Questions (OBs)

Question 1

A patient with post-natal depression.

What is the most appropriate drug to manage this patient’s?

Bupropion
Fluoxetine
Mirtazapine
Olanzapine
Paroxetine

Answer 1

Paroxetine

postpartum sadness - PS - paroxetine and sertraline

Question 2

How would a patient present if they have MgS toxicity? [3]

Answer 2

Symptoms of magnesium sulfate toxicity include loss of deep tendon reflexes, respiratory depression, and cardiac arrest. Loss of deep tendon reflexes is the first sign of magnesium toxicity.

Question 3

How do you treat MgS toxicity? [1]

Answer 3

Calcium gluconate

Question 4

What is the classic triad of vasa praevia? [3]

Answer 4

The classic triad of vasa praevia is rupture of membranes followed by painless vaginal bleeding and fetal bradycardia.

NB:
VASA PRAEVIA = foetal distress in stem (Bradycardic etc), probably some mention of ROM

PLACENTA PRAEVIA = baby fine usually, just painless PV bleed

Question 5

Patient presents with palpitations, tremors, sweating, and diarrhoea.

They have given birth 10 days ago.

How do you manage them? [1]

Answer 5

The thyrotoxicosis phase of postpartum thyroiditis is generally managed with propranolol alone

Question 6

Which antibodies would you find in post-partum thyroiditis? [1]

Answer 6

Thyroid peroxidase antibodies are found in 90% of patients

Question 7

Pregnant women (26 weeks), presents with PV bleeding. She is Rh -ve.

How do you treat with regards to her Rh status and why? [2]

Answer 7

One dose of Anti-D immunoglobulin followed by a Kleihauer test
- Antepartum haemorrhage is associated with fetomaternal haemorrhage (FMH) and therefore an increased risk of Rhesus sensitisation and Rhesus disease of the newborn in subsequent pregnancies
- A Kleihauer test is a test for FMH which detects fetal cells in the maternal circulation and, if present, estimates the volume of FMH to allow calculation of additional anti-D immunoglobulin.

Question 8

Which of the following is a potentially sensitising event in pregnancy and requires administration of anti-D in a RhD-negative woman?

Previously non-sensitised 11 week pregnant woman with first episode of painless vaginal bleeding
Previously non-sensitised 16 weeks pregnant woman undergoing amniocentesis
Previously sensitised 8 week pregnant woman with an ectopic pregnancy
Previously non-sensitised woman after delivery of a RhD-negative baby
Previously sensitised woman after delivery of a RhD-positive baby

Answer 8

Previously non-sensitised 16 weeks pregnant woman undergoing amniocentesis

Question 9

When do you discontinue Mg treatment for eclampsia? [1]

Answer 9

Magnesium treatment should continue for 24 hours after delivery or after last seizure

Question 10

Which of the following immunoglobulins is responsible for attacking a Rhesus-positive foetus from a Rhesus-negative mother?

IgA

IgM

IgE

IgD

IgG

Answer 10

Question 11

At what gestation should anti-D be administered?

12 weeks

18 and 28 weeks

32 and 37 weeks

28 and 34 weeks

20 weeks

Answer 11

28 and 34 weeks

Question 12

A 37-year-old woman presents for review. She is 26 weeks pregnant and has had no problems with her pregnancy to date. Blood pressure is 144/92 mmHg, a rise from her booking reading of 110/80 mmHg. Urine dipstick reveals the following:

Protein negative
Leucocytes negative
Blood negative

What is the most appropriate description of her condition?

Moderate pre-eclampsia
Mild pre-eclampsia
Gestational hypertension
Normal physiological change in blood pressure
Pre-existing hypertension

Answer 12

Gestational hypertension
- The correct answer is gestational hypertension. This is because the patient has a significant increase in blood pressure (≥140/90 mmHg) after 20 weeks of gestation without any proteinuria or other systemic features. According to UK guidelines, gestational hypertension is diagnosed when there is new-onset hypertension during pregnancy without any proteinuria or other features suggestive of pre-eclampsia.

