Obstetrics and Gynaecology Flashcards
A nervous 42yo woman presents herself to the antenatal clinic very worried that she has missed right time to have the combined test for Down’s syndrome screening. She is now 17 weeks pregnant and is v.concerned about her age. You counsel her about the appropriate alternative, the quadruple test and arrange to have this done. What assays make up the quadruple test?
A - AFP, PAPP-A, Inhibin B, beta hCG
B - Unconjugated oestradiol, hCG, AFP and Inhibin A
C - beta hCG, PAPP-A, Nuchal translucency, Inhibin A
D - AFP, Inhibin B, beta hCG, Oestradiol
E - Unconjugated oestradiol, PAPP-A, beta hCG, Inhibin A
B - Unconjugated oestradiol, hCG, AFP and Inhibin A
At 42 she is at a relatively high risk (1 in 55). The combined test is only reliable between 10-13 weeks, it utilises PAPP-A and beta-hCG and the Nuchal Translucency scan. After 13 weeks it is no longer an accurate test - This excludes answer A,C,D, and E. How I remember - The quadruple test has nothing to do with ‘B’ or beta. Its Inhibin A, Alpha Fetoprotein, and hCG (NOT beta hCG)
a 33yo nulliparous woman is 29wks pregnant. She was referred to the Rapid access clinic for investigation of a solitary breast lump. Unfortunately the biopsy showed a carcinoma. After much counselling a decision is made on further treatment. What options are available to her?
A - Tamoxifen
B - CT Abdo-Pelvis
C - Radiotherapy
D - Chemotherapy
E - Bone Isotope scan to look for mets
D - Chemotherapy
A difficult question to answer due to the lack of information on how aggressive the cancer is. But in general terms, Tamoxifen is contraindicated in pregnancy and breastfeeding as it is highly teratogenic CT and the Bone scan are both unacceptable levels of radiation for a non therapeutic intervention. Radiotherapy is a last resort in pregnancy Chemotherapy can be used in the second and third trimesters Regardless a course of Betamethasone should be started to aid lung development in anticipation of an early delivery.
A 38yo woman with DM (type 2) attends clinic. she has a BMI of 48 and is controlling her blood sugars with insulin. You have a long discussion with this woman about her weight. What should not be routinely offered to this woman?
A - Post-natal thromboprophylaxis
B - Vitamin C 10mg BD
C - Regular screening for pre-eclampsia
D - Referral to an obstetric anesthetist
E - An active 3rd stage of labor as increased risk of postpartum hemorrhage.
B - Vitamin C
It should be vitamin D
Obese women need to be offered weight-loss support, high dose folic acid and diabetic screening. VTE risk is high for the obese and for pregnancy Pre-eclampsia screening should be offered to all Obese women offer an increased challenge for anesthesia so should be referred there is also an increased risk of PPH, so an active 3rd stage is called for.
A nulliparous woman is seen at the antenatal clinic 27 weeks into her first pregnancy. Routine screening with a 75g oral glucose tolerance test for gestational DM is performed. which result would confirm a diagnosis of GDM?
A - Fasting plasma venous glucose of greater than 5.0 micromoles/L
B - 2-hour plasma venous glucose of greater than 7.8 micromoles/L
C - Random plasma venous glucose of greater than 4.8 micromoles/L
D - 2-hour plasma venous glucose of less than 7.0 micromoles/L
E - 2-hour plasma venous glucose of less than 7.8 micromoles/L
B - 2-hour plasma venous glucose of greater than 7.8 micromoles/ L
GDM is very common, affecting 2-5% of pregnancies in the UK. Risk factors include - previous macrosomic baby, previous GDM, high BMI, positive family history and ethnicity. Those at risk should be screened. The WHO defines GDM as encompassing impaired glucose tolerance and diabetes ( a fasting greater than 5.6 or a 2 hour greater than 7.8)
A 29yo attends her booking visit and has screening bloods taken. Which of these are the most appropriate tests?
A - Hepatitis C, HIV, Syphilis and Toxoplasmosis
B - Rubella, Hepatitis B, Hepatitis C, Sypilis
C - Syphilis, Rubella, Hep B, HIV
D - HIV, CMV, Rubella, Hep B
E - HIV, Syphilis, Rubella, and group B Streptococcus
C - Syphilis, Rubella, Hep B, HIV
The above is recommended by NICE Toxoplasmosis and CMV are too infrequent in the population to be warranted inclusion in a screening program. Hep C screening is not cost effective.
A 30yo nulliparous woman is 29wks. She presented to hospital with minor, painless, unprovoked PV bleeding of about a teaspoon full. Her anomaly scan at 20wks showed a low lying placenta. Her fetus is moving well and CTG is reassuring. What is the most appropriate management?
A - Allow home as it is a small bleed
B - Admit and give steroids
C - Admit, IV access, observe bleed free for 48hrs before discharge.
D - Admit, IV access, Group and save and administer steroids if there is further bleeding.
E - Group and save, FBC and allow home; review in clinic in a week.
D - Admit, IV access, Group and save and administer steroids if there is further bleeding.
Bleeding in pregnancy is very common. need to be aware of a placenta praevia or placental abruption. Abruptions tend to be large painful bleeds. The small bleed could precede a large bleed so discharge is the wrong answer. Steroids at this stage are not indicated 48hrs is a bit too long to keep the woman in hospital due to nosocomial risks.
A 34yo woman attends antenatal clinic for a routine ultrasound scan. Abnormalities of placentation are detected and an MRI organised. The MRI report shows; ‘The placenta is in the lower anterior uterine wall with evidence of invasion to the posterior wall of the bladder’. What is the most likely diagnosis?
A - Placenta Accreta
B - Placenta Percreta
C - Placenta Increta
D - Placenta Praevia
E - Ectopic Pregnancy
D - Placenta Praevia
Placenta Accreta is the firm adhesion of the placenta to the uterine wall, Increta is the invasion through the myometrium and percreta is invasion beyond the myometrium.
A 28yo pregnant woman attend A&E with a history of clear vaginal loss. She is 18 weeks pregnant and so far has had no problems. Her medical history includes a large cone biopsy of the cervix and an allergy to penicillin. She is worried as the fluid continues to come and now there is some blood. On examination it is apparent that her membranes have ruptured. What is the most appropriate initial management?
A - Discharge, Ultrasound scan the next day
B - Offer her a termination as its not possible for this pregnancy to continue.
C - Admit, Infection markers. Ultrasound and steroids
D - Ultrasound, infection markers and observation
E - Discharge and explain that she will probably miscarry at home.
D - Ultrasound, infection markers and observation
The outlook for this pregnancy is poor but there is a chance the pregnancy will continue, so option B is not correct.
The risk of chorioamnionitis precludes sending her home immediately, ruling out E and A
Before 24 weeks there is no role for steroids so option
A 37yo woman in her 4th ongoing pregnancy presents to the labour ward at 34 week’s gestation complaining of a sharp pain in her chest, worse on inspiration. An ABG shows: pH 7.51, PO2 8.0kPa, PCO2 4.61, base excess 0.9. What is the most appropriate investigation?
