O&G #2

Question 1

You examine a woman’s abdomen who has attended for induction of labour
at 40 weeks þ 12 days. The abdomen is soft and non-tender. It is difficult to
feel any definite presenting part in the pelvis. The baby is longitudinal lie,
you can feel a smooth part on the patient’s left side and the right side feels
more irregular. The fundus has a ballottable object. You find the fetal heart
above the umbilicus.
How is the position best described?

A. Breech

B. Occipitoposterior

C. Occipitotransverse

D. Occipitoposterior fully engaged

E. Transverse lie

Answer 1

A – Breech

This is a breech presentation for a number of reasons. Firstly, no definite presenting
is felt in the pelvis, as the bottom is softer than the head. The head is felt by
balloting in the fundus of the uterus. The heartbeat is heard above the umbilicus.
The back is on the left where the smoothness was felt and the feet are on
the right where it was more irregular.
Abdominal examination specific to obstetrics
Observe the woman to assess her overall wellbeing. Specifically you are looking
for discomfort, which may suggest labour or abdominal pain, jaundice, itching,
pallor, oedema and an estimate of weight. Observations can be viewed to assess
blood pressure, heart rate and temperature.
For abdominal examination the woman should lie flat in a semi-prone or left
lateral tilt to avoid aortocaval compression. She should be exposed from just
below her breasts to her symphysis pubis.
Inspection is the first stage and you should look for size of the abdomen, striae and
scars. You can often see fetal movements later in pregnancy. Palpation helps
assess liquor volume and how firm/soft the uterus is. You may also feel fetal movements
or contractions if there are any. This will also reveal any uterine tenderness
or irritability. Next feel into the pelvis to look for a presenting part and, if so, if
there is any engagement. Turn to face the pelvis, i.e. with your back to the
woman’s head and use two hands on each side of the uterus at the level of the
umbilicus to gently work your way towards the pelvis with dipping motions in
and out to try to palpate a presenting part. Once you have found a presenting
part try to assess if it is a head or a bottom. A head will feel harder and can generally
be balloted between your hands if it is free. A bottom will feel softer, is
harder to define and cannot be balloted. If you are unsure of the presenting
part, Pawlik’s grip can be used (grasp the presenting part between the thumb
and forefinger). However, this is painful for the woman and should be avoided
if possible. Engagement of the presenting part should be assessed at this point.
This is described in ‘fifths of the head palpable’ abdominally. A head is said to
be engaged if it is less than two-fifths palpable as this describes a position in
which the widest diameter of the head has descended into the pelvis.

Question 2

A 21-year-old primigravida of 41 weeks gestation rings the labour ward
complaining of gradual-onset abdominal cramping pains approximately
every 15 to 20 minutes. She is concerned as she has had a mucous-like
pink loss vaginally. She has good fetal movements.
What is the most likely explanation for this?

A. Bloody show

B. Cervical ectropion

C. Cervical polyp

D. Placenta praevia

E. Vasa praevia

Answer 2

A – Bloody show

The ‘show’ is a bloody mucus-like loss vaginally that is associated with preparation
for labour. This cervical mucus plug is lost due to pre-labour cervical
changes. Contractions may commence in the following days. If there is any
concern about the amount of bleeding, a speculum examination can be done
to check that there is not excessive bleeding or that the cervix is not dilated.

Question 3

An 18-year-old girl attends the emergency department with generalized
lower abdominal pains which have been present for a couple of days. She
also complains of a purulent per vagina discharge. She recently had an
intrauterine device inserted as emergency contraception after a condom
she was using failed 3 weeks ago. Currently, she feels hot and sweaty. Her
periods are regular. Observations show a heart rate 96/min, blood pressure
110/70 mmHg and temperature 38.88C. Her abdomen is soft with moderate
tenderness in the lower abdomen. There is no guarding or rebound tenderness.
Speculum examination reveals a purulent discharge. Cervical excitation
was detected on vaginal examination. A urine result is awaited.
What is the most likely diagnosis?

A. Ectopic pregnancy

B. Mittelschmerz

C. Ovarian cyst torsion

D. Pelvic inflammatory disease

E. Urinary tract infection

Answer 3

D – Pelvic inflammatory disease

This girl has pelvic inflammatory disease (PID) – infection of the pelvic organs
from ascending infection through the genital tract, normally via sexual
contact. Common presentations include constant lower abdominal pain, a
purulent discharge per vagina, dyspareunia (pain on intercourse), postcoital
or irregular bleeding, and menorrhagia or dysmenorrhoea. Fever, vomiting,
anorexia and malaise are also seen in women with more severe active infection.
Lower abdominal tenderness, cervical excitation, tenderness on pelvic examination
and pyrexia are seen on examination. High vaginal and endocervical
swabs must be taken and a urine sample should be sent for culture. Immediate
treatment is with antibiotics (e.g. doxycycline and metronidazole), analgesia
and admission to hospital in severe cases. There should be follow-up with
the genitourinary medicine services to enable education, a full sexual health
screen and contact tracing. Complications include tubo-ovarian abscesses,
Fitz-Hugh–Curtis syndrome (perihepatitis leading to perihepatic adhesions),
tubal infertility, ectopic pregnancy and chronic pelvic pain.

Question 4

A woman is in early labour. The CTG has been reactive with a baseline rate
of 140, multiple accelerations, no decelerations and variability of 15–20.
The trace 30 minutes later shows a baseline rate of 135, with no accelerations
or decelerations and a variability of 5–7 beats.
What could explain the features of this trace?

A. Maternal pyrexia

B. Normal trace

C. Pre-terminal trace

D. Sleep pattern of fetus

E. Thumb sucking of fetus

Answer 4

D – Sleep pattern of fetus

Question 5

A 44-year-old woman is a regular attendee at the gynaecological clinic. At
her current appointment she complains again of her abdominal pain that
has been present for over 10 years. She says the pain is low in her
abdomen, aching in character with no radiation, associated with nausea,
but with no correlation to her periods. It is worse at night and she finds it
hard to sleep as she is concerned about the pain. She takes no painkillers
as she does not want to put chemicals into her body. She complains of dyspareunia
and is concerned that she may have a sexually transmitted infection
contracted from her husband despite his assurance to her that he has
not been unfaithful. She has previously had two negative diagnostic laparoscopies,
three negative hysteroscopies and multiple negative smear and
swab tests. She is also seeing a neurologist for chronic headaches.
What is the most likely diagnosis?

A. Adhesions from surgery

B. Chronic pelvic inflammatory disease

C. Endometriosis

D. Functional pain

E. Ovarian cysts

Answer 5

D – Functional pain

This woman probably has functional abdominal pain. This can only be a diagnosis
of exclusion once every other pathology has been ruled out. Women must
be told that when investigations are initiated sometimes no cause can be
found for pelvic pain. This can cause resolution of symptoms in some cases
due to the reassurance it provides. If no pathology is found the woman must
be questioned about sexual and social circumstances as there may be an underlying
problem such as relationship difficulties, sexual abuse or fears about
sexuality or fertility. From the information provided in the question it is likely
that relationship difficulties are responsible for the pain. When managing such
cases it is difficult to ensure you do not miss any newly developing pathology.
Conversely, if investigations continue being performed this may reinforce the
concept that there may be something wrong, and the patient may continue
to worry about the pain

Question 6

Which of the following movement occurs during crowning of the head
during labour?

A. Effacement

B. Extension

C. External rotation

D. Flexion

E. Internal rotation

Answer 6

B – Extension

Question 7

A 21-year-old woman is asking about contraception, specifically condoms.
How effective are condoms if used correctly?

A. 80% effective

B. 85% effective

C. 95% effective

D. 98% effective

E. 100% effective
Practice

Answer 7

D – 98% effective

Condoms are 98% effective if used correctly which means that two women in
100 will get pregnant in a year. This of course is dependent on age, frequency
of sexual intercourse and correct usage. It is useful to compare this with using
no contraception where 80 to 90 sexually active women out of 100 will
become pregnant in a year.
It is important to discuss advantages and disadvantages of condoms and alternative
forms of contraception. The advantages of condoms are that they are only
used during sexual intercourse, they reduce the risk of some sexually transmitted
infections including HIV, there are no side-effects, they are suitable for
most people and they are easily available. However, the disadvantages are
that putting them on can interrupt sex, there is a risk they can split or slip off,
latex allergy and spillage of semen. Condoms are made less effective if the
penis touches any area close to vagina before application of condom, if the
condom splits or is damaged or slips off or if oil-based products are used
(such as baby lotions) with latex condoms which damage the condoms.

Question 8

A 37-year-old woman at 17 weeks gestation attends clinic after having had
a triple test result of 1:200. After counselling, she and her partner decide
they need to know definitely whether the pregnancy is affected by
Down’s syndrome.
Which test would be most appropriate?