Question 13

[] and an [] is the preferred method of induction of labour if the Bishop score is > 6

Answer 13

Amniotomy and an intravenous oxytocin infusion is the preferred method of induction of labour if the Bishop score is > 6
- NB if the Bishop score is ≤ 6
vaginal prostaglandins or oral misoprostol
mechanical methods such as a balloon catheter can be considered if the woman is at higher risk of hyperstimulation or has had a previous caesarean

a score of < 5 indicates that labour is unlikely to start without induction
a score of** ≥ 8** indicates that the cervix is ripe, or ‘favourable’ - there is a high chance of spontaneous labour, or response to interventions made to induce labour

Question 14

Mneumonic for which drugs shouldnt be used when breastfeeding? [+]

Answer 14

LAMBAST mothers ceen taking:
Lithium
Amiodarone
MTX
Benzos
Aspirin
Sulfonamides
Tetracyclines

Carbimazole, cipro, chloramphenicol

Question 15

If a previous pregnancy has had neonate sepsis, e.g. due to Group B Strep (GBS), how do you prevent this in a future pregnancy? [1]

Which drug is given for GBS prophylaxis? [1]

Answer 15

Maternal intravenous antibiotic prophylaxis during labour should be offered to women with a previous baby with early- or late-onset GBS disease
- benzylpenicillin is the antibiotic of choice for GBS prophylaxis

Question 16

In which cases would GBS Intrapartum Antibiotic Prophylaxis be given? [5]

Answer 16

• A positive GBS screening culture at 35-37 weeks gestation.
• A previous infant with GBS disease.
• GBS bacteriuria during the current pregnancy.
• Unknown GBS status and risk factors such as preterm labour (< 37 weeks) or prolonged rupture of membranes ( > 18 hours).
• women with a pyrexia during labour (>38ºC)

Question 17

What is the current position of the fetal vertex shown in this image?

Left occiput posterior
Occiput anterior
Right occiput posterior
Left occiput anterior
Right occiput anterior

Answer 17

baby’s OCCIPUT is pointing to the mother’s LEFT thigh and the occiput against the mother’s spine/back (POSTERIOR)

Question 18

Explain what happens when maternal anti-D antibodies cross the placenta? [2]

Answer 18

Haemolytic disease of the newborn occurs:
- when a Rhesus negative woman becomes pregnant with a Rhesus positive foetus.
- This is usually not a problem during the first pregnancy.
- However, during subsequent pregnancies, the maternal anti-D antibodies can cross the placenta and lead to haemolysis of foetal red blood cells.
- Anti-D is given during pregnancy to neutralise maternal anti-D antibodies and reduce the risk of haemolytic disease of the newborn.

Question 19

A patient has pre-exisiting hypertension prior to becoming pregnant.

How do you reduce the risk of pre-eclampsia? [1]

Answer 19

A woman at moderate or high risk of pre-eclampsia should take aspirin 75-150mg daily from 12 weeks gestation until the birth

Question 20

A patient is having twins. There is a risk of TTTS.

When during the pregnancy is this most likely to occur? [1]
How do you detect this? [1]

Answer 20

TTTS usually occurs in early or mid-pregnancy, thus ultrasound examinations performed between 16 and 24 weeks focus on detecting this condition
- After 24 weeks the main purpose of ultrasound examinations is to detect fetal growth restriction.

Question 21

Why is a cervical membrane sweep the first step in inducing labour? [1]

Answer 21

A cervical membrane sweep increases the likelihood of spontaneous labour initiating as it causes release of prostaglandins

Question 22

Which treatment for asymptomatic bacteruria can be given in the first [1] and third [1] trimester of pregnancy?

Answer 22

Nitrofurantoin is usually a good choice for the treatment of urinary tract infections (UTIs) in the first / second. Avoid in third trimester as risk of neonatal haemolysis
- Nitrofurantoin - use for new babies

Cefalexin is an appropriate choice unless contraindicated by allergies or previous urine culture sensitivities.

Question 23

What dose of vit. D should you give throughout pregnancy? [1]

Answer 23

Correct. The recommended daily dose of vitamin D for pregnant women is 10 micrograms, which is equivalent to 0.01 milligrams. This helps maintain bone health for both the mother and developing baby.

Question 24

Describe the process of the Rubin manoeuvre [1]

When is it indicated? [1]

Answer 24

The Rubin manoeuvre is an internal intervention used to help relieve shoulder dystocia.
- It involves applying pressure behind the anterior shoulder to rotate the shoulders into the oblique diameter and facilitate delivery.
- This manoeuvre is performed after external manoeuvres have failed.