A - CTPA
B - MRI
C - D-dimer
D - Ventilation/perfusion Scintigraphy
E – Ultrasound
D - Ventilation/perfusion Scintigraphy
Ultrasound and MRI are not useful for confirming a PE
D-dimer is mainly useful as a predictor, it is also raised in pregnancy anyway
So it comes down to a V/Q scan or a CTPA. Both are diagnostically useful but a V/Q has by far the lower dose of ionizing radiation so is preferred in pregnancy.
A 32-year-old woman in her second pregnancy presents at 36 weeks gestation
with a history of passing a gush of blood stained fluid from the vagina an hour
ago, followed by a constant trickle since. The admitting obstetrician reviews her
history and weekly antenatal ultrasound scans have shown a placenta praevia.
What is the most appropriate management? She has a firm, posterior cervix and
has not been experiencing any contractions.
A. Induction of labour with a synthetic oxytocin drip
B. Cervical ripening with prostaglandins followed by a synthetic oxytocin drip
C. Digital examination to assess the position of the fetus
D. Monitor for 24 hours and manage as for preterm pre-labour rupture of
membranes (PPROM)
E. Caesarean delivery
E. Caesarean delivery
The low lying placenta in this case immediately precludes a vaginal delivery in any case, ruling out A and B.
The gush of blood and steady trickle implys rupture of membranes, premature in this case. Being 36 weeks makes the PPROM pathway rather pointless as it applies mainly to pre-34/36 weeks.
Option C is contraindicated outside of a pre-term labour scenario due to risk of infection
Maternal physiology changes throughout pregnancy to cope with the additional
demands of carrying a fetus. Which of the following changes best represents a
normal pregnancy?
A. Stroke volume increases by 10 per cent by the start of the third
trimester
B. Plasma volume increases disproportionately to the change in red cell
mass creating a relative anaemia
C. Plasma levels of fibrinogen fall, reaching a trough in the mid-trimester
D. Systemic arterial pressure rises to 10 mmHg above the baseline by term
E. Aortocaval compression reduces venous return to the heart, in turn
increasing pulmonary arterial pressure
B. Plasma volume increases disproportionately to the change in red cell
mass creating a relative anaemia
Stroke volume is over 30% higher at the start of the third trimester
There is an increase in fibrinogen and factors VII, X and XII
There is no change in the systemic of pulmonary blood pressure
A 30-year-old woman attends the antenatal clinic asking to be sterilized at the
time of her elective caesarean. She is 34 weeks into her second pregnancy having
had her first child 2 years ago via an emergency caesarean section. She is not sure
that she wants any more children. Further more, she does not wish to try for a
vaginal birth. She has tried the contraceptive pill in the past but does not like the
side effects. You talk to her about other options, including the sterilization she is
requesting. What is the best management option for this woman?
A. Mirena coil
B. Sterilization at the time of her caesarean section
C. T380 coil
D. Implanon
E. Vasectomy
C. T380 coil
If she is sure she doesn’t want a hormonal method then A and D (depot injection) are out.
You can’t suggest a vasectomy wiothout the partner in the consultation!
C (copper coil) is the best option as it can be reversed if needed and it is less of a risk than performing a sterilisation.
If she insists then a second opinion will be needed due to her young age.
A 41-year-old multipara attends the antenatal clinic at 36 weeks gestation
complaining of lower abdominal cramps and fatigue when mobilizing. Clinical
examination is unremarkable save for a grade I pansystolic murmur, loudest over
the fourth intercostal space in the midaxillary line. What is the most appropriate
management?
A. Urgent outpatient echocardiogram and referral to a maternal–fetal
medicine consultant
B. Reassurance and a 38-week antenatal clinic follow-up
C. Admission and work-up for cardiomyopathy
D. Post-natal referral to a cardiologist
E. Admission to the labour ward for induction of labour
B. Reassurance and a 38-week antenatal clinic follow-up
Dilation of the tricuspid valve leading to a mild regurgitant murmur is a normal consequence of pregnancy.
At this gestation abdominal pain and fatigue are also normal.
Any cardiac investigations are likely to cause alarm for no reason. Equally induction is not indicated in the 38th week for no cause.
A 32-year-old HIV positive woman who booked for antenatal care at 28
weeks gestation arrives on the delivery suite at 37 weeks with painful regular
contractions and a cervix dilated to 4 cm. Ultrasonography confirms a breech
singleton pregnancy with a reactive fetal heart rate. What is the most appropriate
management option?
A. Await onset of labour, avoid operative delivery, wash the baby at
delivery
B. Induce labour with synthetic prostaglandins
C. Await onset of labour, but have a low threshold for expediting vaginal
delivery using forceps
D. Await onset of labour, avoid operative delivery, administer steroids to
the infant immediately after birth
E. Caesarean delivery, wash the baby at delivery
E. Caesarean delivery, wash the baby at delivery
In HIV there is a requiremtn to avoid instrument delivery and amniocentisis. (C)
Generally a caeserean should be performed as it reduces the risk of vertical transmission. (A) is not perfered for that reason
Steroids have no place here at all (D)
There is also no benifit to expidiating a vaginal delivery for the above (B)
A 41-year-old multiparous woman attends accident and emergency at 32 weeks
gestation complaining of sudden onset shortness of breath. A CTPA demonstrates
a large saddle embolus. What is the most appropriate treatment regimen?
A. Load with warfarin to achieve a target international normalized ratio
(INR) of 3.0
B. Load with warfarin to achieve a target international normalized ratio
(INR) of 2.5
C. Load with warfarin to achieve a target international normalized ratio
(INR) of 20
D. 80 mg enoxaparin twice daily
E. 7.5 mg fondaparinux once daily
D. 80 mg enoxaparin twice daily
Warfarin is teratogenic so thats 3 options out
Of the two LMWH, both are efficous in treating pulmonary embolism, butonly Enoxaparin is licenced in pregnancy.
A 21-year-old woman attends the labour ward with per vaginal bleeding of 100 mL.
She is 32 weeks pregnant and has had one normal delivery in the past. An important
history to note is that of an antepartum haemorrhage in her last pregnancy and she
smokes 10 cigarettes a day. Her 20-week anomaly ultrasound revealed a posterior
fundal placenta. She admits she and her partner had intercourse last night and is
concerned by terrible abdominal pains. What is the most likely diagnosis?
A. Vasa praevia
B. Placenta praevia
C. Placenta accreta
D. Placental abruption
E. Cervical ectropion
D. Placental abruption
Her anomoly scan rules out (B)
(A) is a rare complication at the time of rupture of membranes that can lead to fetal demise, it is typically painless
(C) is diagnosed at the time of placental delivery
(E) would be a possibility, especially as it is common in pregnancy and intercourse can lead to bleeding. The severe pain goes strongly against this and leads to a likely diagnosis of abruption.
At a booking visit a first time mother is told that she is rhesus negative. Which of
these answers is the most appropriate advice for the mother?
