Obstetrics and Gynaecology Flashcards
A nervous 42-year-old woman presents herself to your antenatal clinic very worried that she has missed the right time to have her combined test for Down’s syndrome screening. She is now 17 weeks pregnant, and is very 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, and beta hCG
b) Unconjugated oestradiol, hCG, AFP, and inhibin A
c) Beta hCG, PAPP-A, nuchal translucency, and inhibin A
d) AFP, inhibin B, beta hCG, and oestradiol
e) Unconjugated oestradiol, PAPP-A, beta hCG, and inhibin A
B
10-13 weeks:
Nuchal translucency
PAPP-A
beta-hCG
14-20 weeks: Unconjugated oestradiol Total hCG AFP Inhibin A
Integrated test uses the combined test and the quadruple test.
A 33-year-old nulliparous woman is 29 weeks pregnant. She was referred to the rapid access breast clinic for investigation of a solitary breast lump. Sadly, a biopsy of this lump revealed a carcinoma. After much counselling from the oncologists and her obstetricians a decision is reached on her further treatment. What option below may be available to her?
a) Tamoxifen
b) Computed tomography (CT) of the abdomen-pelvis
c) Radiography
d) Chemotherapy
e) Bone isotope scan to look for metastases in order to stage the disease
D
Chemotherapy is teratogenic in the first trimester but safer in the mid and third trimesters. Birth should be 2-3wks after most recent session to allow bone marrow regeneration.
Tamoxifen is teratogenic in pregnancy and breastfeeding.
Radiotherapy is contraindicated in pregnancy unless life-saving.
CT and bone isotope scans wouldn’t be clinically useful enough to warrant the dose of radiation.
A 38-year-old woman with type 2 diabetes attends the maternal medicine clinic. She has a body mass index (BMI) of 48 and is currently controlling her sugars with insulin. You have a long discussion about her weight. What should not be routinely offered to this woman?
a) Post-natal thromboprophylaxis
b) Vitamin C 10mg once a day
c) Regular screening for pre-eclampsia
d) Referral to an obstetric anaesthetist
e) An active third stage of labour as increased risk of postpartum haemorrhage
B
Obesity is a risk factor for maternal death, failed regional anaesthesia, and postpartum haemorrhage.
In pregnant women with a BMI >30kg/m^2:
Offer mechanical and pharmaceutical thromboprophylaxis
Offer screening for diabetes
Give Vitamin D 10mg once a day
Offer an antenatal anaesthetic review
Actively managed the third stage of labour with syntometrine and controlled cord traction.
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 diabetes mellitus (GDM) is performed. Which of the following would confirm a diagnosis of GDM?
a) Fasting plasma venous glucose of greater than 5.0μmol/L.
b) 2-hour plasma venous glucose of greater than 7.8μmol/L.
c) Random plasma venous glucose of greater than 4.8μmol/L.
d) 2-hour plasma venous glucose of greater than 7.0μmol/L.
e) 2-hour plasma venous glucose of less than 7.8μmol/L.
B
2-5% pregnancies in the UK are complicated by diabetes, and 85% are GDM.
Risk factors include: High BMI Previous macrocosmic baby Previous GDM Family history of diabetes Ethnicity
A 75g OGTT is offered to at risk women, and a 2-hour plasma venous glucose of greater than 7.8μmol/L confirms GDM.
A 29-year-old woman is seen at her booking visit and has blood taken for screening. Which of these is the most appropriate set of booking tests?
a) Hepatitis C, HIV, syphilis, and toxoplasmosis
b) Rubella, hepatitis B, hepatitis C, and syphilis
c) Syphilis, rubella, hepatitis B, and HIV
d) HIV, CMV, rubella, and hepatitis B
e) HIV, syphilis, rubella, and group B Streptococcus
C
CMV, toxoplasmosis, and hepatitis C are not cost effective to screen for.
A 34-year-old woman attends antenatal clinic for a routine ultrasound scan. Abnormalities of placentation are detected and an MRI scan is organised by the foetal medicine consultant. 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
B
Placenta accreta is firm adhesion of the placenta to the uterine wall without extending through the full myometrium.
Placenta increta extends through the full myometrium.
Placenta percreta extends through and beyond the myometrium, e.g. into the bladder.
Risk factors of the above include uterine scar tissue, for example after uterine cavity surgery.