Question 25

Describe the process going on in this image [1]

Answer 25

Question 26

You should think chorioamnionitis in women with [] with a triad of maternal [2], and fetal [1]

Answer 26

You should think chorioamnionitis in women with preterm-PROM with a triad of maternal pyrexia, maternal tachycardia, and fetal tachycardia

Question 27

What is the last maneuver used to birth babies stuck with shoulder dystocia? [1]

Answer 27

Gaskin maneuver, which utilizes downward traction on the head to allow the posterior shoulder to descend and be delivered.

Unsure if actually used

Question 28

Which of the following statements regarding TTTS is true?

The recipient twin is more likely to survive to birth

There is currently no treatment available

The recipient twin is at risk of developing foetal hydrops

The donor twin is not at risk of developing heart failure

One of the foetuses usually develop normally

Answer 28

The recipient twin is at risk of developing fluid overload and as a consequence, foetal hydrops and heart failure

Question 29

In TTTS, which pathologies are the donor and recipient twins at risk of suffering? [2]

Describe the pathophysiology of TTTS [4]

Answer 29

Donor twin:
- high output cardiac failure as a result of severe anaemia

Recipient twin
- can suffer from fluid overload due to excess blood volume.

Pathophysiology:

Stage 1:
- unequal blood flow between twins sharing a placenta results in recipient twin having too much amniotic fluid (polyhydramnios), and donor twin with little or no amniotic fluid (oligohydramnios)

Stage 2:
- Donor’s twin bladder doesn’t fill or empty because blood is diverted to kidneys, brain and heart.

Stage 3:

Stage 4:
- hydrops (massive fluid retention) develops - which is indicative of heart failure in the recipient twin, whilst the donor is suffering from HF

Question 30

G1 PO, aged 30.

When is the earliest time she can be offered ECV for a breeched baby?
When would this change? [1]

Immediately
39 weeks
37 weeks
36 weeks
38 weeks

Answer 30

36 weeks
- If the lady was multiparous ECV would be offered from 37 weeks.

Question 31

Placental abruption is characterised by constant pain, shock out of keeping with the visible loss, [description x2] uterus

Answer 31

Placental abruption is characterised by constant pain, shock out of keeping with the visible loss, tender and tense uterus

Question 32

Chickenpox exposure in pregnancy - if not immune give… if they’re at what stage in their pregnancy? [2]

Answer 32

Chickenpox exposure in pregnancy - if not immune give either oral antivirals
- Women who develop chickenpox during pregnancy should be treated with oral aciclovir 800mg 5 times a day for 7 days if >20 weeks pregnant.

Question 33

Vaginal PGE2 or oral misoprostol is the preferred method of induction of labour if the Bishop score is ≤ 6

Answer 33

[] or [] is the preferred method of induction of labour if the Bishop score is ≤ 6

Question 34

Name 5 short term complications of delivery

Answer 34

Sepsis
PPH
Perineal Tears
Sheehans syndrome
Baby blues

Question 35

What is the difference between a tear and an episiotomy? [1]

Answer 35

An episiotomy is a cut made by a healthcare professional into the perineum and vaginal wall to make more space for the baby to be born.

Episiotomies are done with your consent.
- They are only done if your baby needs to be born quickly, often if you are having an instrumental (forceps or vacuum assisted) birth, or if you are at risk of a serious perineal tear.

Tears happen spontaneously as the baby stretches the vagina and the perineum during birth.

Question 36

How much blood loss occurs in vaginal [1] and C-section [1] PPH?

Answer 36

Vaginal > 500ml
C-section > 1000ml

Question 37

What are the differences in primary and secondary causes of PPH?

Question 38

After a perineal tear - what clinic would a patient be booked into for their follow up care? [1]

Answer 38

OASI clinic
- obstetric anal sphincter injury

Question 39

What two key presentations would make you think a patient is suffering from Sheehan’s syndrome? [2]

Answer 39

amenorrhea and difficulty to lactate (w/ a Hx of PPH)

Question 40

Which are T/F? [5]

Answer 40

A: True
B: True - may be prolonged by anaemia as worsens fatigue and excerbates mood swings
C - false
D - false
E - false

Question 41

Which are T/F? [5]

Answer 41

A: True
B: False - some medications need tapering
C - true
D - false
E - false - if patient needs inpatient treatment for mental health and have baby - usually cared for in mother / baby unit

Question 42

SBA

Answer 42

D

NB: A - more than 80% develop their first pys. disease post-partum

Question 43

Answer 43

• Dx: PE
• Investigations: CXR - prove to radiologist that have excluded other pathologies; CTPA or V/Q
• Tx: LMWH

Question 44

Answer 44

E

Question 45

Answer 45

C

Question 46

Answer 46

A

Question 47

Answer 47

E - most common cause

Question 48

When is vitamin K indicated in a newborn? [1]
What does it prevent? [1]

Answer 48

After every birth
- prevents haemorrhagic disease of the newborn / Vitamin K deficiency bleeding (VKDB) is now the preferred term for haemorrhagic disease of the newborn (HDN).
- Vitamin K is required for the production of clotting factors II, VII, IX and X.

