrombosis. Her antenatal risk factors include: - Body mass index more than 30 kg/m2 - Parity more than 3 - Age more than 35 RCOG guidelines suggest that any woman with three risk factors for venous thromboembolism during pregnancy be treated with low-molecular weight heparin from 28 weeks until 6 weeks postnatal.

Question 26

A 20-year-old pregnant lady is found to be anaemic 10 weeks gestation. A full blood count is ordered: Hb - 85 g/L MCV - 95 fL The lab also reports a high reticulocyte count. A blood film shows target cells and Howell-Jolly bodies. What is the most likely cause of the anaemia? Folate deficiency Anaemia of chronic disease Iron deficiency B12 deficiency Sickle cell disease

Answer 26

Sickle cell disease The full blood count confirms a normocytic anaemia. Folate and B12 deficiency cause megaloblastic anaemia which is characterised by macrocytosis. Iron deficiency and thalassaemia typically cause microcytosis. Therefore, based on the MCV it can be inferred that sickle cell disease is the most likely answer. In addition, the Howell-Jolly bodies suggest hyposplenism which can occur in Sickle cell disease due to splenic infarctions. The high reticulocyte count suggests increased destruction (e.g. haemolysis) or increased loss (e.g. bleeding) of red cells. Sickle cell disease results in a chronic haemolytic anaemia due to premature destruction of abnormally shaped red cells. This would result in a high reticulocyte count.

Question 27

At her booking visit, a woman mentions to her midwife that she has been previously diagnosed with immune thrombocytopenic purpura (ITP). Which procedure carries the greatest risk of haemorrhage in the newborn? External cephalic version Forceps delivery Prolonged ventouse delivery Fetal blood sampling Caesarean section

Answer 27

Prolonged ventouse delivery

Question 28

A hepatitis B serology positive woman gives birth to a healthy baby girl. She is surface antigen positive. What treatment should be given to the baby? Hep B vaccine Hep B vaccine and 0.5 millilitres of HBIG within 12 hours of birth 0.5 millilitres of HBIG within 12 hours of birth only Hep B vaccine and 0.5 millilitres of HBIG within 12 hours of birth with a further hepatitis vaccine at 1-2 months and a further vaccine at 6 months No treatment required

Answer 28

Hep B vaccine and 0.5 millilitres of HBIG within 12 hours of birth with a further hepatitis vaccine at 1-2 months and a further vaccine at 6 months

Question 29

A 27 year-old lady is day 1 post emergency caesarean section for failure to progress in the first stage. She has been complaining of pain and heavy vaginal bleeding since delivery and in the morning was noted to have heavy, offensive lochia and a boggy poorly contracted uterus above the umbilicus. What is the most appropriate treatment? Urgent ultrasound scan Speculum examination Examination under anaesthesia IV antibiotics and review after first dose Urgent MRI scan

Answer 29

Examination under anaesthesia This is a typical history of retained products, which can happen after caesarean section if care is not taken to make sure that all the placental membranes are removed. The uterus does not contract down well as the products are still in the cavity, and the discharge is offensive suggesting that the products have become infected.

Question 30

17-year-old girl who is nine weeks pregnant has a surgical termination of pregnancy. She feels well a few hours after the procedure. Which of the following risks is most common following a TOP? Infection Haemorrhage Uterine perforation Cervical trauma Failure

Answer 30

Infection

Question 31

A 16-year-old girl comes to your GP surgery worried that she has not yet started her periods. She is quite short, has a webbed neck, low set ears and widely spaced nipples. A heart murmur is heard on auscultation. What type of murmur are you most likely to hear? Systolic, loudest over the pulmonary valve Diastolic, loudest over the pulmonary valve Systolic, loudest over the aortic valve Systolic, loudest over mitral valve Diastolic, loudest over mitral valve

Answer 31

Systolic, loudest over the aortic valve From the clinical picture, you should have a differential diagnosis of Turner's syndrome. Patients with Turner's syndrome are prone to have bicuspid aortic valve, aortic valve stenosis and/or aortic coarctation. For this reason, you would be expecting to hear a systolic murmur which is loudest over the aortic region.