A. Amniocentesis

B. Chorionic villus sampling

C. Fetal tissue sampling

D. Nuchal translucency test

E. Second trimester ultrasound scan

Answer 8

A – Amniocentesis

The ‘triple test’ uses a number of serum markers, with the age of the mother and
confirmed gestation of the pregnancy to give a ‘risk’ of the fetus having Down’s
syndrome. A ‘positive’ result is said to be anything above a risk of 1 in 250. In
these cases, more invasive testing is offered. The most appropriate next
course of action in this case would be amniocentesis as this will give a definite
diagnosis. Chorionic villus sampling also gives a definite answer but this is preferably
performed between 11–14 weeks, and this woman has already had her
triple test which is performed at 15–16 weeks.
Amniocentesis is known as a diagnostic test as it gives a definite diagnosis rather
than suggesting a risk of a condition. It is performed from 15 weeks gestation as
there is increased risk of miscarriage and talipes if performed earlier. Risk of miscarriage
is 0.5–1%. Amniotic fluid is extracted using a transabdominal needle
under ultrasound guidance. Fetal cells shed from the gut and skin, contained
in amniotic fluid, are cultured for chromosome analysis to be performed. A
full karyotype takes 2–3 weeks; however, polymerase chain reaction (PCR) or
fluorescent in situ hybridization (FISH) can be used for a more rapid result for
a number of conditions such as trisomies, triploidy and Turner syndrome. Indications
for chromosomal analysis include for diagnosis in a positive Down’s
syndrome screening test or for a pregnancy which is known to be high risk of
chromosomal disorders, DNA analysis for genetic diseases, enzyme assays for
inborn errors of metabolism, fetal infection and information about rhesus isoimmunization
via bilirubin. Anti-D is given in RhD negative women.
Second trimester ultrasound scan. Approximately two-thirds of babies with
Down’s syndrome will have normal appearances on an 18-week scan. Minor
defects will be seen on the other one-third but these only show an association
and are not diagnostic. The purpose of this scan is to detect abnormalities in
structural anatomy, measure fetal growth and site the placenta. It can determine
fetal sex with 99% accuracy.

Question 9

Which of these increases your risk of developing endometrial carcinoma?

A. Combined oral contraceptive pill

B. Early menopause

C. Late menarche

D. Multiparity

E. Obesity

Answer 9

E – Obesity

The majority of uterine cancers arise from the endometrium which is the epithelial
lining of the uterine cavity. It is a single layer of columnar ciliated cells
which form mucus-secreting glands by invaginating into the cellular stroma.
Both the glandular and stromal (supporting) parts of this can undergo malignant
change. Endometrial cancer is the most common cancer of the female
genital tract, occurring most commonly in the over-65s. The majority of
tumours are adenocarcinomas (.90%).
Risk factors include those related to unopposed oestrogen exposure:
† Increasing age – generally found in postmenopausal women, only 5% in
under-40s.
† Obesity – due to the production of oestrogens from peripheral androgens
by aromatization
† Nulliparity
† Early menarche – before age 12
† Late menopause – after age 52
† Unopposed oestrogen therapy – oestrogen-only hormone replacement
therapy
† Tamoxifen – despite having anti-oestrogen properties for breast cancer
it has weak oestrogenic activity on the genital tract.
† Oestrogen-secreting tumours, e.g. granulosa/theca cell ovarian tumours –
although these are rare they are associated with endometrial hyperplasia/
carcinoma in 10% of cases
† Carbohydrate intolerance
† Polycystic ovary syndrome (PCOS) – due to continuous anovulation
therefore unopposed oestrogen
† Personal history of breast or colon cancer
† Family history of breast, colon or ovarian (endometrium type) cancer
The combined oral contraceptive pill, progesterones and pregnancy
are protective. Affected women present with postmenopausal bleeding (in
postmenopausals) and irregular/intermenstrual bleeding or menorrhagia
(in premenopausals).

Question 10

You consent a woman for a Caesarean section. Which out of the following
would you say was a frequently occurring risk?

A. Bladder injury

B. Hysterectomy

C. Persistent wound and abdominal discomfort in the
months after
surgery

D. Risk of placenta praevia or placenta accreta in subsequent
pregnancies

E. Ureteric injury

Answer 10

C – Persistent wound and abdominal discomfort in the months
after surgery

Whoever gains consent must ensure the patient understands what is being
done, why it is being done, the consequences of having the treatment and
conversely the consequences of not having the treatment and the alternative
treatments to the one being offered. The person gaining consent should understand
the risks in full. Consent for intimate examinations should be recorded
in the notes and performed in the presence of a chaperone. Consent for any
operation should be documented on a formal consent form.
Serious risks for Caesarean section as quoted by the Royal College include
hysterectomy (0.7–0.8%), need for further surgery at a later date (0.5%),
ICU admission (0.9%), bladder injury (0.1%), ureteric injury (0.03%), fetal
laceration (2.0%), increased risk of uterine rupture in subsequent pregnancies
(0.4%), antepartum stillbirth (0.4%) and increased risk of placenta praevia or
accreta in subsequent pregnancies (0.4–0.8%).
Frequent risks include persistent wound and abdominal discomfort in the first
few months following surgery and an increased risk of further Caesarean sections
in future pregnancies. Other procedures that should be documented on
the Caesarean consent form include blood transfusion, repair of bladder and
bowel damage, surgery on major vessels, ovarian cystectomy/oophorectomy
if unsuspected pathology is found and hysterectomy

Question 11

Ovulation is preceded by 18 hours by a sudden surge in which hormone?

A. Activin

B. Follicle-stimulating hormone

C. Luteinizing hormone

D. Oestradiol

E. Progesterone

Answer 11

C – Luteinizing hormone

Luteinizing hormone is a glycoprotein produced by the anterior pituitary in
response to gonadotrophin-releasing hormones from the hypothalamus.

Question 12

A 28-year-old woman attends labour ward for induction of labour at
term þ 12. She has some contraction pains but these are mild and she is
not troubled by them. She has had an uncomplicated pregnancy and had
two previous normal deliveries both of which needed inducing due to postmaturity.
The CTG is normal. A scan is done which shows a transverse lie of
the fetus. The cervix is 3 cm dilated.
What would be the next course of action?

A. Artificial rupture of membranes

B. Emergency Caesarean section

C. Oxytocin

D. Prostaglandin

E. Semi-elective Caesarean section

Answer 12

E – Semi-elective Caesarean section

This lady would not be suitable for a normal delivery as the baby is in a transverse
position. She would therefore need a semi-elective section which would be
classified as grade 3 on the RCOG guidelines. Urgency of Caesarean section is
indicated as follows: Grade 1 – immediate threat to the life of the woman or
the fetus; Grade 2 – maternal or fetal compromise which is not immediately
life-threatening; Grade 3 – no maternal or fetal compromise but needs early
delivery; and Grade 4 – delivery timed to suit woman or staff. This would not
be a true elective section of grade 4 as she has started to contract and the
cervix is starting to dilate. It would not be grade 1 or 2 as there is no fetal or
maternal compromise.
Indications for an elective section include:
† Term singleton breech (if external cephalic version (ECV) is contraindicated
or failed)
† Twin pregnancy with breech first twin
† HIV
† Primary genital herpes in the third trimester
† Grade 3 and grade 4 placenta praevia
A Caesarean section should not be routinely offered in:
† Twin pregnancy (if first twin is cephalic at term)
† Preterm birth
† Small for gestational age babies
† Hepatitis B or C infection
† Recurrent genital herpes at term

Question 13

How long does it take for a single sperm to be created from start to finish?

A. 12 hours

B. 64 hours

C. 12 days

D. 64 days

E. Varies from 12 hours to 12 days

Answer 13

D – 64 days

Spermatogenesis takes place when the adult male reaches puberty and occurs
under the influence of testosterone. The whole process of spermatogenesis
takes 64 days. Primordial germ cells divide by mitosis and differentiate into
spermatogonia, which lie immediately beneath the basement membrane of
seminiferous tubules. As spermatogenesis progresses, the germ cells move
from the basement membrane into the lumen of the seminiferous tubules.
Spermatogonia divide by mitosis and differentiate into primary spermatocytes.
Primary spermatocytes contain 46 double-structured chromosomes. These
divide by meiosis. The primary spermatocytes initially complete the first
meiotic division to give secondary spermatocytes. Secondary spermatocytes
therefore contain 23 double-structured chromosomes which complete
the second meiotic division to give spermatids. Spermatids contain 23 single
chromosomes. Spermatids undergo spermiogenesis (below) to give spermatozoa.

Question 14

Which of these terms describes a dip in the fetal heart rate of 20 beats per
minute which starts with the contraction and has recovered to normal by
the end of the contraction?

A. Early decelerations

B. Late decelerations

C. Reduced variability

D. Sinusoidal trace

E. Variable decelerations

Answer 14

A – Early decelerations

Question 15

A 31-year-old woman attends the GUM clinic saying she had unprotected
sexual intercourse with a new partner 3 weeks ago. She reports seeing a
dull red spot on her labia which has now turned into a single, painless,
well demarcated ulcer. She is otherwise well.
What is the most likely diagnosis?

A. Chancroid

B. Granuloma inguinale

C. Herpes simplex

D. Lymphogranuloma venereum

E. Syphilis

Answer 15

E – Syphilis

Treponema pallidum, which is spread by sexual contact, is responsible for
syphilis. Primary syphilis occurs 10 to 90 days after initial infection when a
dull red papule appears on the site of inoculation. It ulcerates to give a single,
painless well-demarcated ulcer known as a chancre. This heals to leave a thin
scar within 8 weeks. Diagnosis is by dark field microscopy from the serum at
the base of the chancre or direct immunofluorescence and serology. The
patient can go on to develop secondary, latent, gummatous and neurosyphilis.
Treatment is with penicillin.
Chancroid is caused by the Gram-negative bacterium Haemophilus ducreyi, and is
found mostly in tropical countries. It is an ulcerative condition of the genitalia
(single/multiple painful superficial ulcers) which develops within a week of
exposure. Inflammation may lead to a phimosis. Enlargement and suppuration
of inguinal lymph nodes may occur, leading to a unilocular abscess (bubo) that
can rupture to form a sinus. Diagnosis is by microscopy and culture. Treatment is
with appropriate antibiotics (e.g. azithromycin).
Lymphogranuloma venereum (LGV) is a sexually transmitted infection caused by
serovars L1, L2 and L3 of Chlamydia trachomatis. It is mainly found in the tropics.
Between 3 and 21 days after infection, one-third of people develop a small painless
papule which ulcerates and heals after days. The patients then develop lymphadenopathy
which is unilateral in two-thirds of cases. Inguinal abscesses
(buboes) may form and develop a sinus. Acute ulcerative proctitis may
develop when infection takes place via the rectal mucosa. Diagnosis is by
culture or serology. Treatment is with tetracycline

Question 16

A couple who are experiencing difficulties in conceiving are undergoing
investigation. The semen analysis of the male partner reveals asthenospermia.
What does this mean?