Question 49

The bleeding in classic VKDB most often presents as bleeding from where? [4]

Answer 49

• Gastrointestinal bleeding.
• Bleeding from the skin and mucous membranes - eg, the nose and gums.
• Prolonged bleeding following circumcision.
• Bleeding from the umbilical stump.

Question 50

Describe the presentation of red degeneration of fibroid [2]
Describe the pathophysiology [1]

Answer 50

TOM TIP: Look out for the pregnant woman with a history of fibroids presenting with severe abdominal pain and a low-grade fever in your exams. The diagnosis is likely to be red degeneration.
- Uterine contractions would come and go, these pains are more constant

Red degeneration may occur as the fibroid rapidly enlarges during pregnancy, outgrowing its blood supply and becoming ischaemic. It may also occur due to kinking in the blood vessels as the uterus changes shape and expands during pregnancy.

Question 51

What is the most common type of fibroid degeneration? [1]

Desribe how you would differentiate this from other types? [1]

Answer 51

Hyaline degeneration
- involves the replacement of fibroid tissue with hyaline tissue; leading to the accumulation of homogenous, glassy, eosinophilic material.

Question 52

Describe what is meant by cervical cerclage [1]

When is it indicated? [2]

Answer 52

A cervical cerclage is a treatment that involves temporarily sewing the cervix closed with stitches.
- Cervical cerclage is offered to women with a cervical length less than 25mm on vaginal ultrasound between 16 and 24 weeks gestation, who have had a previous premature birth or cervical trauma (e.g. colposcopy and cone biopsy).
- “Rescue” cervical cerclage may also be offered between 16 and 27 + 6 weeks when there is cervical dilatation without rupture of membranes, to prevent progression and premature delivery.

Question 53

Describe how you diagnose SROM [3]

Answer 53

Maternal Hx

Speculum exam - if no amniotic fluid observed then perform IGFBP-1 and PAMG-1 tests

PAMG-1 Test:
* Basis: PAMG-1 is a protein primarily found in amniotic fluid, present in extremely low concentrations in other body fluids.
* Result in SROM: Positive if amniotic fluid is detected in the vaginal fluid.

IGFBP-1 Test:
* Basis: IGFBP-1 is a protein produced by the decidua (the uterine lining during pregnancy) and is present in high concentrations in amniotic fluid.
* Result in SROM: Positive if amniotic fluid is present in vaginal secretions.

Question 54

How do you treat PPROM? [3]

Answer 54

An antibiotic (preferably erythromycin) should be given for 10 days or until the woman is in established labour (whichever is sooner) following the diagnosis of PPROM, and corticosteroids and magnesium sulfate, considered or offered.

Question 55

What is meant by uterine retraction? [1]

Answer 55

the state of uterine muscle fibres remaining shortened after contracting during labour

Question 56

What increases the chance of atony of uterus? [+]

Answer 56

Overdistension of the Uterus:
* Multiple Gestation: Twins or higher-order multiples.
* Polyhydramnios: Excessive amniotic fluid stretches the uterus.
* Macrosomia: Large fetal size leads to uterine overdistension.
* Prolonged Labor: Excessive uterine stretching during prolonged contractions.

Exhaustion of Uterine Muscle (Myometrium):
* Prolonged Labor: Extended uterine contractions cause fatigue.

Infection:
* Chorioamnionitis: Infection during labor weakens the myometrium.

Medications:
* Magnesium Sulfate: Used for preeclampsia or eclampsia; relaxes smooth muscle and reduces uterine tone.

Grand Multiparity: Repeated pregnancies reduce uterine tone and elasticity.