A. It is important to have anti-D as it will make sure your baby does not
develop antibodies
B. If you have any bleeding before 12 weeks be sure to get an injection of
anti-D
C. Anti-D will stop your body creating antibodies to your baby’s blood
that may help protect the health of your next child
D. If your partner is rhesus negative you do not need to have anti-D
E. You need one injection that will cover your pregnancy even if you have
episodes of vaginal bleeding
C. Anti-D will stop your body creating antibodies to your baby’s blood
that may help protect the health of your next child
Having anti-D has no efect on a first pregnancy, it is also not nessesary before 12 weeks. Thats A and B excluded.
Although D is true, the risk of the partner not being the father excludes this (according to the book anyway)
And in the case of bleeding you will need further doses, excluding E
A 42-year-old para 4 with a dichorionic–diamniotic (DCDA) twin pregnancy at 31 weeks gestation presents to hospital with a painful per vaginam bleed of 400 mL. The bleeding seems to be slowing. She is cardiovascularly stable, although having abdominal pains every 10 minutes. There is still a small active bleed on speculum and the cervix appears closed. Both fetuses have reactive CTGs. She has had no problems antenatally and her 28-week ultrasound revealed both placentas to be well away from the cervix. What is your preferred management plan?
A. Admit to antenatal ward, ABC, iv access, Group and Save, CTG,
steroids, consider expediting delivery
B. Reassure and ask to come back to clinic next week if there are any problems
C. Admit for observation, iv access
D. Admit to labour ward, ABC, iv access, full blood count, cross-match 4
units of blood, CTG, steroids, consider expediting delivery
E. As bleeding settled and placenta not low, offer admission but arrange
follow-up if refused
D. Admit to labour ward, ABC, iv access, full blood count, cross-match 4
units of blood, CTG, steroids, consider expediting delivery
The significant PV bleed is concerning for a placental abruption. This is a sequale more common in twin pregnancies.
B and C both fail to take into account the seriousness of the situation. The woman should not be allowed to go home for the same reason (E).
Between A and D, the differnce is that in D you are more worried about blood loss so are getting crossmatched units, an appropriate step in this case.
You are the FY1 covering the antenatal ward. A 27-year-old nulliparous woman who is 36 + 5 pregnant has been admitted to your ward with
suspected pre-eclampsia. The emergency buzzer goes off in her room. You are the first to attend and find your patient flat on the bed having a generalized seizure – what do you do?
A. Call for help, ABC, nasopharyngeal airway, iv access and wait for fit to stop
B. Call for help, ABC, protect her airway, prepare for grade 1 caesarean section
C. Call for help, ABC, left lateral tilt, wait for seizure to end, listen in to fetus
D. Call for help, ABC, left lateral tilt, protect airway, prepare magnesium
E. Call for help, ABC, protect airway, prepare magnesium, check blood pressure
D. Call for help, ABC, left lateral tilt, protect airway, prepare magnesium
The first steps in this suspected eclamptic fit are to lie her flat and tilting to the left lateral (to prevent obsrtruction of venous return and in case of vomiting), and calling for help.
The options of C and D are best in line with this management, in addition you do need to protect her airway and prepare Mg to stabilise. This leaves otion D.
Of the other two options, inserting an airway adjunct or a cannula in a fitting patinet is a risk and is not an immediate management.
B may actually be the reality, but in this question you are an F1 and need to be managing the patient not preparing for surgery.
A 38-year-old woman in her first pregnancy is 36 weeks pregnant. She presents to the labour ward feeling dizzy with a mild headache and flashing lights. Her past medical history includes systemic lupus erythematosus (SLE), renal stones and malaria. Her blood pressure is 158/99 mmHg with 2+ protein in her urine. Her platelets are 55 × 109/L, Hb 10.1 g/dL, bilirubin 62 μmol/L, ALT 359 IU/L, urea 2.3 mmol/L and creatinine 64 μmol/L. What is the most likely diagnosis?
A. Thrombotic thrombocytopenic purpura (TTP)
B. HELLP syndrome
C. Idiopathic thrombocytopenic purpura (ITP)
D. Systemic lupus erythematosus (SLE)
E. HIV
B. HELLP syndrome
TTP is charecterised by; micoangiopathic haemolytic anemia, hrombocytopenia, fever, neurological involvement and renal impairment. In this case renal function is normal.
ITP is a diagnosis of exclusion
there isn’t anything to sugesst this is caused by HIV or SLE
This woman has haemolysis, elevated liver enzymes, and low platelets, therefore HELLP
A 19-year-old woman in her first pregnancy presents to the GUM clinic with
an outbreak of primary herpes simplex infection on her labia. She is 33 weeks
pregnant. What is the best advice regarding her herpes?
A. Aciclovir from 36 weeks until delivery
B. Caesarean section should be performed if she labours within the next 8
weeks
C. Reassure as the infection will pass and pose no further concern
D. If she labours within 6 weeks, a caesarean should be recommended
E. Aciclovir for 10 days and an elective caesarean at 39 weeks
D. If she labours within 6 weeks, a caesarean should be recommended
There is no evidence that antenatal Aciclovir reduces vertical transmission (A and E)
it takes 6 weeks until the infection is considered to be clear, if she labours within that period a caesarean should be reccomended. If she refuses then per-natal IV aciclovir has a role.
Unconditional reassurance (C) is not appropriate due to the above.
A 33-year-old woman presents to hospital with a 2-day history of itching
on the soles of her feet and the palms of her hands. Her pregnancy has been
straightforward and she has good fetal movements. Liver function tests reveal an alanine transaminase (ALT) of 64 IU/L and bile acids of 30 μmol/L. You suspect that she might have developed obstetric cholestasis. Which of the following bits of advice is true?
A. She could have intermittent monitoring in labour
B. Ultrasound and CTG surveillance help prevent stillbirth
C. Poor outcomes can be predicted by bile acid levels
D. Ursodeoxycholic acid (UDCA) helps prevent stillbirth
E. Meconium stained liquor is more common in labour
E. Meconium stained liquor is more common in labour
the itching and deranged LFTs (especially the bile acid) is typical of obstetric cholestasis. The liver function should be checked weekly. Stillbirth is a risk, so induction in week 37-38 is reccomended. Meconium stained liquor is more common.
UDCA treats the symptoms of OC but has no effect on stillbirth rates. (D) there is no link between outcomes and bile acid levels (C) and constant CTG monitoring in Labou is warrented (A).
option B is just ilogical
A 24-year-old woman who is 32 weeks pregnant presents to the labour ward with a terrible headache that has not improved despite analgesia. It started 2 days ago and came on suddenly. She has stayed in bed as it hurts to be in sunlight and she vomited twice this morning. Her past medical history includes a macroprolactinoma (which has been removed) and occasional migraines. She is haemodynamically stable with no focal neurology or papilloedema. You arrange for her to have a CT of her head as an emergency, which adds no further information to aid your
diagnosis. There are red cells on lumbar puncture but no organisms are isolated. What is the most likely diagnosis?