A. Complete absence of sperm

B. Localized infection

C. Morphologically defective sperm

D. Poorly motile sperm

E. Reduced sperm count

Answer 16

D – Poorly motile sperm

Male infertility can be due to problems with sperm production, sperm function
or sperm delivery. The quality of sperm can be investigated using semen analysis.
Two semen analyses are needed 3 months apart as sperm count varies and it
takes almost 3 months for spermatogenesis to be completed.
Conditions that may be seen on semen reports are:
Asthenospermia Poorly motile sperm, i.e. lack the normal forward
movement
Azoospermia Complete absence of sperm such as testicular failure
Oligospermia Reduced sperm count of normal appearance
Teratospermia Morphologically defective, with abnormalities of head,
midpiece or tail
Leucospermia Infection
Leucospermia and antisperm antibodies can both be associated with agglutination
and can affect sperm function.
The World Health Organization (WHO) provides reference ranges for semen
analysis (below) although this does not give accurate predictive values about
which man will father a child. This semen analysis only has predictive value
when morphology is below 15% and motility is below 20%.

Question 17

A 29-year-old primigravida has just given birth to a baby who is unwell and
has had to be taken to the special care baby unit. On examination of the
baby, the paediatricians find dermatomal skin scarring, neurological
defects, limb hypoplasia and eye defects. During the pregnancy the
woman states she had two episodes of vaginal bleeding at weeks 7 and
9. She also states she felt unwell at 14 weeks with a fever and general
malaise followed by an itchy vesicular rash all over her body.
From the description of mother and baby below choose the most likely
infection in pregnancy.

A. Chickenpox

B. Cytomegalovirus

C. Parvovirus

D. Rubella

E. Salmonella

Answer 17

A – Chickenpox

Chickenpox is caused by the DNA varicella zoster virus (human herpesvirus 3)
via airborne spread and direct personal contact with vesicle fluid. There is an
incubation period of 3 to 21 days. There is a prodromal malaise and fever followed
by an itchy rash of maculopapules which become vesicular and crust over before healing. It is infectious 48 hours before the rash appears and until
the vesicles all crust over, which normally takes 5 days. The disease is often
seen in children where a mild infection ensues.
Ninety percent of women are immune due to previous infection. A varicella
vaccine is available and should be considered in women wishing to get pregnant
who are non-immune. Around 3 in 1000 pregnancies are affected. The sequelae
of infection are more serious in pregnant women with a risk of pneumonia
(10%), hepatitis, encephalitis and mortality (1%). Diagnosis is clinical and
treatment supportive with advice to avoid other pregnant women.
Affected women should be offered varicella zoster immunoglobulins within
10 days of exposure if they are not already immune. If chickenpox develops,
she should be advised to avoid other pregnant women and should be given
oral aciclovir if she is seen within 24 hours of the onset of the rash.
The fetus is at risk of developing fetal varicella syndrome, particularly if infection
occurs before 16 weeks, which includes dermatomal skin scarring, neurological
defects, fetal growth retardation, limb hypoplasia, eye defects and hydrops
fetalis

Question 18

A 35-year-old Afro-Caribbean woman presents with a long history of very
heavy periods. She has visited you now as she cannot cope with the bleeding
and she has a swelling in her abdomen. On examination, you feel a
uterus equivalent to 18 weeks pregnancy; however, she says that she has
not been sexually active for 3 years.
What is the most likely diagnosis?

A. Cervical cancer

B. Cervical ectropion

C. Endometrial carcinoma

D. Large endometrial polyps

E. Uterine fibroids

Answer 18

E – Uterine fibroids

Fibroids (leiomyomata) are whorls of smooth muscle cells interspersed with
collagen. They are benign tumours of the myometrium. Fibroids are present
in 20% of women of reproductive age and are largely asymptomatic. They
are more common in nulliparous and Afro-Caribbean women. They can be multiple
and vary widely in size. Presentation depends on the size and location of fibroids as some are microscopic and others have been known to be 40 kg! The
most common presentation is menorrhagia with intermenstrual bleeding and
abdominal swelling. Pressure on the bladder can lead to frequency of micturition
or hydronephrosis, due to ureteric compression. Other presenting features
include infertility, miscarriage, dyspareunia or pelvic discomfort. Fibroids can be
distinguished on ultrasound as intramural (within the uterine wall), subserous
(beneath the serosal surface of the uterus) or submucosal (beneath the
mucosal surface of the uterus). Treatment is not required if fibroids are asymptomatic.
Medical treatment includes progesterone tablets and gonadotrophinreleasing
hormone analogues. Surgical options include myomectomy (abdominally,
laparoscopically or hysteroscopically), uterine artery embolization and
hysterectomy.

Question 19

A 23-year-old woman has had two children, one by normal delivery the
other by Caesarean section for fetal distress. She is now in labour. She is
currently 7 cm dilated with membranes intact. The head is low in the pelvis.
Which emergency is she at increased risk of?

A. Cord prolapse

B. Fetal distress

C. Shoulder dystocia

D. Uterine inversion

E. Uterine rupture

Answer 19

E – Uterine rupture

Uterine rupture can occur gradually as labour progresses or more suddenly. A
complete rupture is where the uterine cavity communicates directly with the
peritoneal cavity and the fetus enters the abdominal cavity. This often results
in fetal death (75%) and is life-threatening to the mother due to massive
intra-abdominal haemorrhage particularly if the rupture extends into the
uterine arteries or the broad ligament plexus of veins. Incomplete uterine
rupture is where the uterine cavity is separated from the peritoneal cavity by
the visceral peritoneum of the uterus alone.
Uterine rupture is extremely rare in primigravida and in women who have had
one normal delivery. Increased risk is seen in women with any previous uterine
surgery. There is a 0.6% risk of rupture occurring at the scar site of a previous
Caesarean section in a woman attempting a VBAC (Vaginal Birth After Caesarean).
This risk is increased further if prostaglandins or oxytocin are used. The risk
is increased to almost one-third if the previous section was a classical section
(midline uterine incision rather than the normal lower segment transverse
incision) and most obstetricians would not allow these women to labour,
instead delivering them by elective Caesarean section.
A uterine rupture presents with CTG abnormalities, abdominal pain, maternal
tachycardia, fetal parts being palpable on abdominal examination and
vaginal bleeding (although much bleeding is intraperitoneal). Prior to this
the patient may experience scar tenderness in between contractions, cessation
of contractions, haematuria, vaginal bleeding or evidence of shock from hypovolaemia.
Management is initially the same for any obstetric emergency. Stop any
oxytocin infusion. An immediate laparotomy is needed to deliver the baby
and arrest bleeding. The uterus should be repaired if possible; else an
emergency hysterectomy must be performed.

Question 20

Which measurement is the most reliable indicator of gestational age after
14 weeks?

A. Amniotic fluid level

B. Biophysical profile

C. Biparietal diameter

D. Crown–rump length

E. Femur length

Answer 20

C. Biparietal diameter

Ultrasound scanning (USS) is a means of monitoring pregnancy and to date is
without proven maternal or fetal risk. Scans can be performed abdominally or
transvaginally.
The biparietal diameter or head circumference is used to date a fetus over
14 weeks. Because the fetus becomes more flexed in shape after this point,
the crown–rump length, which is used before 14 weeks, is less accurate. A discrepancy
of more than 14 days between the estimated delivery date (EDD) from
the scan and last menstrual period (LMP) means the EDD should be changed to
the date acquired from the biparietal measurements rather than from the LMP.
As gestation increases the accuracy of dating the pregnancy by ultrasound
decreases and therefore it is very difficult to give ‘late bookers’ an accurate
EDD which creates problems for planning of induction of labour if spontaneous
labour does not occur by 41 weeks.
The second trimester scan is generally done at 20 weeks as this allows time for a
termination to be planned before 24 weeks if any abnormality is detected and
termination is requested. A detailed fetal structural anatomical survey is performed.
If any abnormality is detected the parents are referred to the fetal medicine
unit. Fetal growth and liquor volume are measured at this scan although it is
very rare that intrauterine growth restriction or oligohydramnios would be seen
this early. If parents wish to know the sex of the baby then most units will
provide this information, however due to misuse of this information by some
cultures it is not offered by all centres. The placental site is determined and if
it is covering or near to the os then a re-scan must be completed at 34 weeks
to exclude placenta praevia

Question 21

Which of the following is the most common cause of secondary postpartum
haemorrhage?