Question 57

Describe the difference for spinal, epidural and general anesthesia:
* onset
* duration
* consciousness
* pain relief
* risk to fetus
* complications
* indication

Answer 57

Question 58

Describe the treatment algorithm for GD [3]

Answer 58

• if glucose targets are not met within 1-2 weeks try altering diet and exercise
• if glucose targets are not met within 1-2 weeks of altering diet/exercise metforminshould be started
• if glucose targets are still not met insulin should be added to diet/exercise/metformin - short acting insulin only

Question 59

The most common explanation for short episodes (< 40 minutes) of decreased variability on CTG is []

Answer 59

The most common explanation for short episodes (< 40 minutes) of decreased variability on CTG is that the foetus is asleep

Question 60

If fetal movements have not yet been felt by [] weeks, referral should be made to a maternal fetal medicine unit

Answer 60

If fetal movements have not yet been felt by 24 weeks, referral should be made to a maternal fetal medicine unit

Question 61

Where exactly would you investigate in using a speculum exam to see if PPROM has occurred? [1]

Answer 61

Careful speculum examination to look for pooling of amniotic fluid in the posterior vaginal vault is the first-line investigation for preterm prelabour rupture of the membranes

Question 62

Early scan to confirm dates occurs when? [1]

Answer 62

10 -13+6 weeks

Question 63

A history of sudden collapse occurring soon after a rupture of membranes is suggestive of []

Answer 63

A history of sudden collapse occurring soon after a rupture of membranes is suggestive of amniotic fluid embolism

Question 64

How do you manage a patient with grade III/IV placentra praevia if picked up early on US? [1]

Answer 64

Women with grade III/IV placenta praevia should be offered an elective caesarean section at 37-38 weeks

Question 65

An ultrasound is indicated if lochia persists beyond [] weeks

Answer 65

An ultrasound is indicated if lochia persists beyond 6 weeks

Question 66

Explain the different stages of lochia changes and what you expect them to look like / last [3]

Answer 66

3 stages of lochia are rubra, serosa and alba (red, yellow, white).
- usually takes about 6 weeks to stop but can take 12 weeks
- Lochia is heavy at first but gradually subsides to a lighter flow until it goes away

Lochia rubra is the first stage
* Dark or bright red blood.
* Lasts for three to four days.
* Flows like a heavy period.
* Small clots are normal.
* Mild, period-like cramping.

Lochia serosa is the second stage of lochia.
* Pinkish brown discharge that’s less bloody and more watery.
* Lasts for four to 12 days.
* Flow is moderate.
* Less clotting or no clots

Lochia alba is the last stage of lochia.
* Yellowish white discharge.
* Little to no blood.
* Light flow or spotting.
* Lasts from about 12 days
to six weeks.
* No clots.

Question 67

What is the difference in induction of GD and previous DM labours? [2]

Answer 67

GDM are induced at term
Previous DM are induced at 38 weeks

Question 68

When would you admit a pregnant patient due to their hypertension? [1]

Answer 68

Pregnant women with blood pressure ≥ 160/110 mmHg are likely to be admitted and observed

Question 69

Name 5 absolute contraindications for the induction of labour [5]

Answer 69

Cephalopelvic disproportion
Major placenta praevia

Vasa praevia

Cord prolapse

Transverse lie

Active primary genital herpes

Previous classical Caesarean section

Question 70

What is the difference between a membrane sweep and amniotomy? [1]

Answer 70

An amniotomy is where the membranes are ruptured artificially using an instrument called an amnihook.

Membrane sweep is performed by inserting a gloved finger through cervix and rotating it against the fetal membranes, aiming to separate the chorionic membrane from the decidua

Question 71

When is insulin indicated as the first line tx for GD? [1]

Answer 71

If at the time of diagnosis of gestational diabetes, the fasting glucose level is >= 7 mmol/l immediate insulin (plus or minus metformin) should be started

Question 72

If a patient has DMT1 and is pregnant - what do they need to take is it puts them as a high risk group? [1]

Answer 72

DMT1 or DMT2 puts patients at high risk of pre-eclampsia, so need to be given aspirin

Question 73

Name 5 factors that are high risk for pre-eclampsia [5]

Answer 73

• hypertensive disease in a previous pregnancy
• chronic kidney disease
• autoimmune disease, such as systemic lupus erythematosus or antiphospholipid syndrome
• type 1 or type 2 diabetes
• chronic hypertension

Question 74

Which factors make up the Bishop score? [5]

Answer 74

Question 75

Name a tocolytic [1]

Answer 75

Terbutaline

Question 76

A patient presents with umbilical cord prolapse.

You want to perform a c-section.