Question 32

A 34-year-old woman who is 35 weeks pregnant presents to her general practitioner with painful blisters affecting the vagina and cervix, along with inguinal lymphadenopathy. She has never had these symptoms before. The GP diagnoses primary genital herpes. Which of the following management strategies is most appropriate? Simple analgesia only Oral aciclovir for 5 days Oral aciclovir until delivery and delivery by caesarean section Caesarean section Oral aciclovir until delivery

Answer 32

Oral aciclovir until delivery and delivery by caesarean section Guidelines issued by the Royal College of Obstetricians and Gynaecologists state that women who present with first-episode genital herpes during their third trimester should be managed with daily suppressive oral aciclovir 400mg until delivery. Delivery should be by caesarean section due to a high risk of neonatal HSV (herpes simplex virus) transmission.

Question 33

A 30-year-old primigravida lady with an epidural in-situ is in her 2nd stage of labour, she has been pushing for 2 hours and is now exhausted. On examination, the fetus is felt in the occipitoanterior position and with a station of +1. The cardiotocogram readings are normal and reassuring. What is the most appropriate next step in management? Emergency caesarian section Augmentation with IV syntocinon Instrumental delivery Membrane sweeping Amniotomy

Answer 33

Instrumental delivery Remember that +1 means the baby is below station not above it. So it is nearly out. Instrumental delivery is classically used in this scenario.

Question 34

You are performing a routine examination of a woman who is 37 weeks pregnant. She mentions she is short of breath. Which of the following new signs in a cardiac examination would not be considered normal? Third heart sound Pulmonary oedema Peripheral oedema Ejection systolic murmur Forceful apex beat

Answer 34

Pulmonary oedema Acute pulmonary oedema is the fourth most common cause of maternal morbidity and a frequent cause of ITU admission during pregnancy. Peripheral oedema is caused by increased fluid pressure both from sodium and water retention and venous stasis from pelvic obstruction, whereas pulmonary oedema is caused by a change in hydrostatic pressure, either from the heart or from reduced osmotic pressure. These are associated with more sinister underlying conditions, such as sepsis, cardiac disease and from iatrogenic sources. If pulmonary oedema presents with hypertension the diagnosis is likely to be pre-eclampsia, an obstetric emergency. The increased cardiac output and volume increase which occur normally during pregnancy lead to the above signs; an ejection systolic murmur is heard in 96% of women and 84% have a third heart sound. Forceful apex beat is not a cause for concern provided it is still within 2cm of the mid-clavicular line

Question 35

A 22-year-old woman has just had an artificial rupture of membranes in order to augment a slowly progressing labour. Her partner is helping her move into a more comfortable position when she suddenly becomes breathless and collapses from the bed. She is unconscious and unresponsive with a blood pressure of 82/50 mmHg and a heart rate of 134 beats per minute. What is the most likely diagnosis? Myocardial infarction Vasovagal syncope Postural orthostatic tachycardia syndrome Hypovolaemic shock Amniotic fluid embolism

Answer 35

Amniotic fluid embolism A history of sudden collapse occurring soon after a rupture of membranes is suggestive of amniotic fluid embolism. The patient is clearly too unwell for this to be a simple vasovagal event. Amniotic fluid emboli can indirectly lead to myocardial infarcts, but It is hard to arrive at a primary diagnosis of myocardial infarction without mention of preceding chest pain. Occult bleeding and hypovolaemic shock would also typically evolve at a slower pace. Postural orthostatic tachycardia syndrome is more common in women of a reproductive age but would not be associated with marked hypotension as present here.

Question 36

A 19-year-old woman has a positive pregnancy test and is found to have an ectopic pregnancy after an intrauterine pregnancy is excluded. She has no pain or other symptoms at this time. Her serum beta-human chorionic gonadotropin (B-hCG) level is 1397 IU/L. A transvaginal ultrasound reveals a 29mm adnexal mass but no heartbeat. There is no free fluid in the abdomen. She says she would like a follow-up appointment following her treatment. What is the first line treatment? Methotrexate Urgent laparoscopic salpingectomy Monitor B-hCG Misoprostol Mifepristone

Answer 36

Methotrexate The National Institute for Health and Care Excellence (NICE) states that if a woman has a small (1500. There is a risk of infertility if a problem arises with the remaining Fallopian tube in the future.