A. Migraine
B. Viral meningitis
C. Cerebral vein thrombosis (CVT)
D. Subarachnoid haemorrhage (SAH)
E. Idiopathic intracranial hypertension (IIH)
A. Migraine
You could convince yourself it was any of the options to be fair.
But, the lack of haemodynamic compromise, no focal neurology and no papiloedema goes against this. (D)
a Cerebral vein Thrombus is classically post-partum and will often have focal neurology (C).
The lack of an infective presentation goes against Viral meningitis (B)
(E) is often associated with young obese women but would have papilloedema.
A 19-year-old woman in her first pregnancy is admitted to the labour ward with a 4-hour history of lower abdominal pain – she is 22 weeks pregnant. She has not had any vaginal bleeding but describes a possible history of rupture of her membranes. Her past medical history includes an appendectomy and a large cone biopsy of her cervix. On examination she has palpable lower abdominal tenderness, her cervix is 2 cm dilated, she has an offensive vaginal discharge and her temperature is 38.9ºC. Her white cell count is 19.0 × 109/L and her C-reactive protein is 188 mg/L. There are no signs of cardiovascular compromise. How would you manage this woman?
A. Insert a cervical suture
B. 12 mg betamethasone, atosiban for tocolysis and antibiotics
C. Head down, bed rest, antibiotics and await events
D. Antibiotics and induce labour
E. Caesarean section
The Large cone biopsy puts her at risk of cerviacal compromise - PROM.
There is a sceptic picture here also, this combined with the dilated cervix indicates a sceptic miscarrige. option A on it’s own would not deal with the presenting scenario and is contraindicated in the case of infection.
At 22 weeks the foetus is not viable and so there is no role for steriods (B) tocolytics is contraindicated in chorioamnionitis.
The woman needs antibiotics and to have the focus of infection removed - this is option D.
Watching and waiting is not appropriate due to the severity of the case (C)
Caesarean is not advisable in a 22 week gestation.
A 24-year-old multiparous woman is 23 weeks pregnant. She has not had chicken pox before. She goes to a collect her 3-year-old son from a birthday party and comes into contact with a child with an infective chicken pox infection. She is naturally very anxious. What is the best course of management?
A. Wait and see if she develops a rash. If she does treat with aciclovir
B. Test for varicella antibodies and give varicella zoster immunoglobulin
(VZIG) within the first 24 hours
C. Test for varicella antibodies and give aciclovir within the first 24 hours
D. Test for varicella antibodies and give VZIG within 10 days
E. Reassure that there is no significant risk at present as contact was so brief
D. Test for varicella antibodies and give VZIG within 10 days
women who contract chicken pox during pregnancy are at risk of a more significat effect on themselves as well as the risk of fetal varicella syndrome if the exposure is before 28wks. This syndrome includes eye defects hypoplasia of the limbs and neurological defects.
There has been significant contact in this case, and her 3 year old may well be incubating the virus, so options A and E are inappropriate.
Although she may not think she has had chicken pox, she may have developed a sub-clinical infection previously. testing for antibodies will guide your management. Aciclovir can be started within 24hours of the RASH APPEARING so C is not correct.
Becuase of the cost involved you don’t start VZIg straight away in case she is immune (excludes B). The guidance is that VZIg is effective within 10 days.
A 32-year-old woman in her third pregnancy is 37 weeks pregnant and has an
extended breech baby on ultrasound. After discussion in the antenatal clinic,
which of the following is not an absolute contraindication to an external cephalic
version (ECV)?
A. Multiple pregnancy
B. Major uterine abnormality
C. Antepartum haemorrhage within 7 days
D. Rupture of membranes
E. Small for gestational age with abnormal Doppler scan
E. Small for gestational age with abnormal Doppler scan
I gon’t the wrong idea with answer A and thought it meant multiparous as oppossed to twin/triplet etc. Obviously that’s contra indicated.
Bleeding (C), major abnormalities (B), and a lack of fluid to protect the baby (D), are all absolute contra indications
(E) is only a relative contra indication
A 24-year-old type 1 diabetic woman has just had her first baby delivered by
caesarean section at 35 weeks due to fetal macrosomia and poor blood sugar
control. The operation is straightforward with no complications. She has an insulin
sliding scale running when you review her on the ward 12 hours postoperatively.
She has begun to eat and drink. How would you manage her insulin requirements?
A. Continue the sliding scale for 24 hours
B. Change her back to her pre-pregnancy insulin and stop the sliding scale
C. Halve the dose of insulin with each meal for the next 48 hours
D. Stop the insulin now that baby is delivered
E. Sliding scale for 48 hours to prevent hyperglycaemia
B. Change her back to her pre-pregnancy insulin and stop the sliding scale
Stopping the insulin (D) is a bit mad as she’s a Type 1…
As soon as the patient is eating there is no need to continue the sliding scale (A or E)
Halving the dose is likely to not give her enough control (C)
The only sensible option is to return to the normal insulin dose but continue to monitor.
A 19-year-old woman is referred to your pre-conception clinic. She has SLE
and wants to fall pregnant. She is currently not on any treatment and has no
symptoms. As part of your general counselling you should talk about the risks
associated with pregnancy. Which of the following is not a particular risk to a
woman with SLE?
A. Fetal growth restriction
B. Diabetes mellitus
C. Pre-eclampsia
D. Stillbirth
E. Preterm delivery
B. Diabetes mellitus
Pregnancy increases the chance of a flare up of SLE by 40-60%.
it carries the risk of , spontaneous miscarriage, Fetal Death (D), Pre-eclampsia (C), pre-term delivery (E) and fetal growh restriction (A). All of which make sense as SLE is a systemic disease of the connective tissue. THere is no reason why a connective tissue disease would affect an endocrine system as in Diabetes Mellitus (B)
A 44-year-old women who is 18 weeks pregnant presents to your clinic with
a 2-day history of a viral illness. She is extremely anxious and is in floods of
tears. She recently had some soft cheese in a restaurant and after an internet
search she is convinced she has a particular infection. What infection is she
concerned about?
A. Toxoplasmosis
B. Cytomegalovirus (CMV)
C. Listeria monocytogenes
D. Hepatitis E
E. Parvovirus B 19
C. Listeria monocytogenes
A - Toxoplasmosis is associated with cats, cat faeces, or unwashed fruit and veg
B - Is commonly sub-clinical and found in many people. It’s only an issue in the immunocompromised. No food association
C - this is associated with soft cheese, pate or unpasterised milk. Causes mid-trimester loss, early meconium and pre-term labour. Flu like illness
D - Non-chronic hepatitis, transmitted by faeco-oral route
E - Parvovirus B19 casuses the facial rash of slapped cheek syndrome/fith disease called erythema infectiosum. It has a respiratory droplet route of transmission.
A 26-year-old woman is 37 weeks pregnant and consults you about a rash that
started on her abdomen and has now spread all over her body. Interestingly her
umbilicus is spared. The rash is very itchy and nothing is helping. The rash is
her first problem in this pregnancy. Of interest, her mother has pemphigoid and her sister has psoriasis. What is the most likely cause of her rash?