A. Atonic uterus

B. Disseminated intravascular coagulation

C. Infection

D. Perineal trauma

E. Retained placental fragments

Answer 21

C – Infection

Infection is the most common cause of secondary postpartum haemorrhage and
can be due to retained products of conception such as the placenta. The woman
may complain of malodorous prolonged vaginal bleeding associated with fever
and sweating. Examination reveals tenderness in the lower abdomen. A speculum
examination should be performed and high vaginal swab taken. A full blood
count is taken to look for anaemia and infection. Antibiotics (e.g. cefuroxime
and metronidazole) are first-line treatment. If this does not settle the bleeding
an ultrasound can be done to rule out retained products of conception which
may require surgical evacuation.

Question 22

A 34-year-old woman who is 40 weeks þ 4 days gestation attends the antenatal
day unit with constant pain in the suprapubic area which radiates to
her upper thighs and perineum. It is worse on walking. She has not taken
any analgesia. On examination, her abdomen is soft and non-tender with
tenderness only elicited by compressing her pelvis. There is a cephalic
presentation with the head 2/5th palpable and a right occipitotransverse
position. Her urine dipstick showed a trace of protein only.
What is this most likely cause of her pain?

A. Braxton Hicks contractions

B. Labour

C. Round ligament stretching

D. Symphysis pubis dysfunction

E. Urinary tract infection

Answer 22

D – Symphysis pubis dysfunction

Women with symphysis pubis dysfunction describe pain and discomfort in the
pelvic area which can radiate to the upper thighs or perineum. The pain
worsens as the pregnancy progresses due to the increasing weight of the
uterus. Pain is generally exacerbated by walking and may be severe enough
to limit mobility. The diagnosis is clinical and can be confirmed by increased
pain on pressure over the symphysis pubis or compression of the pelvis.
Treatment is supportive with analgesia, pelvic support braces and crutches.
Symphysis pubis dysfunction is seen in 3% of pregnancies.
Labour is defined as painful regular contractions associated with dilation and
effacement of the cervix and downward progression of the presenting part. It
is important to remember that labour may be triggered by pathological
causes of abdominal pain. The round ligament of the uterus runs from the
uterine horns down through the deep inguinal ring to terminate in the
labia majora. It keeps the uterus in an anteverted position. During pregnancy,
stretching of the round ligament due to the increasing size of the uterus and
the action of progesterone can cause non-specific abdominal pain.
Braxton Hicks contractions are sometimes described as false labour or practice
contractions. The uterus contracts sporadically from early pregnancy and as
labour approaches the frequency and amplitude of these contractions increase.
These are easily confused with labour but Braxton Hicks contractions are characteristically
relieved by time, rest, a warm bath or shower, by drinking water or
changing activities.

Question 23

A 56-year-old woman has a history of leaking urine when lifting her grandchild.
She can no longer do her aerobics class as she is afraid of the consequences
of jumping up and down. She is very distressed and really wants
something to be done about this. She is very tearful during the consultation.
Considering the diagnosis, what is the first-line treatment?

A. Bladder training

B. Botulinum toxin A

C. Oxybutynin

D. Pelvic floor exercises with a trained physiotherapist

E. Surgery following urodynamics

Answer 23

D – Pelvic floor exercises with a trained physiotherapist

This lady is suffering from the symptom stress incontinence. The first-line
treatment is at least 3 months of supervised pelvic floor muscle training.
Genuine stress incontinence (GSI) is the most common type of incontinence in
women. Other causes include overactive bladder (OAB), retention with overflow,
fistula and congenital abnormalities. In GSI there is an involuntary loss of
urine due to raised intra-abdominal pressure without detrusor activity, for
example coughing or sneezing and even walking in some cases. It is important
to understand that the symptom ‘stress incontinence’ does not always mean the
lady has the urodynamic diagnosis of GSI. GSI describes incontinence on activity
such as coughing, laughing, sneezing and running. Incontinent while running
to the toilet is a symptom of urge incontinence. Bedside examination includes
examination of the genital area and asking the patient to cough, looking for
leakage of urine. A neurological examination is needed particularly of roots
S2 to S4 (supply of the urinary and anal sphincters).

Question 24

A 52-year-old woman attends the general practitioner saying that she last
had a period many months ago. She is not sure if she has undergone the
menopause as she has no symptoms.
What is the serum test that will aid a clinical diagnosis of menopause?

A. Follicle-stimulating hormone

B. Human chorionic gonadotrophin

C. Luteinizing hormone

D. Oestrogen

E. Progesterone

Answer 24

A – Follicle-stimulating hormone

The menopause is defined as the permanent cessation of menstruation due to
failure of ovarian follicular development in the presence of adequate gonadotrophin
stimulation. The average age of the menopause in the UK is
50.8 years. Daughters tend to have menopause at the same time as their
mothers. Premature menopause (primary ovarian failure) is diagnosed as the
onset of menopause below 40 years, and can be a result of oophorectomy or
radiotherapy. The perimenopausal period, or climacteric, is of variable duration
as the menstrual cycle lengthens and anovulation ensues.
In simple terms menopause occurs when the supply of oocytes is exhausted.
Most oocytes are lost spontaneously due to aging but some will have been
used for ovulation. The permanent cessation of periods is due to loss of ovarian
follicular activity. Oestradiol production by the granulosa cells of developing follicles
is reduced as menopause approaches, anovulatory cycles become more
common and progesterone production reduces. There is increased production
of follicle-stimulating hormone (FSH) and leuteinizing hormone by the pituitary
due to lack of negative feedback from the diminishing oestrogen levels. (Other
pituitary hormones are not affected.)
The symptoms attributed to the menopause are largely due to oestrogen deficiency.
Immediate effects of the menopause include vasomotor symptoms (hot
flushes, night sweats, sleep disturbance, palpitations and dizziness) and psychological
symptoms (low mood, irritability, poor memory, loss of libido). Intermediate
effects, that take a couple of years to develop, are atrophy of the
vagina and vulva (! atrophic vaginitis, manifesting in dryness, itching, dyspareunia),
and of pelvic tissues (!prolapse) and atrophy of the urethral epithelium
(! dysuria, frequency and urgency). There is a 30% reduction in skin collagen.
Long-term effects of the menopause include osteoporosis with subsequent
pathological fracture (common sites include the distal radius, femoral neck
and vertebrae), and an increase in the risk of atherosclerotic cardiovascular
disease.

Question 25

n/a

Answer 25

n/a

Question 26

You are in the pathology department studying a uterus and placenta that
were removed during an emergency hysterectomy. The pathologist shows
how the placenta has invaded through the uterine wall and specifically
through the outer serosal layer invading the bladder.
What is this known as?

A. Placental abruption

B. Placenta accreta

C. Placenta increta

D. Placenta percreta

E. Placenta praevia

Answer 26

D – Placenta percreta

Placenta accreta broadly describes placental invasion into the uterine wall and is
divided more specifically into placenta increta and placenta percreta (below). It
is caused by over-invasion by the fetal trophoblast through the maternal decidual
barrier when implantation occurs in the first trimester. Risk factors include
previous retained placenta, previous Caesarean section, a history of previous
dilation and curettage (D&C) or suction termination, placenta praevia, high
parity, advanced maternal age and previous postpartum endometritis.
Placenta increta invades the myometrium only. Placenta percreta invades the
myometrium and the outer serosal layer of the uterus. It can invade adjacent
structures including the bladder and bowel.

Question 27

A 42-year-old woman has a 12-month history of heavy periods. She is a
smoker. An ultrasound scan reveals nothing and a recent outpatient hysteroscopy
was normal. She would like a long-term treatment for menorrhagia
and a form of contraception. She is unsure whether she would like more
children.
Which treatment would you offer her?

A. Antifibrinolytics

B. Combined oral contraceptive pill

C. Endometrial ablation

D. Intrauterine or systemic progestogens

E. Prostaglandin inhibitors

Answer 27

D – Intrauterine or systemic progestogens

Progestogens are the most appropriate treatment as it offers her contraception
and reduction in bleeding. She is not suitable for the combined oral contraceptive
pill due to the combination of age and smoking habits and the other
treatments listed do not provide contraception.
Subjective menorrhagia is when women complain of heavy periods. Objective
menorrhagia is .80 mL bloods loss per cycle. Only 50% of women who complain
of heavy bleeding actually have over 80 mL of blood loss but subjective
menorrhagia must still be treated. Sixty percent of women with objective
menorrhagia develop anaemia. The main causes for menorrhagia are dysfunctional
uterine bleeding, uterine pathology such as fibroids, and rarely medical
conditions including clotting disorders.
There are many different ways of administering progestogens and preparation
used is down to personal choice. An oral formulation such as norethisterone
(progesterone-only pill, trade name Micronor or Noriday) can be used starting
on day 5 for 21 days and reduces bleeding by up to 80%. Progestogens can also
be administered by injection every 8 or 12 weeks which can eventually lead to
amenorrhoea if used for long enough, however these can give irregular and
heavy bleeding for the first few months of use. An intrauterine device that delivers
progestogen directly to the lining of uterus is available (Mirena). It can be
kept in situ for 5 years and can reduce bleeding by 95% giving amenorrhoea in many women and also provides excellent contraception. Again irregular
bleeding can be a problem particularly in the first 6 months and this must be
explained to women prior to insertion otherwise there is a very high removal
rate.
Menstrual flow is reduced or stopped by destroying the endometrium by ablation.
Hysteroscopic procedures include laser ablation, resection or coagulation
using an electric roller ball. Microwave ablation, heat ablation and electrocautery
are all non-hysteroscopic procedures. Pregnancy is contraindicated after
ablation. This again would help with the menorrhagia but again would offer
no contraception and the patient in this scenario may want more children.