Question 37

A 38-year-old woman complains of irregular vaginal bleeding. This has been going on for the past 6 months, prior to which she had regular periods (every 28 days and bled for 5 days). She denies any abdominal pain, weight loss or menopausal symptoms. She started her periods at the age of 13 years and has had no problems since then. Her last menstrual period was 10 days ago. She has 2 children, both born by uncomplicated vaginal deliveries. She has had the same partner for 16 years, has never had an STI and there is no chance she could be pregnant. She has regular cervical smears and has never had any abnormal results. Her last smear was 2 years ago. Which of the following is the most appropriate next step? Endometrial biopsy Full blood count Speculum examination Referral to gynaecologist Transvaginal ultrasound scan

Answer 37

Speculum examination Differential diagnosis of irregular vaginal bleeding in a woman over 40 years should include: - Cervical polyp - Cervical ectropion - Cervical cancer - Endometrial polyp - Endometrial cancer - Submucosal fibroid A speculum examination should be the first line investigation performed, as it will allow the chance to detect any immediate abnormalities and will enable a smear to be taken. A bimanual examination should then be carried out to detect any fibroids which may be causing the bleeding. A transvaginal ultrasound scan would be indicated after a complete examination has been performed, to measure endometrial thickness (which may result in endometrial biopsy being indicated) and to look for endometrial polyps or submucosal fibroids. Endometrial biopsy and hysteroscopy would be the gold standard investigations for women over 40 years of age, but risk of malignancy is greatly reduced in women under 40 years and so the above investigations should take place prior to biopsy.

Question 38

A woman who is 28 weeks pregnant presents with shortness of breath and unilateral leg oedema. You suspect a pulmonary embolism and consult your seniors as to the best test to confirm the diagnosis. Which of the following is the best reason to choose a ventilation/perfusion (V/Q) scan over CT pulmonary angiography (CTPA)? It requires less specialist training to perform It is cheaper There is less radiation to the breast tissue It is less harmful to the foetus It is easier to interpret

Answer 38

There is less radiation to the breast tissue

Question 39

An 80 year-old woman presents to her GP with a 1.5cm ulcerated lesion on her left labium majus. Her history includes a two year history of vulval itching and soreness, which has failed to respond to topical steroid treatment. What is the most likely diagnosis? Vulval melanoma Chancre Herpes simplex virus Vulval intraepithelial neoplasia Vulval carcinoma

Answer 39

Vulval carcinoma Vulval carcinomas are commonly ulcerated and can present on the labium majora. Melanomas are usually pigmented. Vulval intraepithelial neoplasia tend to be white or plaque like and don't tend to ulcerate. Herpes simplex tend to be smaller vesicles and chancre tends to be painless and is seen in the first phase of syphilis.

Question 40

A 26 year old woman with long standing hypertension gives birth to a healthy male child. The patient advises that she wishes to breastfeed the child but is concerned about the medication affecting the baby. Which of the following antihypertensive drugs would NOT be safe for the patient to use while breast feeding? Losartan Enalapril Nifedipine Labetalol Atenolol

Answer 40

Losartan The correct answer is Losartan. Losartan is an ARB which are contraindicated in pregnancy unless absolutely essential and not recommended in breast feeding.

Question 41

A 17-year-old woman attends the sexual health clinic to request emergency contraception after unprotected sexual intercourse 24 hours ago. She is not on regular contraception. She is given Levonelle as she declined a intra-uterine device (copper coil) as emergency contraception. After discussion decides she would like to quick start contraception after taking the Levonelle. What contraception method can be started the same day as Levonelle? Progesterone injection (Depo-Provera) Intra-uterine device (Copper coil) Combined oral contraceptive pill Intra-uterine system (Mirena) None

Answer 41

Combined oral contraceptive pill This patient has taken levonelle as an emergency contraception. As levonelle is about 82% effective, a developing pregnancy cannot be excluded. A woman who expresses the wish to start contraception as soon as possible can be offered contraception immediately after taking emergency contraception but only the following methods: combined oral contraceptive pill (COCP) progesterone only pill (POP) progestogen-only implant The above methods are advised for starting contraception after unprotected sex as they can easily be stopped or removed if a pregnancy does occur.