A. Pemphigoid gestationis
B. Pruritic urticarial papules and plaques of pregnancy (PUPP)
C. Impetigo herpetiformis
D. Prurigo gestationis
E. Contact dermatitis
B. Pruritic urticarial papules and plaques of pregnancy (PUPP)
Pemphigoid gestationis is a blistering condition that starts at teh umbilicus and then spreads.
Impetigo herpetiformis is a febrile blistering condition that can lead to maternal and fetal death.
Prurigo gestationis is a rash of the uper arms and trunkwith abdominal sparing
Contact dermatitis is possible if there was a history of use of lotions or creams but unless there was a reason in the history it would not be sparing the umbilicus.
Which of the following drugs is not absolutely contraindicated in pregnancy?
A. Acitretin
B. Fluconazole
C. Mebendazole
D. Sodium valproate
E. Methotrexate
D. Sodium valproate
Valporate should be avoided as it has the highest risk of congenital malformations of all the anti convulsants. But if it is the most appropriate agent for the patient it should be used.
Acitretin is a retanoid and methotrexate is a chemical pregnancy termination agent (amougst other uses) these are both obviously a big no-no.
Mebendazole is an anti worm tablet and has been shown to have toxic effects in animal studies
Fluconazole is an anti fungal and is linked with many congenital abnormalities.
A 42-year-old woman is in her first pregnancy. She conceived with in vitro
fertilization (IVF) and has had a straightforward pregnancy so far. At 25 weeks’
gestation she is seen in clinic with a blood pressure of 142/94 mmHg and protein +
in her urine. A protein creatinine ratio (PCR) comes back as 19. She says that her
blood pressure is often up at the doctor’s. With the information you have to hand
what is the most likely diagnosis?
A. Pre-eclampsia
B. White coat hypertension
C. Essential hypertension
D. Conn’s syndrome
E. Pregnancy-induced hypertension
E. Pregnancy-induced hypertension
(B) is a diagnosis of exclusion and shouldn’t be resorted to without another identifiable cause
(A) Pre-eclampsia is a diagnosis of raised blood pressure and proteinuria, a PCR of less than 30 is considered normal. So this is not the diagnosis in this case
(D) there’s nothing here to suggest Conn’s
The fact that the hypertension has been identified in the context of pregnancy makes this (E) not (C).
A 24-year-old woman attends the antenatal clinic. She has had a glucose tolerance test which is abnormal. A diagnosis of gestational diabetes is made. The primary
purpose of this appointment is to explain to her what gestational diabetes means
to her and her baby. You explain to her that sugar control is important and there
are specific glucose ranges that she should try to adhere to. Which of the following
would be correct advice for this woman?
A. Pre meal blood sugar <7.1 μmol/L
B. Post meal 1-hour sugar <11.1 μmol/L
C. Post meal 1-hour sugar <7.8 μmol/L
D. Post meal 2-hour blood sugar <7.8 μmol/L
E. Pre meal blood sugar <7.8 μmol/L
C. Post meal 1-hour sugar <7.8 μmol/L
Gestational diabetes mellitus is diagnosed as a blood sugar of greater than 7.8 μmol/L one hour after the oral glucose test. As such this is the control level to be aimed for. The pre-meal blood sugars should be less than 5.5μmol/L
A 24-year-old woman in her first pregnancy has a significantly raised glucose
tolerance test at 28 weeks gestation: 4.6 fasting 12.1 at one hour 9.1 at 2 hours
(μmol/L). She is given the diagnosis of GDM. You are asked to counsel her about
the effects of gestational diabetes on pregnancy. Which of the following is not an
additional effect of having GDM?
A. Shoulder dystocia with a macrosomic fetus
B. Stillbirth
C. Neonatal hypoglycaemia
D. 10 per cent chance of developing type 2 diabetes over the next
10 years
E. Pre-eclampsia
D. 10 per cent chance of developing type 2 diabetes over the next
10 years
the risk of developing DM type 2 is actually 35-60% over the next 10-15 years.
All the other statements are correct
A 24-year-old woman who is HIV positive is in her first pregnancy. She is 39
weeks pregnant and is seen by you in the antenatal clinic. She has just transferred
to your care, with no other previous antenatal care. She reports that her pregnancy
has been uncomplicated. Her CD4 count is 180/mm3 and her viral load is 5500
copies/mL. She has come to find out what advice you have for her delivery.
A. Spontaneous vaginal delivery
B. Induction of labour to prevent CD4 decreasing
C. Caesarean section
D. Start highly active antiretroviral therapy (HAART) and await for labour
to start
E. Start HAART, amniotomy and HAART for baby when born
C. Caesarean section
Due to this woman’s viral load being high we want to avoid vertical transmission, caesarean section has evidence that it does reduce the risk.
For the same reasons prolonged rupture of membranes and any artificial rupture should be avoided (B and E)
A normal delivery can be advised, but only if the viral load is undetectable (less than 50 copies/ml) this excludes options A and D in this case.
N.B. Amniotomy = artificial rupture of membranes
A 24-year-old woman attends accident and emergency 4 weeks after having a
positive urinary pregnancy test. She has had 3 days of painless vaginal bleeding
and is passing clots. Over the past 2 days the bleeding has settled. An ultrasound
scan shows an empty uterus. What is the correct diagnosis?
A. Threatened abortion
B. Missed miscarriage
C. Septic abortion
D. Complete abortion
E. Incomplete miscarriage
D. Complete abortion
Threatened abortion = any bleeding before viability (24 weeks currently). after this point bleeding is ante-partum haemorrhage
Missed Miscarriage = The loss of a pregnancy without the passage of products of conception or bleeding.
Septic Abortion = The loss of a pregnancy with evidence of infection, the infection is of the retained conceptus. must be managed actively as there is still a high mortality
Incomplete abortion = The loss of a pregnancy with bleeding and/or passage of some, but not all, products of conception. it can be managed conservatively, medically (misoprostol), or through ‘surgical management of miscarriage’ (previously called evacuation of retained products of conception, ERPC)
A 51-year-old woman in her 12th week of an assisted-conception triplet pregnancy
presents to accident and emergency with severe nausea and vomiting. She has mild
lower abdominal and back pains. Urine dipstick shows blood –ve, protein –ve,
ketones ++++, glucose +. What is the most appropriate management plan?
A. Intravenous crystalloids and doxycycline, urgent ultrasound assessment
B. Discharge with 1 week’s course of ciprofloxacin
C. Referral to the medics for investigation of viral gastroneteritis
D. Intravenous crystalloids, oral antiemetics
E. Referral to the surgeons for investigation of appendicitis
D. Intravenous crystalloids, oral antiemetics
The triplet pregnancy is a risk factor for the development of Hyperemesis gravidarum. The ketonuria also points to this diagnosis as a indicator of dehydration.
The mild back and abdo pains are normal for this stage in pregnancy.