Placenta praevia attaches to the uterine wall close to the cervical opening.
A 30-year-old nulliparous woman is 29 weeks pregnant. She presented to hospital with a history of a minor, unprovoked painless vaginal bleed of about a teaspoonful. Her anomaly scan at 20 weeks showed a low-lying placenta. Her foetus is moving well and CTG is reassuring. What is the most appropriate management.
a) Allow home since the bleed is small
b) Admit and give steroids
c) Admit, IV access, observe bleed-free for 48h before discharge
d) Admit, IV access, Group and Save and administer steroids if bleeds more.
e) Group and Save, FBC, and allow home; review in clinic in a week
D
Antenatal bleeding is common. The most dangerous reasons are placental abruption and placenta praevia.
Abruptions tend to be painful, and this woman has placenta praevia.
Small bleeds can precede larger bleeds so she should be admitted. Steroids tend to be given only if haemodynamically unstable. There is no need to observe for 48h due to the risk of VTE and nosocomial infections.
A 28-year-old pregnant woman attends accident and emergency with a history of clear vaginal loss. She is 18 weeks pregnant and so far has had no problems. Her past medical history includes a large cone biopsy of the cervix and she is allergic to penicillin. She is worried because the fluid continues to come and there is now some blood. On examination it is apparent that her membranes have ruptured. What is the most appropriate initial management.
a) Discharge, USS the next day
b) Offer her a termination as it is not possible for this pregnancy to continue
c) Admit, infection markers, USS, and steroids
d) USS, infection markers, and observation
e) Discharge and explain that she will probably miscarry at home
D
Rupture of membranes this early almost always ends in miscarriage, and large cone biopsy of the cervix is a risk factor for second trimester miscarriage.
She should be admitted, observed, and investigated for infections. The biggest concern is risk of ascending infection, chorioamnionitis, and sepsis from PROM.
In the case of sepsis, induction is required, but as the gestation is under <24wks, steroids for foetal lung maturity are not indicated. She may spontaneously miscarry, or get to 24wks, when steroids and premature delivery may be considered.
PPROM management involves a 10d course of Abx prophylaxis against chorioamnionitis and steroids to aid lung maturation before the 34th week, delivering between 34 and 36 weeks.
A 37-year-old woman in her fourth ongoing pregnancy presents to the labour ward at 34 weeks’ gestation complaining of a sharp pain in her chest, worse on inspiration. An ABG shows: pH 7.51, PO2 8.0kPa, PCO2 4.61kPa, BE 0.9. What is the most appropriate investigation?
a) CTPA
b) MRI
c) D-dimer
d) V/Q scintigraphy
e) USS
D
She likely has a PE, so needs urgent definitive diagnosis. CTPA or V/Q scans will provide this. V/Q scans have a lower radiation dose so are preferred.
A 32-year-old woman in her second pregnancy presents at 36 weeks gestation with a history of a passing 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. She has a firm, posterior cervix, and has not been experiencing any contractions. What is the most appropriate management?
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 foetus
d) Monitor for 24 hours and manage as for preterm pre-labour rupture of membranes
e) Caesarean delivery
E
This is PPROM with placenta praevia, so vaginal delivery is not an option. Digital examinations are contraindicated with antepartum haemorrhage.
Option D involves a 10d course of Abx prophylaxis against chorioamnionitis and steroids to aid lung maturation before the 34th week, delivering between 34 and 36 weeks. As this woman is 36 weeks pregnant, delivery must be expedited with a caesarean section.
Maternal physiology changes throughout the pregnancy to cope with the additional demands of carrying a foetus. Which of the following changes best represents a normal pregnancy?
a) Stroke volume increases by 10% 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 10mmHg above the baseline by term
e) Aortocaval compression reduces venous return to the heart, in turn increasing pulmonary and arterial pressure
B
Stroke volume increases from the first trimester to over 30% higher by the third trimester.
Plasma fibrinogen, and factors VII, X, and XII, increase throughout pregnancy.
Systemic and pulmonary arterial pressures do not alter.
Aortocaval compression does occur, but does not affect pulmonary circulation.
A 30-year-old woman attends the antenatal clinic asking to be sterilised 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 sterilisation she is requesting. What is the best management option for this woman?
a) Mirena coil
b) Sterilisation at the time of her caesarean section
c) T380 coil
d) Implanon
e) Vasectomy
C
As she is ‘not sure that she wants any more children’, sterilisation is not the best option.