Question 42

A 36-year-old woman has delivered her second child at 38 weeks gestation. She had a physiological third stage of labour without drugs. Five minutes after delivery she has a sudden gush of approximately 750 mL of blood. Her vital signs are stable. How should she be initially managed? Syntometrine Blood transfusion Examination under anaesthetic Increase breastfeeding to stimulate uterine contractions Expectant management

Answer 42

Syntometrine An atonic uterus is far the most likely cause of primary post-partum haemorrhage. Due to the degree of blood loss this woman should be advised to have Syntometrine or oxytocin to contract her uterus. In addition, clinicians should perform cord traction during the third stage of labour and massage the uterus after delivery of the placenta. If this does not work then other measures may be required such as blood transfusion and manual removal of the placenta. Although breastfeeding will cause uterine contractions, the blood loss is too great in this case to justify this answer.

Question 43

A 27-year-old lady presented to the maternity unit with contractions at 33 weeks gestation. There has been no rupture of her membranes. As well as initiating steroid treatment what other medication should be given? Magnesium sulphate Indomethacin Salbutamol Nifedipine Intravenous antibiotics

Answer 43

Nifedipine Tocolytics are are medications used to suppress premature labor (from the Greek tokos, childbirth, and lytic, capable of dissolving). They not associated with a clear reduction in perinatal mortality or morbidity, however are very important in delaying labour long enough for steroids to take effect or for in-utero transfer to a neonatal high dependency unit if needed. Atosiban and nifedipine have similar effectiveness in delaying delivery and have fewer maternal side effects than indomethacin. Nifedipine is not licenced for this use, however is much cheaper and is therefore more commonly used than atosiban.

Question 44

Which one of the following prescriptions is contraindicated in pregnancy? Methyldopa for hypertension Topical clindamycin for bacterial vaginosis Doxycycline for malarial prophylaxis Metoclopramide for vomiting Prednisolone for an asthma exacerbation

Answer 44

Doxycycline for malarial prophylaxis All tetracyclines should be avoided in pregnancy.

Question 45

A 24 year-old woman, who is 35 weeks pregnant is found to have a blood pressure of 165/108 mmHg at a routine GP appointment. She is otherwise well. Her only regular medication is 200mg labetalol. Urinalysis reveals 2+ proteinuria. Cardiotocography is normal. Blood tests are as follows: ``` Hb 14 g/l Platelets 270 * 109/l WBC 5.6 * 109/l Na+ 140 mmol/l K+ 3.9 mmol/l Urea 2.4 mmol/l Creatinine 21 µmol/l ``` What is the most appropriate step in her management? Refer patient for a routine check-up in one week's time at GP Increase labetalol and organise a follow up with the community midwife Admit the patient to hospital as an emergency Switch the labetalol to methyldopa Increase the labetalol dose and review in one week's time at GP

Answer 45

Admit the patient to hospital as an emergency Even though the patient is asymptomatic, she has a raised blood pressure above 160/100 mmHg combined with the significant proteinuria. Furthermore, this is despite receiving labetalol treatment. She will need emergency admission for monitoring and management of the hypertension in a controlled environment, with delivery being an option if there is no improvement.

Question 46

A 34-year-old old woman who is 34 weeks pregnant is investigated following vaginal blood loss. She is found to have placenta accreta. Which one of the following is the most important risk factor for this condition? Smoking Obesity Previous caesarean sections Twin pregnancies Endometriosis

Answer 46

Previous caesarean sections

Question 47

What investigation would be used to ascertain whether an ectopic pregnancy had been successfully treated with methotrexate?

Answer 47

Serum HCG

Question 48

What investigation would be used to ascertain whether a 7 week pregnancy is viable?

Answer 48

Trans-vaginal USS

Question 49

A 30 year old with proteinuria and BP 140/90mmHg at 28 weeks gestation. She has a past history of recurrent miscarriage. What is the most likely cause of intrauterine growth retardation (IUGR)? Placental insufficiency Antiphospholipid syndrome Incorrect Smoking Pre eclampsia Essential Hypertension

Answer 49

Pre eclampsia

Question 50

A primigravida has had labour augmented with syntocinon. The cervix is still only 4 cm dilated 8 hours after starting syntocinon. She has a temperature of 380 C. What is the most likely abnormality you may see on the fetal heart rate on the CTG? Tachycardia of 170 bpm Prolonged decelerations – unrelated to contraction returning to normal baseline Incorrect Baseline heart rate 165 bpm, baseline variability

Answer 50

Tachycardia of 170 bpm

Question 51

A primigravida is progressing normally in labour. She has an epidural in place. The midwife pulls the emergency buzzer to get the doctor to see the CTG about 10 minutes after a top-up. What is the most likely abnormality you may see on the fetal heart rate on the CTG? Tachycardia of 170 bpm Prolonged decelerations – unrelated to contraction returning to normal baseline Incorrect Baseline heart rate 165 bpm, baseline variability

Answer 51

Normal baseline heart rate, variability and accelerations, sudden drop to 70 bpm with no recovery.