The management of HG is to rehydrate and provide antiemetics (D)
Without diarrhoea or sepsis we shouldn’t be leaning towards viral gastroenteritis or appendicitis (C, E), and it’s certainly not appendicitis with a mild pain.
Tetracyclines (Doxy) and Quinolones (cipro) are both teratogenic
A 19-year-old woman is referred to your early pregnancy unit as she is having
some vaginal bleeding. This is her first pregnancy, she has regular menses and the
date of her last menstrual period suggests she is 8 weeks gestation today. She is
well apart from her bleeding and is naturally concerned. A transvaginal ultrasound
reveals an intrauterine gestational sac of 18 mm with a yolk sac. What is the most
likely explanation of these findings?
A. A viable intrauterine pregnancy
B. A pseudosac
C. A blighted ovum
D. A pregnancy of uncertain viability
E. An anembryonic pregnancy
D. A pregnancy of uncertain viability
Vaginal bleeding in early pregnancy is common but not normal, it has a miscarrige rate of 20%. This scenario by definition is a threatened miscarrige.
Without a fetal pole or a pulsatation we canot say for certain that this is a viable pregnancy (A)
At 6 weeks we would expect to see a heartbeat, but the dates may be wrong.
C and E are the same thing, it is a gestational sac without a fetal pole or yolk sac. There is a yolk sac in this case.
A psudosac (B) is the development of decidual reaction in an ectopic pregnancy, there would be no yolk sac, and this isn’t ectopic.
A 31-year-old woman is seen in the termination of pregnancy (TOP) clinic requesting a termination. She is 5 weeks pregnant in her first pregnancy. She is otherwise well but does have some lower abdominal pain on the right hand side. On examination her abdomen is soft and non-tender. An ultrasound reveals a small sac in the uterus which might be a pseudosac. What would be your next management step?
A. Urgent referral to hospital to rule out ectopic pregnancy
B. Rescan in 10 days time
C. Blood test for beta human chorionic gonadotrophin (hCG) now and in
48 hours time
D. Arrange for her to come in for a medical termination
E. Arrange a surgical termination of pregnancy
C. Blood test for beta human chorionic gonadotrophin (hCG) now and in
48 hours time
If the sac in the uterus is a psudosac then it points to an ectopic pregnancy, this is supported by the RIF pain.
The woman is, however, heamodynamically stable and has a SNT abdomen so an urgent referral is not needed at this stage (A) as long as she is able to understand red flag symptoms.
She needs a bhCG level now and then again in 48hrs. If there is a 67% rise in bhCG then it indicates that the sac in the uterus is a viable pregnancy, and following an ultrasound scan to confirm in ten days, a TOP can be offered to this woman if she wishes.
If the rise in bhCG is less than this she should be seen for further assesment in hospital
An interuterine pregnancy should always be confirmed prior to offering a TOP.
A 28-year-old woman with a history of pelvic inflammatory disease is 6 weeks
into her third pregnancy. She previously had two terminations. She presents with
lower abdominal pain and per vaginam bleeding. Her beta hCG is 1650 mIU/mL,
progesterone 11 nmol/l. An ultrasound reveals a small mass in her left fallopian
tube with no intrauterine pregnancy seen. There is no free fluid in the Pouch of
Douglas. She is diagnosed with an ectopic pregnancy and is clinically stable but
scared of surgery. How would you manage this case?
A. Laparoscopic salpingectomy
B. Methotrexate
C. Laparotomy + salpingectomy
D. Laparoscopic salpingotomy
E. Beta hCG in 48 hours
B. Methotrexate
This woman has risk factors for an ectopic pregnancy, PID, and previous terminations. Other risks include tubal surgery, previous ectopics and IVF.
A salpingectomy would be definitive but is an extreme step to leave a 28 year old woman with one tube. An open [rocedure is definitely not needed as she is stable.
A salpingotomy (opening the tube but leaving in in situ) may just increase the risk of further ectopic pregnancys.
The criteria for methotrexate use in an ectopic are that it is a small ectopic with no fetal pulse, no clinical compromise, and no free fluid on the pouch of Douglas. This woman is an ideal candidate.
Monitoring the bhCG in 48hrs would indicate if this pregnancy is failing spontaneously. Given that she is a candidate for methotrexate it is the most definitive management.
A 24-year-old woman attends her GP complaining of deep dyspareunia and
post-coital bleeding. She has crampy lower abdominal pain. Of note, she has
been treated in the past for gonorrhoea on more than one occasion. On speculum
examination there is no visible discharge, but the cervix bleeds easily on contact.
What is the most appropriate management?
A. IM cefotaxime, oral doxycycline and metronidazole
B. 1 g oral metronidazole stat
C. Urgent referral to the gynaecology clinic
D. Referral to a sexual health clinic
E. Admission to hospital under the gynaecologists
C. Urgent referral to the gynaecology clinic
The easily bleeding cervix is the alarming factor here. The woman’s significant history of sexually transmitted infections could lead you to think of PID or another infection, for which A,B,D and E are all management options, the cervix bleeding easily is a concern for cervical cancer. At the age of 24 she is not included in the cervical screening program
This concern should be investigated urgently (C)
16-year-old girl attends accident and emergency complaining of mild vaginal
spotting. Her serum beta hCG is 4016 mIU/mL. She is complaining of severe leftiliac fossa pain and stabbing sensations in her shoulder tip. What is the most
appropriate definitive investigation?
A. Diagnostic laparoscopy
B. Serial serum beta hCG measurement
C. Computed tomography of the abdomen and pelvis
D. Clinical assessment with speculum and digital vaginal examination
E. Transvaginal ultrasonography
E. Transvaginal ultrasonography
The severe LIF pain and shoulder tip pain strongly indicates an ectopic pregnancy that has potentially ruptured and the free fluid is irritating the diaphram and causing the reffered shoulder tip pain.
An early pregnancy should be visable if the bhCG is above a 1000 so a TVUS should see an interuterine pregnancy if this sisn’t an ectopic.
The Laparoscopy (A) would only be first line if she was unstable. At this stage it should be performed if the TVUS confirms an ectopic.
CT is too teratogenic (C)
The serial bhCG (B) would only give useful information after 48hrs, given the picture it’s not wise to wait that long.
Clinical assesment (D) would not be definitive
An 18-year-old woman presents to accident and emergency having fainted at work. She is complaining of pain in the lower abdomen. A serum beta hCG performed in the emergency department is 3020 mIU/mL. The on-call gynaecologist performs transvaginal ultrasonography in the resuscitation area which shows free fluid in the Pouch of Douglas and no visible intrauterine pregnancy. Her pulse is 120 bpm and blood pressure 90/45 mmHg. What is the most likely diagnosis?
A. Ruptured ovarian cyst
B. Cervical ectopic pregnancy
C. Ruptured tubal pregnancy
D. Perforated appendix
E. Ovarian torsion
C. Ruptured tubal pregnancy
- collapse and circulatory compromise (low BP, tachycardia)
- A bhCG over 1000 would be a visible pregnancy in the uterus on TVUS, it is not visable. Therefore ectopic
- Fluid in the pouch of douglas indicates a degree of rupture
The ruptured cyst (A) and torsion (E) would both have sudden onset but no haemodynamic compromise. of the two the cyst would have pain that improves with simple analgesia and time, the torsion would not get better.