Question 28

A 55-year-old woman returns to the gynaecology clinic to find out the
results of her cervical screening test. You reassure her that she has a
normal smear result.
What is the next most appropriate step in her management?

A. Colposcopy

B. Recall in 6 months

C. Recall in 1 year

D. Recall in 3 years

E. Recall in 5 years

Answer 28

E – Recall in 5 years

The fact there is a premalignant phase for cervical cancer makes it suitable for
screening, so the premalignant disease can be treated before the invasion
occurs. Cervical screening aims to detect the precancerous lesion (cervical
intraepithelial neoplasia [CIN]) on the cervix which requires a sample of cells
from this area. The previous method, known as a smear test, used a spatula to
scrape cells from the cervix which were then ‘smeared’ onto a slide and examined
under a microscope. Liquid-based cytology (LBC) is the current practice.
The spatula has been replaced by a brush which collects the cells from
the cervix by five full circular rotations. The head of the brush is broken off
into preservative fluid for transport to the laboratory. The sample is then spun
to separate the cells and they are examined under a microscope.
Cervical screening is best taken mid-cycle and is 99.7% specific and 80%
sensitive.
Screening on the National Health Service starts at age 25 and finishes at age 64.
The frequency of recall varies with age to ensure a targeted and effective screening
programme and is done via the general practice on a computer recall
system. If a woman aged 25 to 50 years has a normal smear they are called
back in 3 years. Once they are over 50 years, recall increases to every 5 years.
Those over 65 are only screened if they have had recent abnormal tests or if
they have not been screened at all since age 50. A woman may be recalled
early for a number of reasons. If there are inadequate cells for the study the
patient is recalled in 6 months. If a diagnosis of CIN I is made a repeat is
needed in 6 months as these cells often revert to normal without any treatment.
If on the repeat test the cells still show CIN I, colposcopy will be required. A
single diagnosis of CIN II or III requires referral to colposcopy. Obviously a
diagnosis of invasive carcinoma would require immediate specialist referral.
Immunocompromised patients require annual screening. No more smears are
necessary if the woman has had a hysterectomy for benign disease but if the
hysterectomy was for CIN then vaginal vault smears are required.

Question 29

A 27-year-old attends the antenatal day unit to receive her routine antenatal
anti-D prophylaxis at 28 weeks gestation. This is her first child and
she is rhesus negative. She has already received an anti-D injection after a
bleed early on in pregnancy at 14 weeks.
What action needs to be taken with regards to anti-D prophylaxis?

A. Give antenatal anti-D prophylaxis 250 iu at 28 weeks

B. Give antenatal anti-D prophylaxis 500 iu at 28 weeks

C. Give antenatal anti-D prophylaxis 250 iu at 34 weeks

D. Give antenatal anti-D prophylaxis 500 iu at 34 weeks

E. No action needed at present

Answer 29

B – Give antenatal anti-D prophylaxis 500 iu at 28 weeks

Question 30

A 22-year-old primigravid woman attends the general practice at 16 weeks
gestation. She explains that she would consider termination if she found
out she was carrying a fetus affected by Down’s syndrome. After counselling
you agree to use an initial non-invasive screening test for Down’s syndrome
and spina bifida.
Which of the following tests would you suggest?

A. Amniocentesis

B. Chorionic villus sampling

C. Fetal echocardiography

D. Nuchal translucency test

E. Serum triple test

Answer 30

E – Serum triple test

The triple test is a screening test for Down’s syndrome and spina bifida. A
number of serum markers are used in combination with the age of the
mother and confirmed gestation of the pregnancy to give a risk of Down’s syndrome.
Increasing maternal age is the strongest risk factor. The serum markers
used in the triple test are alpha-fetoprotein (AFP), oestriol and human chorionic
gonadotrophin beta-subunit (bhCG). This is available from 14–20 weeks
(optimal at 15–16 weeks) with results available 2 weeks after the test. High
bhCG, low AFP and low oestriol are associated with Down’s syndrome. Falsepositives
occur in around 5%. A ‘positive’ result is defined as a risk of greater
than 1 in 250. In these cases amniocentesis or chorionic villus sampling is
offered. A finding of raised AFP alone is associated with a break in fetal skin
often indicating neural tube defects such as spina bifida and anencephaly.
As there is a large overlap with the normal and abnormal levels of AFP, further
testing is needed for firm diagnosis such as a scan for spina bifida. This is
the most appropriate test for this woman as due to her young age she has an
inherently low risk of carrying a fetus affected by Down’s syndrome and it is a
non-invasive test.
Fetal echocardiography is used for women with a high risk of fetal cardiac
abnormalities and is done in the second trimester. Indications are women
with congenital heart disease, diabetes or epilepsy, those with a previous child
with congenital heart disease or abnormal or inadequate views of the heart at
routine second trimester scans or a high risk nuchal translucency result. This
has no role in the screening for Down’s syndrome although affected babies
are at increased risk of cardiac abnormalities.
Practice

Question 31

A 25-year-old primigravid woman with a twin pregnancy has a 20-week
ultrasound scan. She is excited to discover that she is carrying one girl
and one boy.
How are these twins described?

A. Dizygotic dichorionic diamniotic

B. Dizygotic dichorionic monoamniotic

C. Dizygotic monochorionic monoamniotic

D. Monozygotic dichorionic diamniotic

E. Monozygotic monochorionic diamniotic

Answer 31

A – Dizygotic dichorionic diamniotic

Dizygotic twins are the most common type of twins (60%). They develop due
to fertilization of two different ova, from the same or opposite ovaries, by
two different sperm so are not identical. They can be of different sexes and
are no more genetically similar than siblings would be. They implant separately
into the decidua and have their own circulation. They are always dichorionic
and diamniotic which means each fetus has its own chorion, amnion and placenta.
Placental tissue may appear continuous due to close implantation sites
but there will be no significant vascular communications.
Chorionicity is best determined by ultrasound in the first trimester. Dichorionic
twins have widely separated first trimester sacs or clearly separate placentae and
a dividing membrane thicker than 2 mm.

Question 32

A 29-year-old woman who has not completed her family has a diagnosis of
large subserous fibroids and troublesome heavy periods. She feels medical
treatments have made no difference to the bleeding.
Which treatment option should be offered?

A. Endometrial ablation

B. Hysterectomy

C. Hysteroscopic resection of fibroids

D. Myomectomy

E. Uterine artery embolization

Answer 32

D – Myomectomy

Following dysfunctional uterine bleeding, uterine pathology is the next most
common cause for menorrhagia. Pathology can be benign such as uterine
fibroids, endometrial polyps, adenomyosis or pelvic infection, or it is rarely
malignant such as endometrial cancer.
Fibroids are benign tumours of myometrium containing whorls of smooth
muscle cells with collagen. They are largely asymptomatic and are present in
20% of women of reproductive age, more commonly in Afro-Caribbean and
nulliparous women. Presentation depends on the size and location of fibroids
as they vary widely in size; some are microscopic and others have been
known to be 40 kg! They can be intramural (within the uterine wall), subserous
(beneath the serosal surface of the uterus) or submucosal (beneath the mucosal
surface of the uterus). The most common presentation of fibroids is menorrhagia
with intermenstrual bleeding and abdominal swelling. Pressure on the
bladder from a large anterior fibroid can lead to frequency of micturition or to
hydronephrosis due to ureteric compression. Other presenting features may
be infertility, miscarriage, dyspareunia or pelvic discomfort. Treatment is not
required if fibroids are asymptomatic. Medical treatment for menorrhagia
associated with fibroids includes progesterone tablets and gonadotrophinreleasing
hormone analogues. Surgical options include a myomectomy either
abdominally, laparoscopically or hysteroscopically, or a hysterectomy.
Myomectomy allows conservation of a patient’s fertility. This is either an abdominal
or a laparoscopic procedure. The pseudocapsule of the fibroid is incised, the
bulk of the tumour is enucleated and the resulting defect is sealed. Risks of this
procedure include uncontrolled bleeding requiring hysterectomy, recurrence of
fibroids and adhesion formation leading to reduced fertility. Hysteroscopic
resection is not an option in this case as they are not submucosal.

Question 33

A 29-year-old woman who is at 33 weeks gestation describes a sudden gush
of water from her vagina. She has no abdominal pain and has felt good fetal
movements. Abdominal examination reveals a cephalic presentation. Speculum
examination shows a clear fluid draining from the cervix. The CTG
shows a baseline rate of 140, with four accelerations in a 20-minute
period, a variability of 5–15 beats and no decelerations. The tocograph
shows a flat line.
What medication would you give her for prophylaxis against infection?