Question 52

A primigravida has been induced at 37 weeks because of intrauterine growth restriction. After slow progress syntocinon was started 4 hours ago. She is now draining thick fresh meconium. What is the most likely abnormality you may see on the fetal heart rate on the CTG? Tachycardia of 170 bpm Prolonged decelerations – unrelated to contraction returning to normal baseline Incorrect Baseline heart rate 165 bpm, baseline variability

Answer 52

Baseline heart rate 165 bpm, baseline variability

Question 53

A 22-year-old female presents with a one day history of lower abdominal pain. She has no past medical history of note. On examination she has a temperature of 37.5°C, and is exquisitely tender in the left iliac fossa with guarding. Bowel sounds are audible. Which if the following is the most appropriate initial investigation for this patient? (Please select 1 option) Abdominal ultrasound scan Full blood count Plain abdominal x ray Plasma glucose concentration Urinary beta-hCG

Answer 53

Urinary beta-hCG This young woman presents with an acute abdomen and pain in the left iliac fossa. Differential diagnosis would include an ectopic pregnancy despite the paucity of menstrual history which is typical. Therefore the most appropriate investigation would be urinary beta-hCG, that is, a pregnancy test.

Question 54

A 25-year-old woman who has three children and has recently undergone a second termination of pregnancy presents with menorrhagia and seeks appropriate contraceptive advice. Which of the following would be the most appropriate agent for this patient? Dianette Mefenamic acid 'Mirena' intrauterine hormone system Progesterone only pill Tranexamic acid

Answer 54

'Mirena' intrauterine hormone system This woman needs both contraception and treatment for problematical menorrhagia. Progesterone-based long-acting reversible contraception is always recommended over the progesterone-only or combined-oral contraceptive pills due to higher efficacy of contraception. Tranexamic acid may reduce menorrhagia but would not be a contraceptive. Mefenamic acid helps most with analgesia, more than with menorrhagia and is also not a contraceptive. Mirena would be the most appropriate therapy here and would be expected to provide good contraception with amenorrhoea in the majority.

Question 55

A 24-year-old woman presents with secondary amenorrhoea of six months' duration. She denies any past medical or gynaecological history. Her blood results demonstrate low FSH, low LH, low oestradiol, normal TSH and normal T4. What underlying diagnosis would account for these results? Anorexia nervosa Hypothyroidism Panhypopituitarism Polycystic ovary syndrome Premature menopause

Answer 55

Anorexia nervosa This pattern of suppressed gonadotrophins with low oestradiol is commonly seen in anorexia nervosa. It can also be seen with panhypopituitarism, but in this scenario, the thyroid function tests (which are normal) make this unlikely. Suppression of gonadotrophins can be caused by: Anorexia nervosa and other causes of rapid weight loss Extreme exercise Severe illness, such as cancer, or its treatment Drugs, such as the oral contraceptive pill. Treating the underlying causes of the disturbance will often correct the amenorrhoea. For example, patients with anorexia nervosa who put on weight to maintain a BMI >18 kg/m2 will often recommence menstruation. Severe illnesses, such as cancer, can also suppress gonadotrophin release. Many chemotherapy agents can exacerbate this. Giving exogenous oestrogens, for example, as contraceptives, will cause gonadotrophin suppression. This makes ovulation less likely to occur.

Question 56

A 27-year-old woman who is 20 weeks pregnant comes to the antenatal clinic for review. She is completely well and as usual provides a routine urine specimen for analysis. The report comes back to the clinic showing E. coli. Which of the following is the most appropriate intervention? Advise her to drink cranberry juice Arrange an ultrasound scan of the renal tract Do nothing Give antibiotics Request a further urine sample

Answer 56

Request a further urine sample Studies in which women in pregnancy with asymptomatic bacteriuria have been treated appear to show a reduction in the risk of low birth weight babies, pre-term labour and upper urinary tract infection. Whilst these studies mainly used continuous antibiotic therapy from the discovery of asymptomatic bacteriuria until delivery, guidelines still recommend a three to seven day single course of antibiotics. However, in an asymptomatic woman, it must be confirmed on two urine samples before treating, as per SIGN guidelines.