She doesn’t like the side effects of hormonal contraception, so Mirena coil and Implanon are not applicable.
Vasectomy requires her partner to make a decision, and is also not applicable in this situation.
A 41-year-old multipara attends the antenatal clinic at 36 weeks gestation complaining of lower abdominal cramps and fatigue when mobilising. Clinical examination is unremarkable save for a grade 1 pan systolic 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-foetal 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
The described murmur is mild tricuspid regurgitation, which is physiological in pregnancy.
Lower abdominal cramps and fatigue are also common symptoms in pregnancy.
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 4cm. Ultrasonography confirms a breech singleton pregnancy with a reactive foetal heart rate.
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
As this lady is not in established labour, and has a breech singleton pregnancy, a caesarean delivery has the best foetal outcome.
In HIV positive women, washing of the baby after delivery can reduce risk of vertical transmission, but does not change the choice for caesarean section delivery.
A 41-year-old multiparous woman attends A&E 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 INR of 3.0
b) Load with warfarin to achieve a target INR of 2.5
c) Load with warfarin to achieve a target INR of 20
d) 80mg enoxaparin twice daily
e) 7.5mg fondaparinux once daily
D
Warfarin is teratogenic in all trimesters but in different ways depending on gestational age.
Enoxaparin and fondaparinux are both indicated in PE treatment, but efficacy and safety of fondaparinux in pregnancy is not supported by evidence, whereas enoxaparin is.
A 21-year-old woman attends the labour ward with per vaginal bleeding of 100mL. 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
Painful antenatal haemorrhage is a worrying symptom of placental abruption. Abruption is life threatening to mother and child.
Placenta accreta is firm adhesion of the placenta to the uterine wall without extending through the full myometrium. Placenta increta extends through the full myometrium. Placenta percreta extends through and beyond the myometrium. Risk is increased in intrauterine scarring.
Placenta praevia attaches to the uterine wall close to the cervical opening, and is characteristically a painless bleed.
Vasa praevia is a rare painless bleed on ROM, associated with sudden foetal compromise and often intrauterine death.
Cervical ectropion is a normal phenomonen and causes painless vaginal bleeding.
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
Foeto-maternal transfer of blood in Rh- mothers of Rh+ babies causes maternal sensitisation with production of anti-D antibodies.
Subsequent Rh+ babies’ RBCs will be attacked by the maternal anti-D antibodies, causing haemolytic anaemia.
1500IU of anti-D is given at 28wks, with further doses in the case of sensitising events such as vaginal bleeding, abdominal trauma, or ECV.
Rh- fathers would indicate a Rh- baby, but as many 1 in 10 partners are not the real fathers, so it can’t be assumed.
A 42-year-old para 4 with a dichorionic-diamniotic twin pregnancy at 31 weeks gestation presents to hospital with a painful per vaginal bleed of 400mL. 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 foetuses 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, FBC, 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
Painful vaginal bleeding is in keeping with placental abruption, which is a very serious complication.
Admission, ABC, IV access, Group and Save, and CTG should be done to monitor and prepare. 4U of blood should be cross-matched as there is a high risk of blood transfusion required. Steroids should be given to aid foetal lung maturation, and admission should be to the labour ward in order to prepare for emergency delivery.
You are the FY1 covering the antenatal ward. A 27-year-old nulliparous woman who is 36 weeks and 5 days 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 generalised 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 to foetus
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
This is an eclamptic fit, which is a life-threatening situation.
The left lateral position should be assumed and her airway protected. Additional airway insertion and obtaining IV access is dangerous in an actively fitting woman. Magnesium sulphate is a cerebral membrane stabiliser and must be given ASAP.
The mother, and not the foetus, must be the primary concern, so checking foetal heart before stabilising and monitoring the mother is incorrect.
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 SLE, renal stones, and malaria. Her BP is 158/99 mmHg with 2+ protein in her urine. Her platelets are 55X10^9/L, Hb 10.1 g/dL, bilirubin 62 62 μmol/L, ALT 359 IU/L, urea 2.3mmol/L and creatinine 64 μmol/L. What is the most likely diagnosis?
a) TTP
b) HELLP syndrome
c) ITP
d) SLE
e) HIV
B
TTP is microangiopathic haemolytic anaemia, thrombocytopenia, fever, neurological involvement, and renal impairment.