A. Atosiban

B. Betamethasone

C. Co-amoxiclav

D. Erythromycin

E. Gentamicin

Answer 33

D – Erythromycin

Preterm pre-labour rupture of membranes (PPROM) is where the membranes
rupture without contractions before 37 weeks and occurs in 2–3% of pregnancies.
The woman describes a gush of fluid per vagina associated with a continuous
trickle subsequently. Diagnosis is made on sterile speculum examination to
visualize the amniotic fluid draining from the cervical os, and the patient is asked
to cough during examination to elicit a gush of fluid from the cervix. A vaginal
swab, urine specimen and liquor specimen are taken to test for infection. A
digital examination should not be performed due to the risk of introducing infection.
Other investigations that may help in diagnosis are the nitrazine test which
measures the pH of the vagina. Amniotic fluid is more alkaline than normal
vaginal secretions, however there are false-positives with blood, urine, semen
or antiseptic cleaning agents. An ultrasound may be performed to check for
reduced liquor if there is a convincing history but no liquor seen on examination.
If pre-labour rupture of membranes occurs at term the majority of women
labour within 24–48 hours and if this does not occur naturally they are augmented.
However if rupture of membranes occurs preterm the risks of continuing
the pregnancy such as maternal and fetal infections have to be weighed up
against the risks of prematurity, therefore the management is usually conservative
before 34 weeks and the woman is monitored for any signs of impending
infection. Monitoring includes regular temperature and pulse, daily CTG,
twice-weekly blood tests for white cell count and CRP and weekly or twoweekly
ultrasound scans. Outpatient management can be used where the
patient monitors her temperature at home and attends for daily CTG and
other tests needed. Concerning features suggesting imminent infection or
chorioamnionitis include maternal pyrexia, high white cell count or CRP, foul
smelling liquor or meconium, uterine tenderness or fetal tachycardia.

Question 34

A 38-year-old woman is asking about the combined oral contraceptive pill
(COCP). She used to be on it prior to having her family and is hoping to
return to using it for contraception. She suffers from hypertension for
which she takes ramipril. Her body mass index is 28 and she is currently
trying to lose weight.
Can you safely prescribe her the COCP and, if not, why not?

A. No – combination of age and hypertension

B. No – combination of body mass index and hypertension

C. No – high body mass index alone

D. No – taking ramipril alone

E. Yes

Answer 34

A – No – combination of age and hypertension

The combination of age over 35 and hypertension is considered too much of a
risk of arterial disease to safely prescribe the combined oral contraceptive pill
(COCP).

Question 35

Which of the following is the male cell that contains 23 single chromosomes
prior to spermiogenesis?

A. Primary spermatocyte

B. Secondary spermatocyte

C. Spermatid

D. Spermatogonia

E. Spermatozoon

Answer 35

C – Spermatid

Question 36

A 31-year-old woman is admitted to labour ward in early labour. The
midwife notices that she has had a positive vaginal swab taken that requires
antibiotic treatment only when she is in established labour.
What organism was found on the swab?

A. Bacterial vaginosis

B. Cytomegalovirus

C. Group B streptococcus

D. Herpes

E. Toxoplasmosis

Answer 36

C – Group B streptococcus

Up to one-quarter of women have vaginal colonization by group B streptococcus
(GBS) at some stage of pregnancy. Infection is asymptomatic to the mother
so it is detected using culture of vaginal swabs which are taken opportunistically
when a mother is to be examined for any reason. GBS is associated with preterm
rupture of membranes and neonatal sepsis. Fifty percent of babies born to GBSpositive
women will become colonized during vaginal delivery but only about
1% develop infection. Neonatal GBS sepsis causes 1 in 65 of all neonatal
deaths. If it is picked up on routine swabs, the woman should deliver on an
obstetric unit so antibiotics can be given in labour to reduce neonatal infection.
Antibiotics should be given if GBS is detected incidentally in the vagina or urine
in the current pregnancy or if a woman has had a previous baby with neonatal
GBS infection. There is no need for antibiotics if GBS was detected in the previous
pregnancy with no ill effects to the baby. There is no need for antibiotics
if the woman is having a Caesarean section. Intravenous penicillin G is the antibiotic of choice, given as soon as possible after the onset of labour and at
least 2 hours before delivery.
There is no national screening programme for GBS as initial positive results may
become negative without treatment. Also there is no evidence for antenatal
treatment as infection may quickly return following treatment

Question 37

A 47-year-old woman has noticed increasing heaviness of her regular menstrual
periods over the past year. She now she finds them unmanageable
with regular flooding. Her last smear showed moderate dyskaryosis and a
biopsy was taken which demonstrated CIN II. She had a normal hysteroscopy
and pelvic scan 4 months ago. She has completed her family.
Despite numerous medical options from her general practitioner she still
feels the condition is worsening and is getting to the end of her tether.
What treatment would you suggest?

A. Cone biopsy

B. Endometrial ablation

C. Subtotal hysterectomy

D. Total hysterectomy

E. Uterine artery embolization

Answer 37

D – Total hysterectomy

This patient is clearly distressed and requires more than just medical treatment.
If this had been simple menorrhagia without the complication of the CIN II then
she could have been treated with endometrial ablation or hysterectomy either
total or subtotal. However, in patients with CIN II, it is recommended that if
there are other reasons for a hysterectomy to be performed then hysterectomy
can be considered as a treatment for CIN, in effect to ‘kill two birds with one
stone’. The patient must still be followed up with vault smears due to the
increased risk of vaginal intraepithelial neoplasia.
A hysterectomy is the only treatment that will ensure amenorrhoea. Obviously
in this case a total hysterectomy, which removes the uterus and cervix, would
be performed otherwise this would not treat the CIN. This could be undertaken
vaginally or abdominally. A total hysterectomy with bilateral salpingo-oophorectomy
also removes (ectomy) the tubes (salpingo) and ovaries (oophor). The
uterus alone is removed in a subtotal hysterectomy and the tubes, ovaries and
cervix are retained. Risks of hysterectomy include bleeding, infection, pain,
damage to bowel and urinary tracts, postoperative thromboembolism and
vaginal prolapse in later life. Subtotal hysterectomies tend to be quicker with
less risk of damage to the urinary tract and bowel

Question 38

A 26-year-old primigravid woman has been induced at 40 weeks due to
moderate pre-eclampsia with 6 mg vaginal prostaglandin and artificial
rupture of membranes. She is not on an oxytocin infusion. There are no
other antenatal complications. On vaginal examination her cervix is 5 cm
dilated and fully effaced, with the presenting part at station –1. She has
an epidural in situ so she does not feel the contractions. Suddenly she develops
abdominal pain and there are deep decelerations on the CTG. On examination,
her uterus feels hard. She feels faint and her blood pressure is low
with a maternal tachycardia.
What event has just occurred?

A. Amniotic fluid embolism

B. Epidural failure

C. Placental abruption

D. Uterine hyperstimulation

E. Uterine rupture

Answer 38

C – Placental abruption

Placental abruption describes separation of the placenta from the uterus prior to
third stage of labour. Mild abruption, where there is minimal separation, may
present with little pain or bleeding and with minimal consequence to fetus or
mother. Major abruptions present with sudden-onset constant, sharp, severe
low abdominal or back pain, maternal shock and variable amounts of vaginal
bleeding. The uterus is irritable and tender and may become hard due to
tonic contraction. The tense uterus means it is difficult to palpate fetal parts
and there is often loss of fetal movements. Intrauterine death from hypoxia is
common unless action is taken. The clinical condition of the mother and
degree of shock may not correlate well with the amount of blood loss seen vaginally
as bleeding can be contained behind the placenta (concealed abruption).
In this case the epidural was effective for the level of pain from contractions but
the increased level of pain from the abruption was such that it was registered by
the mother despite the epidural. Delivery must be expedited and in this case a
Caesarean section is required. If the cervix had been fully dilated an instrumental
delivery could have been considered.
Risk factors for abruption are hypertension, pre-eclampsia, sudden decompression
after membrane rupture in polyhydramnios or multiple pregnancies, previous
abruption (10% recurrence), trauma to the abdomen and tobacco or
cocaine abuse although the cause is unknown in many cases. The incidence is
0.5–2%.

Question 39

A 16-year-old girl attends her general practitioner with complaints of heavy
and painful periods. She is normally fit and well and is not sexually active.
She needs first-line treatment for these complaints.
What is the most appropriate treatment option?

A. Antifibrinolytics

B. Combined oral contraceptive pill

C. Gonadotrophin-releasing hormone analogues

D. Intrauterine or systemic progestogens

E. Prostaglandin inhibitors

Answer 39

E – Prostaglandin inhibitors

This girl is suffering from menorrhagia (heavy cyclical menstrual bleeding over
several consecutive cycles) and primary dysmenorrhoea (excessively painful
periods). The first-line treatment is with non-steroidal anti-inflammatory drugs
(NSAIDs), e.g. mefanamic acid or ibuprofen. NSAIDs act as prostaglandin synthesis
inhibitors to reduce pain and also reduce blood loss by up to 25%.
Side-effects are mainly gastrointestinal.
If this does not provide sufficient relief of symptoms, further options can be
considered.
Antifibrinolytics (e.g. tranexamic acid) inhibit the breakdown of a formed clot.
These are only to be taken during the heavy days of menstruation. Menstrual
loss is reduced due to increased clot formation in the spiral arteries by reducing
fibrinolytic activity by inhibiting plasminogen activator. For this reason they
must not be used by women with predisposition to thromboembolism. This
can reduce blood loss by 50%.
The combined oral contraceptive pill (COCP) can reduce the amount of pain
and bleeding by 50% experienced during menstruation. It can also regulate
periods if there is an erratic cycle. This has to be discussed sensitively as it is a
form of contraception and there can be issues with using contraception. Progestogens
can reduce bleeding and also act as contraception. They are useful if the
patient is not suitable for the COCP due to contraindications such as weight, age
and smoking habits.
Gonadotrophin-releasing hormone (GnRH) analogues are not first-line
treatments for menorrhagia or dysmenorrhoea. They are used in dysmenorrhoea
caused by endometriosis or can be used to shrink fibroids prior to definitive
treatment. GnRH analogues cause amenorrhoea by down-regulating the
pituitary hormones, leading to inhibition of ovarian activity. There are consequences
of the hypoestrogenic state (similar to menopause) including hot
flushes and vaginal dryness. Loss of bone mineral density is also a problem
with use over 6 months therefore they should only be used short-term or with
add-back therapy such as tibolone (a synthetic steroid often used as hormone
replacement therapy).