She has dilated at 4cm.

What can you give to prevent further dilattion? [1]

Answer 76

Terbutaline
- Tocolytics may be useful in umbilical cord prolapse to reduce uterine contractions

Question 77

If a pregnant woman reports reduced fetal movements then [] should be used to confirm fetal heartbeat as a first step

Answer 77

If a pregnant woman reports reduced fetal movements then handheld Doppler should be used to confirm fetal heartbeat as a first step

Question 78

If low-lying placenta is found at the 20-week scan then rescan at [] weeks to assess

Answer 78

If low-lying placenta is found at the 20-week scan then rescan at 32 weeks to assess

Question 79

For how long of the pregnancy do you take:
- Folic acid? [1]
- Vitamin D? [1]

Answer 79

Folic acid: 12 weeks

Vitamin D: whole course

Question 80

Which drugs are CI in breastfeeding? [+]

Answer 80

LAMBASTCC
Lithium
Aspirin
Methotrexate
Benzo
Amiodarone
Sufonylurea
Tetracycline
Carbimazole / Ciprofloxacin

Question 81

Describe whether warfarin and aspirin are ok during pregnancy and breastfeeding [2]

Answer 81

Warfarin= not in pregnancy, fine in breastfeeding
Aspirin= fine in pregnancy (up to 36wks), not in breastfeeding

Question 82

Describe the effect of pregnancy on serum urea, serum creatitnine and urine proteins

Answer 82

Reduced urea, reduced creatinine, increased urinary protein loss

Question 84

Describe the results seen in quadruple test for Edward’s syndrome [4]

Answer 84

↓ AFP
↓ oestriol
↓ hCG
↔ inhibin A

Down’s Syndrome - HI
H - High hCG
I - High Inhibin

Edward’s Syndrome - Everything low + anything Inhibin

Question 85

Which of these is a contraindication for using epidural anaesthesia during labour?

Coagulopathy
Obesity
Multiple gestation
Pre-eclampsia
Prolonged labour

Answer 85

Coagulopathy

Question 86

All patients dx with PCOS are offered what testing and how often? [1]

Answer 86

Annual glucose tolerance testing

Question 87

What percentage of complete molar pregnancies go on to become invasive? [1]

Answer 87

15%

Question 88

How do you feed LBW babies who cannot be fed their mother’s breast milk? [1]

Answer 88

Low-birthweight infants who cannot be fed their mother’s breast milk should be fed donor human milk

Question 89

What volume of amniotic fluid is considered to be consistent with polyhydramnios? [1]

Answer 89

> 2-3 L of amniotic fluid

Question 90

What pathology effecting the eyes occurs for babies born pre-32 weeks? [1]

Answer 90

Retinopathy of prematurity is an important cause of visual impairment in babies born before 32 weeks gestation

Question 91

PPH - What is the first line ‘surgical’ intervention? [1]

Answer 91

Postpartum haemorrhage: intrauterine balloon tamponade is the first-line ‘surgical’ intervention if other measures fail
- other options include: B-Lynch suture, ligation of the uterine arteries or internal iliac arteries

Question 92

In which cases is external cephalic version indicated [2] / not indicated [+]?

Answer 92

Indicated if not in active labour (indicated by 3/4 cm dilatation) AND if amniotic sac not ruptured

● contraindicated if in active labour
● antepartum haemorrhage within the last 7 days
● abnormal cardiotocography
● major uterine anomaly
● ruptured membranes
● multiple pregnancy (except delivery of second twin).

Question 93

[] or [] are the SSRIs of choice in breastfeeding women

Answer 93

Sertraline or paroxetine are the SSRIs of choice in breastfeeding women

Question 94

How do you treat DMT2 in pregnancy? [2]

Answer 94

the management of type 2 diabetes in pregnancy ‘women with pre-existing diabetes can be treated with metformin, either alone or in combination with insulin’.