HELLP is pre-eclampsia with haemolysis, elevated LFTs, and low platelets.
ITP is a diagnosis of exclusion.
SLE and HIV can both cause thrombocytopenia, but are unlikely compared to 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
Primary herpes during pregnancy may risk vertical transmission. If the infection is within 6 weeks of the due date, or labour is within 6 weeks, caesarean section is recommended. If refused, IV acyclovir during labour and close postnatal monitoring is used.
A 33-year old woman presents to hospital with a 2-day history of itching on the soles of her feet and the plasma of her hands. Her pregnancy has been straightforward and she has good foetal movements. LFTs reveal an 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) US and CTG surveillance help prevent stillbirth
c) Poor outcomes can be predicted by bile acid levels
d) UDCA helps prevent stillbirth
e) Meconium stained liquor is more common in labour
E
Obstetric cholestasis is pruritus and deranged LFTs. LFTs should thence be monitored weekly.
The main concern is stillbirth, which cannot be predicted. Preterm labour and meconium stained liquor is more likely. Continuous CTG should be done throughout labour.
UDCA is not licensed but helps itching with no apparent side effects, though it doesn’t help prevent stillbirth.
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 an emergency head CT, 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
d) Subarachnoid haemorrhage
e) Idiopathic intracranial hypertension
A
Migraines are most common, particularly in pregnancy, and presents with these symptoms. All the other causes present with the above symptoms, too.
Viral meningitis would also give fever, and neck stiffness.
CVTs classically presents postpartum. 2/3 also have neural deficits.
SAH often has papilloedema, and focal neurology.
IIH is associated with papilloedema in young obese women. It is raised ICP with no hydrocephalus or SOLs.
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 and appendicectomy and a large cone biopsy of her cervix. On examination she has palpable lower abdominal tenderness, her cervix is 2cm dilated, she has an offensive vaginal discharge and her temperature is 38.9C. Her WCC is 19.0x10^9/L and her CRP 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
D
This woman is septic, with PROM, offensive vaginal discharge, abdominal pain, fever, and past history of cone biopsy.
She must be treated with antibiotics and, sadly, induction of labour.
Cervical sutures and tocolysis are contraindicated in infection.
The foetus is not viable, so steroids are not indicated.
A 24-year-old multiparous woman is 23 weeks pregnant. She has not had chicken pox before. She goes to 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 acyclovir.
b) Test for varicella antibodies and give VZIG within the first 24h
c) Test for varicella antibodies and give acyclovir 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
Pregnant women are at higher risk of complications from chicken pox, and foetal varicella syndrome is a risk before 28 weeks gestation.
Varicella antibodies should be tested for, and VZIG given within 10 days if her antibody screen is negative.
Acyclovir is only used to treat chicken pox within 24 hours of the rash appearing, so is not necessary yet.
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?
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
3-4% of babies are breech at term. ECV is offered from 36wks in nullips, and 37wks in multips. Success ranges from 30-80%.
Relative CIs: Small for gestational age with abnormal Doppler scan Pre-eclampsia Scarred uterus Oligohydramnios
Absolute CIs (little or no room to turn foetus, or risk of abruption): Multiple pregnancy Major uterine abnormalities Antepartum haemorrhage ROM
A 24-year-old type 1 diabetic woman has just had her first baby delivered by caesarean section at 35 weeks due to foetal 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
As soon as the mother is eating and drinking again (usually around 6h after operation), pre-pregnancy insulin can be started, and the sliding scale can be stopped.
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) Foetal growth restriction
b) Diabetes mellitus
c) Pre-eclampsia
d) Stillbirth
e) Preterm delivery
B
Pregnancy increases the likelihood of a flare of SLE by 40-60%.
Risks include: Spontaneous miscarriage Foetal death Pre-eclampsia Preterm delivery Foetal growth restriction
A 44-year-old woman 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
c) Listeria monocytogenes
d) Hepatitis E
e) Parvovirus B19
C
Listeriosis is a food-borne infection often by unpasteurised cheese and pate. It can cause mid-trimester loss, early meconium, and preterm labour.
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
PUPP starts in stretch marks on the abdomen, spreads over the body with periumbilical sparing. It starts at 34wks and disappears after birth.