A 50-year-old woman comes to your clinic with a 2-year history of no periods. Her
GP has confirmed that her luteinizing hormone and follicle-stimulating hormone levels are menopausal. Her night sweats and hot flushes are unbearable and are preventing her from going to work. She would like to start hormone replacement therapy (HRT) but is very worried about the side effects. Which of the following is incorrect?
A. There is evidence that HRT prevents coronary heart disease
B. There is a small increase in the risk of strokes
C. There is an increased risk of breast cancer
D. There is an increase in the risk of ovarian cancer
E. There is an increase in the rate of venous thromboembolism
A. There is evidence that HRT prevents coronary heart disease
oestrogen increases the risk of ovarian and breast Ca (D and C)
There is a small increased risk of stroke (B) and a small increase in DVT risk (E)
A 24-year-old woman who is 9 weeks pregnant is brought to accident and
emergency by ambulance with left iliac fossa pain and a small vaginal bleed.
An abdominal ultrasound scan performed at the bedside demonstrates a cornual
pregnancy and free fluid in the pelvis. Her observations are: pulse 119 bpm, blood
pressure 74/40 mmHg, respiratory rate 24/minute. What is the most appropriate
definitive management?
A. Transvaginal ultrasound scan
B. Serum beta hCG estimation
C. Diagnostic laparoscopy
D. Admission to the gynaecology ward and fluid resuscitation
E. Urine pregnancy test
C. Diagnostic laparoscopy
A cornual pregnancy is a specific ectopic (see image). This patient has a confirmed ectopic and she is haemodynamically compromised, urgent curative action is needed.
A TVUS doesn’t add anything when we have a diagnosis (A)
Likewise a bhCG doesn’t change anything either, it’s purely diagnostic and we have a diagnosis already. (B)
option D is too conservative, fluid resucitation won’t improve the situation.
Finally E is the same situation, no curative effect.
A 26-year-old woman presents to accident and emergency with left-sided lower
abdominal pain and a single episode of vaginal spotting the day before. A
urinary beta hCG is positive, and her last period was 6 weeks ago. A transvaginal
ultrasound shows two gestational sacs. What is the most likely diagnosis?
A. Ruptured theca lutein cyst
B. Appendicitis
C. Diverticulitis
D. Complete miscarriage
E. Urinary tract infection
A. Ruptured theca lutein cyst
This pain has localised to the wrong side for appendicitis (B)
Diverticulitis is extremely unlikely in this age group (C)
A complete miscarriage would not have a positive bhCG or have gestational sacs on the scan (D)
A UTI would have urinary symptoms and classically would localise to the suprapubic area (E)
A functional ovarian cyst is common in women of child bearing age and a theca lutein cyst of cyst is more common in multiple pregnancy. In this case it seems to have ruptured and bleed slowly into the peritonium.
A 32-year-old woman with paranoid schizophrenia is admitted for antenatal
assessment at 36 weeks’ gestation with twins. Her pregnancy is complicated
by intrauterine growth restriction and impaired placental flow. She has had no
psychotic symptoms in this pregnancy. Her obstetricians recommend an early
caesarean section and argue it is in the best interests of the mother and her
babies and to prevent further fetal insult. She has repeatedly said that despite the
significant risks, which she understands, she refuses caesarean delivery. What is
the most appropriate action?
A. Detain under Section 5 of the Mental Health Act and deliver by
caesarean section
B. Detain under Section 2 of the Mental Health Act and deliver by
caesarean section
C. Determine that the patient lacks mental capacity and, acting in her best
interests, delivery by caesarean section
D. Determine that the patient lacks mental capacity and, acting in her
fetus’ best interests, deliver by caesarean section
E. Encourage volunatary admission to the antenatal and repeatedly explain
the benefits of caesarean delivery
E. Encourage volunatary admission to the antenatal and repeatedly explain
the benefits of caesarean delivery
The patient has made a solid case that she has capacity and that she is not suffering from an active psyciatric condition at this time. If she has capacity and is not sufferin from a mental health condition then there is no place for the MH act or the MC act.
E is the only possible option here
On a side note, in the UK you can never legally act on the best interests of a fetus.(option D)
Which of the following would be incorrect advice to give a woman requesting a
caesarean section for non-medical indications?
A. You are twice as likely to have a stillbirth in a subsequent pregnancy
B. The risk of damaging the bladder is one in 20
C. There is an increased risk of placenta praevia in future pregnancies
D. 1–2 per cent babies suffer lacerations
E. The risk of infection is 6 per cent
B. The risk of damaging the bladder is one in 20
A 5% risk is grossly exagerrated here, the real risk is 1:1000
the rest are all correct. 6% is a standar infection risk, there is a chance the baby will suffer a laceration and the scar on the uterus can lead to placenta praevia.
The incrreased risk of still birth was found in a 2014 Danish study, I couldn’t find a mechanism for this.
A 24-year-old Jehovah’s Witness is brought to accident and emergency with a
Glasgow coma scale (GCS) score of 3, BP 90/30 mmHg and pulse 110 bpm. Her
husband reports that her last menstrual period was 8 weeks ago and she complained this morning of lower abdominal pain and vaginal spotting. Ultrasonography suggests a ruptured ectopic pregnancy. As part of the resuscitative measures employed before emergency laparotomy, a transfusion of group O-negative blood is prepared. Her husband interrupts and says that as a Jehovah’s Witness she would absolutely refuse all blood products even at risk of death, and has previously signed an advance directive stating this. What is the most appropriate option?
A. Avoid transfusion and volume-replace with colloids before emergency
transfer to theatre
B. Avoid transfusion and use a Cell Saver auto-transfuser in theatre
C. Avoid transfusion and immediately transfer to theatre
D. Stabilize the woman in accident and emergency before transfer to
theatre
E. Transfuse the woman with group-O negative blood and immediately
transfer to theatre
E. Transfuse the woman with group-O negative blood and immediately
transfer to theatre
in order to be accepted a legally valid advance directive needs to be seen by the clinician in person. The husbands asertation cannot be taken in to account. Te clinicain must act in the patient’s best interests.
The woman is severly compromised and needs resucitation with blood, any avoidance of transfusion completely (B and C) is completely out.
Blood is the best option to stabilise prior to immediate transfer to theatre.
An unbooked 26-week pregnant woman sees you at the hospital to request
a termination of pregnancy. She says that if she leaves here today without
a termination she will try and do it herself by stabbing her abdomen. Your
consultant arranges an urgent psychiatric review which finds no grounds
under which to detain this woman in regards to her mental health. Under these
circumstances, if a termination was performed, which part of the Abortion Act
would it fall under?