Question 95

Intrahepatic cholestasis of pregnancy increases the risk of []

Answer 95

Stillbirth

Question 96

Intrahepatic cholestasis of pregnancy increases the risk of stillbirth

How do you manage birth of baby of mother who is suffering from this? [1]

Answer 96

induction of labour is generally offered at 37-38 weeks gestation

Question 97

If pre-term labour occurs (< 34 weeks) what do you give? [3]

Answer 97

-Steroids
-Erythromycin for 10 days until delivery (prevent NEC) if membranes are broken
-Tocolytics to prevent current pre-term labour

Question 98

If pre-term labour occurs at < 30 weeks - what could you consider giving for neuroprotection? [1]

Answer 98

< 30 weeks consider magnesium sulphate for neuroprotection

Question 99

How long after being called should Cat 1 and 2 C-sections occur? [2]

Answer 99

Cat 1: 30 mins
Cat 2: 75 misn

Question 100

Describe the difference between Actim-Partus and Actim PROM vaginal swabs

Answer 100

Actim-PROM vaginal swab
* An Actim-PROM vaginal swab detects insulin-like growth factor binding protein-1 (IGFBP-1) in vaginal fluid. The concentration of IGFBP-1 is much higher in the amniotic fluid than in the maternal blood.
* Therefore, a positive Actim-PROM suggests pre-labour rupture of membranes.

Actim-Partus vaginal swab
- Actim Partus is for identifying risk of pre-term and imminent delivery after 22 weeks.

Question 101

When calculating SFH height, how much difference can you allow in cm that means still healthy? [1]
E.g. what is a normal range for SFH height for a baby at 30 weeks? [1]

Answer 101

From 24 weeks of pregnancy, the SFH is equal to gestational weeks with the accuracy and precision of ± 2 cm. For example, if a patient’s SFH is 30 cm, her gestational weeks should be in range of 28–32 weeks of pregnancy.

Question 102

First line treatment in PPD? [1]

Answer 102

Cognitive behaviour therapy (CBT) and sertraline

Question 103

A patient comes in with low BP, but otherwise normal observations.

She has a distended stomach that is dense but not peritonitic. Her chest has reduced breath sounds.

Last week she harvested 22 eggs.

What is the current presentation? [1]
Describe normal features of this [2]

Answer 103

Ovarian hyperstimulation syndrome
- known side effect of fertility treatments
- characterised by increase in ovarian size and shifting of fluids
- can result in ascites and pleural effusions
- OHSS is a hypercoagulable state, so it is important to ensure these patients receive appropriate thromboprophylaxis

Question 104

A mother has acute Hep B infection.

How do you treat this to prevent vertical transmission? [2]

Answer 104

Complete course of vaccination + hepatitis B immunoglobulin within 24hrs of delivery

NB: The same course of action is required for mothers with a chronic hepatitis B infection.

Question 105

Which of the following methods is the best to quantify proteinuria for the diagnosis of pre-eclampsia?

Urine protein:creatinine ratio (PCR)

Urine output

Urinalysis

Urine microscopy, culture and sensitivity (MC&S)

24 h urine collection

Answer 105

Which of the following methods is the best to quantify proteinuria for the diagnosis of pre-eclampsia?

Urine protein:creatinine ratio (PCR)

Urine output

Urinalysis

Urine microscopy, culture and sensitivity (MC&S)

24 h urine collection

Question 106

What urine protein:creatinine ratio (PCR) would indicate significant proteinuria for pre-eclampsia? [1]

Answer 106

A urine PCR of 30 mg/mmol or more is the threshold for significant proteinuria. Urine PCR is more accurate and easier to use than a 24 h urine collection test.

Question 107

How do you treat GBS in newborn if you think there is a high risk? [1]

Answer 107

The most effective method of preventing GBS infection in the newborn is intrapartum antibiotic prophylaxis.
- Antibiotics, commonly penicillin, are administered intravenously during labour and delivery if risk factors for GBS infection are present.

Question 108

Post-perineal tear, what treatment do you give and why? [1]

Answer 108

Give laxatives to prevent constipation and risk of further tears

Question 109

What does the lambda sign indicate on US? [1]

Answer 109

The lambda sign on ultrasound indicates a dichorionic diamniotic twin pregnancy.

Question 110

A lambda sign is seen on US.

When would be the advised delivery period? [1]

Answer 110

37 weeks

Question 111

Describe how you treat anaemia post birth [2]

Answer 111

If asymptomatic:
- Oral Ferrous fumarate 200mg OD

If severe:
- give IV iron

Question 112

A mother has just given birth and is noted to be anaemic. She also suffers from hypothyroidism.

Describe how you would treat this patient [2]

Answer 112

Oral Ferrous fumarate 200mg OD
- But: oral iron decreases the absorption of oral Levothyroxine; advise patients to take at least 4 hours apart.