Question 57

A 67-year-old woman is reviewed 6 months after she had a mastectomy following a diagnosis of breast cancer. Which one of the following tumour markers is most useful in monitoring her disease? CA 125 CD 34 CA 15-3 CA 19-9 CD 117

Answer 57

CA 15-3

Question 58

A 21-year-old female notices a bloody discharge from the nipple. She is otherwise well. On examination there are no discrete lesions to feel and mammography shows dense breast tissue but no mass lesion. What is the most likely diagnosis? Galactocele Lipoma Duct ectasia Intraductal papilloma Fat necrosis

Answer 58

Intraductal papilloma

Question 59

A 35-year-old woman has undergone a wide local excision. The histology shows an invasive lobular carcinoma present at 3 of the resection margins. Cavity shavings taken at the original operation are also involved. Sentinel node biopsy was negative. What is the most appropriate management option? Mastectomy Axillary node clearance Radiotherapy Chemotherapy Excision of margins

Answer 59

Mastectomy This patient has an extensive disease process and lobular cancers are notorious for being multifocal. In this case a mastectomy is the safest next step.

Question 60

A 28-year-old female presents with a painless lump in the upper outer quadrant of her left breast. Imaging using ultrasound is indeterminate (U3). Two core biopsies have now been performed and both show normal breast tissue (B1). What is the most appropriate management option? Wide local excision Breast lump excision biopsy Image guided wide local excision Radiotherapy Discharge to routine follow-up

Answer 60

Breast lump excision biopsy The imaging and biopsy results are not concordant. At this stage an excision biopsy is the safest option.

Question 61

A 32-year-old Indian lady presents with breast lump. She has a 4 month old child. Clinically she has jaundice and there is erythema of the left breast. What is the most likely diagnosis? Ductal carcinoma in situ Lobular carcinoma in situ Invasive ductal carcinoma Invasive lobular carcinoma Inflammatory carcinoma

Answer 61

Inflammatory carcinoma Inflammatory breast cancers have an aggressive nature. Dissemination occurs early and is more resistant to adjuvent treatments than other types of breast cancer. Often occurs in pregnancy or lactation.

Question 62

A 72-year-old female presents with a painless breast lump. Clinically she has a 4cm diameter irregular breast mass, with no other palpable masses. What is the most likely diagnosis? Ductal carcinoma in situ Lobular carcinoma in situ Invasive ductal carcinoma Invasive lobular carcinoma Inflammatory carcinoma

Answer 62

Invasive ductal carcinoma A post menopausal woman is more likely to have a ductal carcinoma and they tend to occur at a single focus within the breast.

Question 63

A 72-year-old woman presents with 2 breast lumps. She has a history of breast cancer in the opposite breast 5 years ago. What is the most likely diagnosis? Ductal carcinoma in situ Lobular carcinoma in situ Invasive ductal carcinoma Invasive lobular carcinoma Inflammatory carcinoma

Answer 63

Invasive lobular carcinoma This is likely to be an invasive lobular carcinoma, mainly due to the multifocal lesions and the history of previous breast cancer in the opposite breast.

Question 64

A 55-year-old women presents with nipple discharge. On examination she has a slit like retraction of the nipple in the centre of this area is a small amount of cheese like material. No discrete mass lesion is palpable in the underlying breast. What is the most likely diagnosis? Duct ectasia Lactational breast abscess Breast cyst Intraductal papilloma Atypical ductal hyperplasia

Answer 64

Duct ectasia Duct ectasia is a common alteration in the breast that occurs with ageing. As the ducts shorten and dilate a degree of symmetrical slit like retraction occurs. A small amount of cheese like discharge may occur.

Question 65

A 49-year-old woman presents with a tender lump around the areola associated with a green nipple discharge. What is the most likely diagnosis? Fibroadenosis Duct papilloma Breast abscess Fat necrosis Mammary duct ectasia

Answer 65

Mammary duct ectasia

Question 66

A 41-year-old woman presents with pain and an irregular mobile lump in her left breast. What is the most likely diagnosis? Lipoma Paget's disease of the breast Breast cancer Sebaceous cysts Fibroadenoma

Answer 66

Breast cancer Irregular and painful are not indicative of fibroadenoma