A. The continuance of the pregnancy would involve risk to the life of the
pregnant woman greater than if the pregnancy were terminated
B. The termination is necessary to prevent grave permanent injury to the
physical or mental health of the pregnant woman
C. The pregnancy has not exceeded its 24th week and continuance of
the pregnancy would involve risk, greater than if the pregnancy were
terminated, of injury to the physical or mental health of the pregnant
woman;
D. The pregnancy has not exceeded the continuance of the pregnancy and
would involve risk, greater than if the pregnancy were terminated, of
injury to the physical or mental health of any existing child(ren) of the
family of the pregnant woman
E. There is a substantial risk that if the child were born it would
suffer from such physical or mental abnormalities as to be seriously
handicapped.
B. The termination is necessary to prevent grave permanent injury to the
physical or mental health of the pregnant woman
answers C and D refer to terminations before 24 weeks and so are out completely.
There is no evidence here to support option E.
We are at this point left with A or B as options. Legally speaking it is easier to justify that the woman will cause grave harm to herself in this scenario, there is probably a risk of death but it is not as likely as grave harm. For this reason B is the correct answer, although this is a seriously dodgy scenario, terminating a potentially viable fetus.
A 24-year-old woman in her first pregnancy presents to the labour ward in
labour. She and her partner express an overwhelming desire to avoid a caesarean
section. Her labour does not progress and after 9 hours her cervix is still only
3 cm dilated. Unfortunately, the fetal heart slows to 60 beats and does not recover
after 5 minutes. Your senior registrar explains the situation to the woman and
recommends an immediate caesarean section. She refuses and her partner tells
you to stop harassing them. You explain that their unborn child will die if this
continues. What options do you have?
A. Caesarean section under general anaesthesia (GA) under Section 3 of the
Mental Health Act
B. Caesarean section under GA under Section 2 of Mental Health Act
C. No action. Allow fetus to die
D. Caesarean section without Mental Health Act application
E. Caesarean section under GA under Section 5(2) of the Mental Health Act
C. No action. Allow fetus to die
This one is grimly straigtforward. The woman does not appear to be suffering from a mental health condition and so the MH act would not be appropriate. THis act also only convers treatment for mental health conditions.
Any caesarean without consent would be a criminal act, unfortunately answer C is the only option here.
A 16-year-old Muslim woman attends accident and emergency department with
her father. She complains of a 1-day history of left iliac fossa pain and mild
vaginal spotting. A urinary beta hCG test is positive. As part of your assessment
the patient consents to a vaginal examination. She insists you do not tell her father
that she is pregnant, and you consider her to be competent in her judgement. Her
father becomes angry and says you must not perform a vaginal examination. How
should you proceed?
A. Perform the examination with a chaperone present and tell the father
that it is a routine examination
B. Perform the examination with a chaperone present and explain that
parental consent is not necessary in this situation
C. Defer performing the examination and document the situation fully
D. Perform the examination with a chaperone present having assessed the
girl’s Gillick Competence
E. Perform the examination with a chaperone present having assessed the
girl’s Fraser Competence
B. Perform the examination with a chaperone present and explain that
parental consent is not necessary in this situation
The girl is over 16 so is considered competent to consent to a procedure as per the same criteria as an adult. This means that any Gillick/Fraser considerations are not relevant. (D and E)
A necessary clinical examination should not be delayed due to the father’s (actually irrelevant) viewpoint.
At this point I disagree with the book answer of B, normalising the examination and performing the exam with a chaperone seems the less confrontational option here (A). The book argues that option A breeches the girl’s confidentiality but I do’t see how that is true.
A 32-year-old woman is rushed to accident and emergency as the viction of a
high speed vehicle collision. She is 35 weeks pregnant and unconscious. There
is evidence of blunt abdominal trauma and she is showing signs of grade 3
hypovolaemic shock. The consultant obstetrician on call immediately attends
the resus call and recommends immediate perimortem caesarean delivery in a
resuscitative effort to improve the management of her shock. Her husband has
been brought into resus by the police, and insists that she would refuse caesarean
section under any circumstances. What is the most appropriate management?
A. Rapid fluid resuscitation until the situation regarding the patient’s
wishes becomes clear
B. Replacement of the lost circulating volume with blood products
C. Admit to the intensive care unit and begin infusing inotropes to restore
the cardiac output
D. Immediate caesarean delivery
E. Resucitation and transfer to the obstetric theatre for emergency
caesarean delivery
D. Immediate caesarean delivery
In such an emergency the best interests of the patient is all that matters, the husband’s wishes are irrelevant. The patient’s wishes are unlikely to become any clearer in the time she has remaining (A)
Replacing with fluid (A) or blood (B) will only buy a little time
Transfering the patient to theatre (E) or ITU (C) is very risky as the patient may arrest en route. The use of inotropes (C) will only partially help as it won’t replace lost volume.
The primary aim of a perimortem caesarean delivery is to save the mother’s life. The procedure reduces the volume of the gravid uterus which reduces venous return and so pre-load on the heart.
A 59-year-old woman has been admitted for a hysterectomy for endometrial cancer.
She has not yet given her consent and the rest of the team is in theatre. You have
performed a hysterectomy before so feel confident in taking her through what will
happen and the risks involved. The General Medical Council (GMC) says that you
should tailor your discussion to all of the options except which of the following?
A. Their needs, wishes and priorities
B. Their level of knowledge about, and understanding of, their condition,
prognosis and the treatment options
C. The onset of their condition
D. The complexity of the treatment
E. The nature and level of risk associated with the investigation
C. The onset of their condition
There are several considerations in regards to assesing how to provide information. A,B,D, and E are all legitimate considerations. Option C is an incorrect statement and should be ‘the nature of thier condition’
Without these five considerations there is an argument that a patient is not fully informed, and thus cannot give adequate consent.
A quality improvement process that seeks to improve patient care and outcomes
through systematic review of care against explicit criteria and the implementation
of change. This is an accepted definition of what?
A. Audit
B. Clinical governance
C. Clinical research
D. Clinical effectiveness
E. Integrated governance
A. Audit
This is a descrition of an audit.
Clinical governance is a wide ranging term that covers audit, researchand a framework for care care improvement
Clinical Reasearch is research that seeks to answer a specific scientific question
Intergrated governence is the combination of clinical and financial governance
Clinical effectiveness is clinical research that also assesses if the novel treatment is acceptable to patients and represents good value for money.
When assessing the fetal presenting part in labour it is important to know the
anatomy of the pelvis. What are the bony landmarks of the pelvic outlet?
A. Pubic arch, ischial tuberosities and the coccyx
B. Pectineal line, ischial spines, coccyx
C. Pubic symphysis, pubic rami, sacrum
D. Pectineal line, ischial tuberosities and the coccyx
E. Pubic arch, ischial spines, sacrum
A. Pubic arch, ischial tuberosities and the coccyx
The pectineal line is a groove that runs along the pelvis and isn’t a vorder of the outlet. This makes (D) and (B) incorrect.
The sacrum forms the pelvin inlet not the outlet, so (C) and (E) are wrong.
The outlet can be seen in the attached illustration.