Pemphigoid gestationis is blistering of the umbilicus spreading over the body.
Impetigo herpetiformis is a blistering condition with fever that can cause maternal and foetal death.
Prurigo gestationis is a rash of the trunk and upper limbs with abdominal sparing.
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 can cause congenital malformations, but if it is the best form of epilepsy control it should be used.
Acitretin and methotrexate are teratogenic. Mebendazole is toxic in animal studies. Fluconazole causes congenital abnormalities.
A 42-year-old woman is in her first pregnancy. She conceived with IVF, and has had a straightforward pregnancy so far. At 25 weeks gestation she is seen in clinic with a BP of 142/94 mmHg and protein + in her urine. A protein creatinine ratio (PCR) comes back as 19. She says that her BP 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 is higher risk here as she’s a 42 year old primip with IVF.
Normally, BP in pregnancy falls to a trough from weeks 22 to 24, and then rises throughout pregnancy.
Pre-eclampsia is a raised BP with proteinuria (PCR >30).
A 24-year-old woman attends the antenatal clinic. She has had a GTT which is abnormal. A diagnosis of GDM is made. The primary purpose of this appointment is to explain to her what GDM 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
In pregnancy, pre-meal blood sugars should be below 5.5μmol/L, and 1-hour post-meal should be below 7.8μmol/L. Outside of pregnancy, 2-hour post-meal measurements are used.
The risks of diabetes in pregnancy include: Neonatal hypoglycaemia Pre-eclampsia Pre-term labour Polyhydramnios Macrosomia Shoulder dystocia
A 24-year-old woman in her first pregnancy has a significantly raised GTT at 28 weeks gestation: 4.6 μmol/L fasting; 12.1 μmol/L at one hour; 9.1 μmol/L at 2 hours. 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 macrocosmic foetus
b) Stillbirth
c) Neonatal hypoglycaemia
d) 10% chance of developing type 2 diabetes over the next 10 years
e) Pre-eclampsia
D
The risks of diabetes in pregnancy include: Neonatal hypoglycaemia Pre-eclampsia Pre-term labour Polyhydramnios Macrosomia Shoulder dystocia
Women with GDM also have a 35-60% chance of developing type 2 diabetes over the next 10 - 15 years.
Delivery is recommended after 38 weeks unless glycemic control is very poor.
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/mm^3 and her viral load is 5500 copies/mL. She has come to find out what advice you have for her delivery.
a) SVD
b) Induction of labour to prevent CD4 decreasing
c) Caesarean section
d) Start HAART and await for labour to start
e) Start HAART, amniotomy, and HAART for baby when born
C
A low CD4 count and high viral load means she’s at risk of AIDS and of vertical transmission. HIV positive mothers should be started on HAART if necessary throughout the pregnancy and onwards, or alternatively antiretroviral treatment from 20 to 28 weeks to prevent transmission.
Viral loads of below 50 copies/mL allow a normal delivery, avoiding prolonged and artificial ROM.
This is a high risk pregnancy, and should be delivered by caesarean section to reduce the risk of vertical transmission.
A 24-year-old woman attends A&E 4 weeks after 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
Abortion and miscarriage historically mean the same thing. Now, the word abortion tends to be avoided, differentiating by using miscarriage and termination.
Threatened abortion is vaginal bleeding before viability (as opposed to antepartum haemorrhage, which is vaginal bleeding after 24 weeks).
Missed miscarriage is the loss of pregnancy without passed products of conception of bleeding.
Septic abortion is loss of an early pregnancy complicated by infection of a retained conceptus.
Complete abortion is loss of pregnancy with expulsion of products of conception.
Incomplete miscarriage is loss of an early pregnancy with bleeding but not total expulsion of products of conception.
A 51-year-old woman in her 12th week of an assisted-conception triplet pregnancy presents to A&E 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) IV crystalloids and doxycycline, urgent USS
b) Discharge with 1 week’s ciprofloxacin
c) Referral to the medics for investigation of viral gastroenteritis
d) IV crystalloids, oral antiemetics
e) Referral to the surgeons for investifation of appendicitis
D
This is hyperemesis gravidarum. HG affects 2% of pregnancies and causes dehydration. Risk is increased in multiple pregnancies.
The mild abdominal and back pain are normal symptoms of pregnancy.
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 18mm 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
Abdominal pain and vaginal bleeding in early pregnancy have a 20% miscarriage rate.