Question 40

A 34-year-old primigravid woman at 39 weeks gestation has been admitted
to labour ward with pre-eclampsia. Her blood pressure will not decrease
below 166/114 mmHg despite being on maximum antihypertensive treatment
and it is decided she requires induction of labour and medication
for prevention of convulsions.
What infusion is used to prevent convulsions?

A. Carbamazepine

B. Diazepam

C. Gabapentin

D. Magnesium sulphate

E. Phenytoin

Answer 40

D – Magnesium sulphate

Clinical features of pre-eclampsia in addition to raised blood pressure (BP)
are headaches, visual disturbances, restlessness or agitation, fluid retention
with reduced urine output, epigastric pain, vomiting, hyperreflexia or signs
of clonus (signs of cerebral irritability), papilloedema, retinal oedema or
haemorrhages, liver tenderness, low platelets ,100106/L, abnormal liver
enzymes or any signs of HELLP syndrome. However, there may be no signs
before convulsions occur.
If a woman develops severe pre-eclampsia she must have regular observations of
BP, urine, bloods and strict fluid balance. Bloods include FBC, U & E, uric acid,
LFTs, albumin and coagulation. The fetus should also be monitored using
CTG or USS as indicated. Severe pre-eclampsia is defined as systolic BP
170 mmHg on two occasions or diastolic BP 100 mmHg on two occasions
together with significant proteinuria of over 1 g/L on a 24-hour collection.
Managing seizures
Prophylactic administration of magnesium sulphate is used for a woman at ris
of convulsions and is continued 24 hours after delivery or 24 hours after the
last fit. Fluid balance, reflexes, respiratory rate and oxygen saturation must be
monitored.
A convulsion is an obstetric emergency and the full team should be involved.
Firstly call for help and summon the senior obstetrician, senior midwife and
anaesthetist. Resuscitation should be initiated as with any person who is convulsing
by firstly checking it is safe for you to approach, limiting injury to the patient
and then initiating management with ABC. The woman should be placed in the
left lateral position to avoid aortocaval compression and to keep the airway
open. An airway should be used if needed and high flow oxygen should be
administered. After a convulsion, provided the CTG is reassuring, the baby
should be delivered once the mother’s condition is stable and the appropriate
people are present. Delivery should not be performed if it is not safe to do so
as the mother’s life has priority over the baby. Magnesium sulphate is also
used for treatment of fits in pregnancy.

Question 41

A 24-year-old primigravid woman who is at 32 weeks gestation attends the
antenatal day unit with intermittent abdominal pains. Abdominal examination
reveals a cephalic presentation and palpable contractions every 3
minutes lasting for 20 seconds. Speculum examination shows a long and
closed cervix. The CTG has a baseline rate of 150 and variability above
5. There are two accelerations in 30 minutes. The tocograph shows
regular uterine activity every 3 minutes.
Which oxytocin receptor antagonist would you use to attempt to delay
labour?

A. Atosiban

B. Indometacin

C. Nifedipine

D. Ritodrine

E. Salbutamol

Answer 41

A – Atosiban

Premature labour is labour before 37 weeks. Labour is suggested by the
presence of painful regular contractions associated with cervical change
although there may just be some lower abdominal pain or silent dilation of
the cervix.
Tocolytics inhibit smooth muscle in the uterus to delay rather than stop labour
to allow time for steroids to take effect and allow transfer of the mother to
a hospital that has adequate facilities for neonatal resuscitation if needed.
They are only given for 48 hours as this is how long the steroids need to
work. Absolute contraindications are maternal condition requiring immediate delivery, intrauterine infection, fetal compromise, lethal fetal congenital abnormality
or fetal death. Relative contraindications include fetal growth restriction,
pre-eclampsia or significant vaginal bleeding.
Atosiban works by competitive inhibition of oxytocin and binds to myometrial
receptors causing an inhibition of intracellular calcium release leading to
muscle relaxation. There are minimal maternal side-effects but it is very expensive.
Beta-sympathomimetics stimulate b-receptors (some are b2 selective) on
myometrial cell membranes to reduce intracellular calcium levels and therefore
inhibit the actin–myosin interaction that would normally lead to uterine smooth
muscle contraction. It is given as an intravenous infusion. They are becoming
less popular due to the high number of side-effects which include tachycardia,
hyperkalaemia, skin flushing, nausea, vomiting, visual disturbances and hyperglycaemia.
More severe consequences such as hypotension, pulmonary
oedema, severe maternal bradycardia and other arrhythmias have been seen
and even maternal death. Due to these side-effects it is important to be sure
of the diagnosis before administering these. Examples are ritodrine, terbutaline
and salbutamol.

Question 42

Which hormone promotes proliferation of glandular and stromal elements
of the endometrium?

A. Activin

B. Follicle-stimulating hormone

C. Luteinizing hormone

D. Oestradiol

E. Progesterone

Answer 42

D – Oestradiol

Oestradiol is a steroid hormone and is mainly secreted by the ovary. Levels of
oestrogen and progesterone are low during the initial stages of the follicular
phase due to the regression of the corpus luteum from the previous cycle.
Primary follicles develop in the ovary under the influence of follicle-stimulating
hormone (FSH) and leuteinizing hormone (LH) and this causes the level of
oestrogen to rise due to increased production by the granulosa cells of these
developing follicles. The increased level of oestrogen leads to negative feedback
to produce a decline in LH and FSH concentrations. The level of oestrogen
reaches its peak 18 hours prior to ovulation and this very high level of oestrogen
is thought to be responsible for the mid-cycle surge in LH (positive feedback)
which initiates ovulation. Immediately prior to ovulation, oestrogen levels fall
and there is a rise in progesterone production. After ovulation the corpus
luteum is formed from the remainder of the follicle, and this is the main
source of oestrogen and progesterone post-ovulation. Oestrogen and progesterone
are maintained at a high level for the luteal phase and only fall when the corpus luteum degenerates and the next cycle starts. Therefore during
menses levels of oestrogen are low. If conception and implantation occur the
corpus luteum is maintained by gonadotrophin released by the trophoblast.
The latter half of the follicular phase of menstrual cycle correlates to the
proliferative phase of the endometrium. The high concentration of oestrogen
seen at this time promotes rapid regeneration of the endometrium that has
been shed during the recent menses. It stimulates proliferation of glandular
and stromal elements of the endometrium to give tubular glands arranged in
a regular pattern, parallel to each other with little secretion. Oestrogen also
stimulates production of increased amounts of thin, clear, stringy cervical
mucus which is easily penetrable by sperm; a feature known as ‘spinnbarkeit’.

Question 43

A 34-year-old primigravid woman who is Rhesus D negative has received
routine antenatal anti-D prophylaxis at 28 and 34 weeks and a further
dose of antenatal anti-D arophylaxis during her pregnancy. She has now
delivered a Rhesus D positive infant.
What action needs to be taken with regards to anti-D prophylaxis?

A. Give antenatal anti-D prophylaxis 250 iu

B. Give antenatal anti-D prophylaxis 500 iu

C. Give blood transfusion

D. Give postnatal anti-D

E. No action needed at present

Answer 43

D – Give postnatal anti-D

Question 44

A 39-year-old woman with a positive pregnancy test complains of a 3-day
history of lower cramping abdominal pain. She complains of bleeding
which started lightly and has become gradually heavier over the 3 days.
On examination, she is tender suprapubically. Speculum examination
reveals bright red blood in the vagina and an open cervical os. She has
had two previous miscarriages.

A. Complete miscarriage

B. Incomplete miscarriage

C. Inevitable miscarriage

D. Menstruation

E. Threatened miscarriage

Answer 44

C – Inevitable miscarriage

This scenario describes an inevitable miscarriage where there is cramping
abdominal pain, vaginal bleeding and dilation of the cervical os. The fetus
may still be alive, but miscarriage will occur.
It is important to counsel women appropriately when they have had recurrent
miscarriages. This woman will have had 3 consecutive miscarriages but as
long as she does not have any specific recurring cause she still has a 60–75%
chance of a successful pregnancy. However, because she has had 3 consecutive
miscarriages she should be investigated.
There are a number of reasons why miscarriages may happen; however, 50%
of miscarriages, both sporadic and recurrent, have no identifiable cause. Fetal
chromosomal abnormalities are seen in half of the first trimester miscarriages
including autosomal trisomy (50%), polyploidy (20%) and 45XO (20%). This
incidence decreases to 20% with second trimester miscarriages. Endocrine
factors include polycystic ovarian syndrome and poorly controlled diabetes.
Immunological causes include autoimmune disease and alloimmune disease.
Uterine anomalies may contribute to miscarriages such as bicornuate or
septae uteri and fibroids. Infection in the mother during pregnancy can lead
to poor outcome for the fetus. Specific infections such as rubella and cytomegalovirus
can cross the placenta and cause miscarriage.

Question 45

A 22-year-old woman who has never been sexually active complains of
sudden-onset sharp left-sided abdominal pain which was localized to the
left iliac fossa. An ultrasound scan demonstrated a mass on the left ovary.
Following the operation to remove her cyst she was told that they had
found hair and teeth inside.
Which tumour did this girl have removed?