This woman is having a threatened miscarriage. There is no foetal pole or foetal pulsation so it isn’t clear if it is viable. The scan should be repeated in 10-14d.
Blighted ovum and an embryonic pregnancies are the same, but yolk sac would not be present. If anembryonic pregnancies are suspected, two scans must be done 10-14d apart to confirm.
Pseudosacs are found in 10-20% of ectopic pregnancies, and are decimal reactions with no yolk sac.
A 31-year-old woman is seen in the 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 10d time
c) Blood test for beta 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
Pregnancy must be confirmed before TOP is offered.
A pseudosac is a decimal reaction to an ectopic pregnancy. It’s unclear that this is a pseudosac, and she is stable and well, so (with safety netting with symptoms of ectopics) she can be managed as an outpatient.
A beta hCG would be required with a repeat in 48h. A 67% rise would suggest that the sac was a viable pregnancy, and a USS in 10-14d would confirm. A TOP could then be arranged. A rise lower than that should be seen in hospital for assessment.
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 vaginal bleeding. Her beta hCG is 1650 mIU/mL, progesterone 11nmol/L. An USS 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 and salpingectomy
d) Laparoscopic salpingotomy
e) Beta hCG in 48h
B
Methotrexate is given IM if the ectopic is small, with no foetal pulse, no clinical compromise, and no free fluid in the pouch of Douglas.
Surgery has a potential risk of decreasing future fertility.
Risk factors for ectopic: Previous tubal surgery Intrauterine use Pelvic infection IVF
Risk of ectopic: Rupture Intra-abdominal bleed Acute collapse Death
Tubal miscarriage can avoid ectopic rupture, which is detected by a fall in beta hCG.
A 24-year-old woman attends her GP complaining of deep dyspareunia and post-coital bleeding. She has cramps 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) 1g 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
An easily bleeding cervix, deep dyspareunia, post-coital bleeding, and a history of STIs raises suspicion of cervical cancer. At 24, she is unlikely to have had previous cervical smears.
The presentation may be STIs or pelvic inflammatory disease, but urgent referral is required nonetheless. Treatment for PID (IM cefotaxime, oral doxycycline and metronidazole) may also be started in tandem with these investigations.
A 16-year-old girl attends A&E complaining of mild vaginal spotting. Her serum beta hCG is 4016 mIU/mL. She is complaining of severe left iliac 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) CT abdomen and pelvis
d) Clinical assessment with speculum and digital vaginal examination
e) Transvaginal USS
E
This describes potential ectopic pregnancy.
CT should be avoided due to radiation dose to the foetus, with teratogenicity of radiation highest in the first trimester.
Clinical assessment, and serial beta hCG measurements are the routine initial investigations, but are not definitive.
Transvaginal USS would provide the highest chance of a definitive diagnosis, followed by confirmation via diagnostic and therapeutic laparoscopy. Beta hCG of above 1000mIU/mL usually gives a visible pregnancy on TVUSS, and certainly above 1500mIU/mL.
Diagnostic laparoscopy would not be appropriate without US imaging.
An 18-year-old woman presents to A&E 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 USS in the resuscitation area which shows free fluid in the pouch of Douglas and no visible intrauterine pregnancy. Her pulse is 120bpm and BP 90/45 mmHg. What is the most likely diagnosis?
a) Rupture ovarian cyst
b) Cervical ectopic pregnancy
c) Ruptured tubal pregnancy
d) Perforated appendix
e) Ovarian torsion
C
Lower abdominal pain, positive pregnancy test, and haemodynamic instability suggest an ectopic pregnancy.
The haemodynamic instability suggests it wouldn’t be a ruptured cyst or ovarian torsion. Both have sudden onset pain, and ruptured cyst pain often subsides with simple analgesia, whereas ovarian torsion does not.
At this level of beta hCG, a cervical ectopic pregnancy would be visible on TVUSS. Therefore, a ruptured tubal pregnancy is likely, and is a surgical emergency.
A 50-year-old woman comes to your clinic with a 2-year history of no periods. Her GP has confirmed that her LH and FSH levels are menopausal. Her night sweats and hot flushes are unbearable and are preventing her from going to work. She would like to start 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 VTE
A
Starting HRT 10 years post-menopause actually increases the risk of heart disease.
The rest are true, as is increased risk of endometrial cancer in oestrogen-only HRT.
A 24-year old woman who is 9 weeks pregnant is brought to A and E by ambulance with left iliac fossa pain and a small vaginal bleed. An abdominal USS performed at the bedside demonstrates a corneal pregnancy and free fluid in the pelvis. Her observations are: pulse 119bpm, BP 74/40 mmHg, RR 24/minute. What is the most appropriate definitive management?
a) Transvaginal USS
b) Serum beta hCG estimation
c) Diagnostic laparoscopy
d) Admission to the gynaecology ward and fluid resuscitation
e) Urine pregnancy test
C
Lower abdominal pain, positive pregnancy test, and haemodynamic instability suggest an ectopic pregnancy. This is confirmed by USS.
TVUSS, serum beta hCG, and urine pregnancy tests would be unlikely to give more information.
This is a surgical emergency, so admission to a ward would not be appropriate, and diagnostic laparoscopy would be the correct option.
A 26-year old woman presents to A and E 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 USS shows two gestational sacs. What is the most likely diagnosis?
a) Ruptured theca lutein cyst
b) Appendicitis
c) Diverticulitis
d) Complete miscarriage
e) UTI
A
Functional ovarian cysts are common in women of childbearing age. One type is a theca lutein cyst which is composed of luteinised follicular cells, triggered by high levels of beta hCG (e.g. in multiple pregnancy).
This woman is pregnant with twins, and has developed a cyst as a result, that has ruptured.
A 59-year-old woman attends the gynaecology clinic complaining of worsening pain during penetrative sexual intercourse. She went through the menopause 9 years before, with very few problems, and did not require HRT. She has been with the same partner for 4 years since the death of her husband with whom she had four children. What is the most likely diagnosis?
a) Ovarian malignancy
b) Chlamydia trachomatis infection
c) Discoid lupus erythematous
d) Atrophic vaginitis
e) Bacterial vaginosis
D
Post-menopause, vaginal lining atrophies progressively as oestrogen levels decrease.
It is important to exclude STIs, acute intrapelvic conditions, and cervical pathology.
A 19-year-old woman is referred to A and E with a fluctuant lower right abdominal pain which started over the course of the morning, associated with vomiting. There is rebound tenderness on examination. She is afebrile. Serum beta hCG is negative. An ultrasound shows free fluid in the peritoneal cavity but no other pathology to account for the pain. White cells are 14x10^9/L and the CRP is 184 mg/L. What is the most likely diagnosis?
a) Acute appendicitis
b) Early ectopic pregnancy
c) Pelvic inflammatory disease
d) Tubo-ovarian abscess
e) Ovarian torsion
A
The location of the pain, the rebound tenderness, and high CRP suggest acute appendicitis.
Ectopic pregnancies would give a positive serum beta hCG.
PID and tube-ovarian abscess would cause fever and high white cell count.
Ovarian torsion tends to be constant pain rather than fluctuating.
A 39-year-old woman is seen in the gynaecology clinic having been diagnosed with polycystic ovarian syndrome (PCOS). She has lots of questions in particular about the associated long-tern risks. Which of the following is not a risk of PCOS?
a) Endometrial hyperplasia
b) Sleep apnoea
c) Diabetes
d) Breast cancer
e) Acne
D
PCOS is diagnosed by two of:
Oligo/amennhorea
Polycystic ovarise
Clinical/biochemical signs of hyperandrogenism
All but breast cancer are long term risks of PCOS. Diet, weight control, and exercise are key to prevent these risks.
A 54-year-old menopausal woman comes to your clinic desperate for HRT as her vasomotor symptoms are very troubling. Her next door neighbour recently developed a DVT while on HRT. She is concerned about the risks of VTE and wants your advice. Which of the following would you not advise?
a) The risk of VTE is highest in the first year of taking HRT
b) She should have a thrombophilia screen prior to starting HRT
c) There is no evidence of a continuing VTE risk after stopping HRT
d) Personal history of VTE is a contraindication to oral HRT
e) If she develops any VTE while on HRT it should be stopped immediately
B
It is not routine to offer thrombophilia screens before starting HRT, but it might be sensible if there was a family history of VTE.