A. Dysgerminoma

B. Fibroma

C. Granulosa cell tumour

D. Teratoma

E. Yolk sac tumour

Answer 45

D – Teratoma

The presentation is of torsion of an ovarian cyst and the operation findings
suggest a teratoma. Germ cell tumours are all very different from each other.
They include dysgerminoma, endodermal sinus or yolk sac tumour, choriocarcinoma
and teratoma. These are more commonly seen in young women and children.
They comprise 20–25% of ovarian tumours but only 4% are malignant.
Teratoma (dermoid cyst) is a common benign cyst which contains elements
of all three embryonic germ cell layers. Teratomas are thought to occur when
the ovum develops without fertilization, known as parthenogenesis. They are
generally seen in women in their 20s. Epithelium, hair and even teeth can be
found in mature teratomas. They are usually small, bilateral and often asymptomatic,
but do cause pain if there is torsion or rupture. Malignant change is rare
(,1%) and is generally seen in squamous cells, in postmenopausal women.
They can be hormonally active and secrete hCG, a-fetoprotein and thyroxine.
Endodermal sinus or yolk sac tumour is the second most common malignant germ
cell tumour of the ovary. The median age of onset is 19 years and it is rarely seen
over 40 years. Patients present with sudden onset pelvic symptoms and a pelvic
mass. There is a normal hCG but increased a-fetoprotein serum levels. Twenty
percent of patients have coexistent teratomas.
Dysgerminomas are the most common malignant germ cell tumour and the
most common ovarian malignancy found in young women with 75% occurring
in women aged 10 to 30 years. It is the most commonly seen ovarian malignancy
in pregnancy. Ten percent are bilateral. There may be an increased
serum hCG level.
Sex cord/stromal tumours are rare and represent only 5% of all ovarian tumours.
These include granulosa cell tumours, thecomas, fibromas and Sertoli/Leydig
cell tumours.
Granulosa cell tumours are usually slow-growing malignant tumours. They commonly
secrete sex hormones primarily oestrogen which can, depending on age
of presentation, lead to precocious pseudopuberty, irregular menstrual bleeding
or postmenopausal bleeding. This is useful when screening for recurrence using
serum oestradiol levels. On histological examination, the pathognomonic
‘gland like’ spaces, Call–Exner bodies and ‘coffee bean’ nuclei are seen.
Fibroma tumours contain fibroblastic-type cells and are rarely malignant. Fibromas
may present with non-malignant ascites and pleural effusion which
resolve after removal of tumour (Meigs’ syndrome).

Question 46

A 33-year-old woman delivers genetically identical twins at 40 weeks. The
midwife examines the afterbirth and finds a separate chorion, amnion
and placenta. The registrar explains to the medical student that mitotic
division to form twins must have occurred before day 3 of embryonic development.
How are these twins described?

A. Dizygotic dichorionic diamniotic

B. Dizygotic dichorionic monoamniotic

C. Dizygotic monochorionic monoamniotic

D. Monozygotic dichorionic diamniotic

E. Monozygotic monochorionic diamniotic

Answer 46

D – Monozygotic dichorionic diamniotic

Monozygotic dichorionic diamniotic twins occur if division occurs at less than
3 days after fertilization (8-cell stage). The two embryos can implant at separate
sites and each has a separate chorion, amnion and placenta. They will have
the same structural appearance in utero as dizygotic twins but will be identical
twins.

Question 47

A 59-year-old woman presents with vague symptoms of abdominal distension
and some weight loss associated with fatigue. On examination, a large
pelvic mass is detected. An ultrasound scan showed a large multiloculated
cyst on her right ovary and some uncertain areas in her abdomen. Her
CA-125 was increased. She had a staging laparotomy and pseudomyxoma
peritonei was seen.
Which ovarian tumour is she likely to have?

A. Brenner tumour

B. Clear cell tumour

C. Endometroid tumour

D. Mucinous tumour

E. Serous tumour

Answer 47

D – Mucinous tumour

Investigations for pelvic masses include blood tests for routine haematological
and biochemical measurements and tumour markers. Tumour markers are
useful in diagnosis, response to treatment and recurrence. Eighty percent of
malignant ovarian masses have an increased CA-125 although a raised CA-
125 may also be seen with peritoneal trauma and a normal CA-125 does not
rule out cancer. Around 65% of ovarian germ cell tumours have an increased
serum hCG, a-fetoprotein or both.
An ultrasound or CT is useful to look for benign explanations for the pelvic
mass such as simple ovarian cysts and uterine fibroids and will also assess
spread to some extent. Malignant cysts tend to have a solid appearance, a
thickened cyst wall, presence of septae within the cyst, bleeding within cyst
and bilateral cysts. A chest X-ray is needed to rule out pulmonary metastases
and to look for pleural effusions. Disease extent is only fully confirmed by laparotomy
and biopsy at the time of definitive surgery. Ovarian cancer is staged as
follows:
Stage 1 Disease macroscopically confined to ovaries
Stage 2 Disease is beyond ovaries, but confined to pelvis
Stage 3 Disease is beyond pelvis, but confined to abdomen
Stage 4 Disease is beyond the abdomen

Question 48

A 27-year-old woman has recently been diagnosed with cervical cancer.
Which of these is related to cervical cancer?

A. Hepatitis B virus

B. Hepatitis C virus

C. Herpes simplex virus

D. Human papillomavirus 6b and 11

E. Human papillomavirus 16 and 18

Answer 48

E – Human papillomavirus 16 and 18

Cervical cancer is the second most common malignancy in women in the world.
The two peaks of diagnosis are 35–39 years and 60–64 years. There are a small
number of women who are diagnosed with early cervical cancer from smear
tests however the vast majority of women diagnosed with invasive carcinoma
have never had screening. Most (80%) are symptomatic, and presentation
can be with abnormal per vagina bleeding (postcoital, intermenstrual or postmenopausal)
or a chronic vaginal discharge (purulent, blood-stained, watery,
mucoid or malodorous). Late disease is often indicated by pain including backache
or referred leg pain, leg oedema, altered bowel habit, haematuria, malaise
and weight loss.
Human papillomavirus (HPV) is a sexually transmitted DNA virus of which there
are over 80 types. There is a strong association between HPV serotypes 16, 18
and 33 and pre-invasive and invasive cervical cancer. HPV is thought to act by
producing proteins E6 and E7 which influence the action of the p53 tumour suppression
gene. There is a vaccine for HPV (Gardasil) which is licensed for both
males and females between 9 and 15 years, and females between 16 and 25
years. Three injections of Gardasil are given at 0, 2 and 6 months and immunity
lasts for at least 5 years. Immunocompromised patients may still be re-infected
despite a completed course. It is hoped that using the vaccine will reduce cervical
and vulval dysplasia and genital warts. Currently about one-third of all
women in their 20s carry the HPV.

Question 49

A 27-year-old woman has an early pregnancy transvaginal scan which
shows an empty uterus with a bhCG result of 2365 iu. She has no pain
and is otherwise fit and well.
What is the most likely diagnosis?

A. Early intrauterine pregnancy

B. Ectopic pregnancy

C. Inevitable miscarriage

D. Missed miscarriage

E. Threatened miscarriage

Answer 49

B – Ectopic pregnancy

The most likely diagnosis in this patient is an ectopic pregnancy despite the
patient having no pain, as with a bhCG result of 2365 iu a gestational sac
should have been visualized if it were intrauterine. A laparoscopy should be considered
to look for the ectopic fetus. If the result of the bhCG had been lower
than 1000 iu and no gestational sac had been seen, the bhCG should be
rechecked in 48 hours to assess whether it was doubling, reaching a plateau
or falling.

Question 50

A 59-year-old woman attends with one episode of watery, bloody vaginal
discharge. She has never had any children and she had menopause aged
55. On examination, she is obese but her abdomen is unremarkable. On
speculum examination you see some purulent bloody discharge and you
take triple swabs.
Considering the likely diagnosis, what would be your next course of action?

A. Await results of triple swabs and follow-up in clinic in one month

B. Dilation and curettage

C. Hysteroscopy and endometrial biopsy

D. Pipelle biopsy and follow-up in clinic in one month

E. Vabra biopsy and follow-up in clinic in one month

Answer 50

C – Hysteroscopy and endometrial biopsy

This woman is at high risk of endometrial cancer and should be urgently referred
for hysteroscopy and endometrial biopsy, the gold standard for investigation.
This can be done as an outpatient procedure or under general anaesthetic if
the woman prefers or if there are other medical problems.
Dilation and curettage used to be the gold standard but is now known to miss
10% of endometrial cancers. This is performed under general anaesthetic Endometrial biopsy can be performed at an outpatient clinic via a Pipelle or Vabra
aspirator. The Pipelle biopsy only samples 4% of the endometrial surface and will
miss one-third of tumours. The Vabra device picks up more tumours as it
samples around 40% of endometrial surface but is more painful and more
expensive. Endometrial biopsy alone should only be used for patients with
very low risk of carcinoma due to the low pick-up rates. At first presentation it
is acceptable to take a Pipelle biopsy as long as the patient is also referred by
fast track for hysteroscopy with endometrial biopsy. If the Pipelle biopsy
shows malignancy then hysteroscopy will be avoided and referral can be
made straight to gynaecology oncology for staging.
Transvaginal ultrasound is used to measure the thickness of the endometrium in
postmenopausal women. Endometrial cancer is unlikely if thickness is less than
4 mm. Malignancy is much more likely if fluid is seen in the endometrial cavity.
Ultrasound can be used as a non-invasive screening test, especially if surgical
measures are not tolerated.