A 34-year-old woman with long-standing menorrhagia attends A and E having fainted at home. She is on the third day of her period, which has been unusually heavy this month. She insists she cannot be pregnant as she has not had sexual intercourse for a year. She is haemodynamically stable. A point-of-care test venous FBC in the emergency department shows:
Hb 5.2g/dL
WCC 8.9x10^9/L
Hct 0.41% L
MCV 80 fL
What should the initial management be?
a) Establish large-bore venous access, commence fluid resuscitation and cross-match four units of packed red cells
b) Call for senior help, establish large-bore venous access and prepare the patient for urgent laparotomy
c) Call for senior help, establish large-bore venous access and give group O Rh negative blood
d) Establish large-bore venous access and begin transfusing group-specific blood as soon as it is available
e) Await the result of a beta hCG test before deciding further management
A
This is significant normocytic anaemia as a result of blood loss from menorrhagia. Fluid resuscitation is needed.
Rapid decompensation may occur, despite her current haemodynamic stability. As she is currently stable, though, the risks of giving non-cross-matched blood are not justified.
A laparotomy is not indicated yet as menorrhagia is the supposed cause, and this would not aid diagnosis.
A 66-year-old post-menopausal woman is referred to you urgently by her GP. She had been complaining of some lower abdominal pain. An USS arranged by the GP shows a 4cm simple left ovarian cyst. A CA 125 comes back as 29 U/mL (normal 0-35 U/mL). What is the most appropriate management?
a) Referral to a specialist cancer unit
b) Laparoscopic ovarian cystectomy
c) Laparotomy and oophorectomy
d) Conservative management
e) Total laparoscopic hysterectomy and bilateral salpingo-oophorectomy
D
If the risk of malignancy index (RMI), calculated using CA125, USS, and menopausal status, is low, then the cyst can be managed conservatively.
Concerning findings: Bilateral cysts Multioculated cysts Solid components Ascites Metastases Large (>5cm) High CA125 Symptomatic
Conservative management involves 4 monthly scans and CA125 levels for 1 year.
A 79-year-old woman attends your clinic with some vaginal bleeding. Her last period was 16 years ago. She has had two children, both via caesarean section, has a normal smear history, and is currently sexually active. On examination, the vagina appears mildly atrophic with some raw areas near the cervix. What is the most important next step in her management?
a) Vagifem nightly for 2 weeks and then twice a week after that
b) Triple vaginal swabs for STIs
c) Pelvic ultrasonography
d) HRT to help the vaginal raw areas
e) Smear test
C
Post-menopausal bleeding requires an USS to exclude cervical or endometrial cancer.
Vagifem and vaginal swabs may well be indicated, but an USS to ensure endometrial thickness is less than 4mm should be performed first.
At laparoscopy, a 21-year-old woman is found to have severe endometriosis. There are multiple adhesions and both ovaries are adherent to the pelvic side wall. The sigmoid colon is adherent to a large rectovaginal nodule. The nodule is excised and the bowel and ovaries freed. Which of the following medications would be appropriate to help treat her endometriosis?
a) Danazol
b) Triptorelin
c) Microgynon 30
d) Tranexamic acid
e) Medroxyprogesterone acetate
B
Triptorelin is a GNRH agonist which creates a temporary menopause for up to 6m. In this case, it gives the best chance of clearance, if followed by a secondary laparoscopy.
Danazol is anti-oestrogenic and anti-progestognenic. It is used for 3-6m.
Microgynon 30 is a combined oral contraceptive pill.
Tranexamic acid is an antifibrinolytic.
Medroxyprogesterone acetate is a progestogen.
A 54-year-old woman comes to your clinic complaining of hot flushes and night sweats that are unbearable. Her last menstrual period was 14 months ago. She has had a levonorgestrel releasing intrauterine system (Mirena) in situ for 2 years as treatment for extremely heavy periods. What treatment would you consider for her symptoms?
a) Elleste Solo
b) Elleste Duet
c) Vagifem
d) Oestrogen implants
e) Evorel
A
Oestrogens help vasomotor symptoms and atrophic vaginitis. Women with a uterus should also take progestogens to reduce the incidence of endometrial cancer with oestrogen replacement. In this case, the Mirena coil provides progestogens so oestrogen therapy (Elleste Solo, containing estradiol) is appropriate.
Elleste Duet contains estradiol and norethisterone, and Evorel is the same combination.
Oestrogen implants do help, but often lead to rapid recurrence of symptoms if levels fall.