Question 113

Which pathologies does the combined test and quadruple test specifically test for? [2]

Answer 113

The combined test is carried out between 10-14 weeks gestation and tests for Down syndrome, Edward syndrome and Patau syndrome

The quadruple test is carried out between 15-20 weeks gestation and tests for Down syndrome

Question 114

When presenting a obstetric case, how do you introduce the case? [5]

Answer 114

Name
Age
Parity
Problem
Solution

Question 115

When would you expect to be able feel a ‘free head’ till in a pregnancy of a nulliparous women? [1]

Answer 115

In a nulliparous woman the foetal head doesn’t engage until 37 weeks (so it is ‘free’ to move around in uterus)

NB: Engagement: when the baby’s head is even with the ischial spines. The baby is said to be ‘engaged’ when the largest part of the head has entered the pelvis.

Question 116

Careful [] to look for [] is the first-line investigation for preterm prelabour rupture of the membranes
- what is 2nd line?

Answer 116

Careful speculum examination to look for pooling of amniotic fluid in the posterior vaginal vault is the first-line investigation for preterm prelabour rupture of the membranes
- if pooling of fluid is not observed NICE recommend testing the fluid for placental alpha microglobulin-1 protein (PAMG-1) (e.g. AmniSureµ) or insulin-like growth factor binding protein-1

Question 117

What investigations should you perform if a pregnant patient experiences a reduction in foetal movements:
- < 24 weeks [2]
- 24 - 28 weeks [1]
- > 28 weeks [4]

Answer 117

< 24 weeks:
- onward referral should be made to a maternal fetal medicine unit if fetal movements haven’t been felt before
- if have - perfom a handheld doppler

24-28 weeks:
- a handheld Doppler should be used to confirm presence of fetal heartbeat.

> 28 weeks:
- Handheld Doppler
- Immediate ultrasound if NO heartbeart detected
- If heartbeat present: CTG for 20 mins
- If concerns still exist - urgnt ultrasound

Question 118

Describe how SFH growth changes throughout pregnancy [2]

Answer 118

First 20 weeks:
- grows by 2cm a week

From 20 weeks+:
- grows by 1cm week

Question 119

If fetal movements have not yet been felt by [] weeks, referral should be made to a maternal fetal medicine unit

Answer 119

If fetal movements have not yet been felt by 24 weeks, referral should be made to a maternal fetal medicine unit

We don’t abort moving babies and 24 weeks is the point at which abortion is no longer allowed

Question 120

which of the following describes Wood’s screw manoeuvre?

• Press on the posterior shoulder
• Put the mother on all fours on the floor
• Put your hand in the vagina and attempt to rotate the foetus 180 degrees
• Hyperflex the mothers legs onto her abdomen and apply suprapubic pressure
• Push the head back in and do an emergency caesarean section

Answer 120

Put your hand in the vagina and attempt to rotate the foetus 180 degrees

Question 121

Explain a risk factor that causes 50% of cord prolapses [2]

Answer 121

premature rupture of membranes causing cord prolapse is because the baby is not yet engaged in the pelvis when the membrane is ruptured which allows the cord if suspended below the baby to become compressed

Question 122

What would be a key differential to distinguish between ectopic and miscarriage? [1]

Answer 122

3. Ectopic pregnancy- classic cervical excitation is more common in ectopic vs miscarriage
   - ‘Chandelier’s sign’

Question 123

How many days can be hcg be detected in the blood? [1]

Answer 123

From day 8 +

Question 124

Which one of the following statements regarding hepatitis B and pregnancy is correct?

Without intervention the vertical transmission rate is around 3%
Only at risk groups should be screened for hepatitis B during pregnancy
Around 30% of mothers with hepatitis B develop pre-eclampsia
It is safe for a mother with hepatitis B to breastfeed her newborn
All pregnant women with hepatitis B should take oral ribavirin in the last trimester of pregnancy

Answer 124

It is safe for a mother with hepatitis B to breastfeed her newborn

Hep B: Breastfeeding

NB: Ribavirin is contraindicated in pregnancy due to its teratogenic effects. For pregnant women with high viral loads, tenofovir is the preferred antiviral medication as it has a good safety profile in pregnancy and is effective in reducing the risk of vertical transmission

Question 125

Magnesium sulphate - monitor … [2]?

Answer 125

Magnesium sulphate - monitor reflexes + respiratory rate

Question 126

As per NICE guidelines; the following would warrant continuous CTG monitoring if any of the following are present or arise during labour [5]

Answer 126

• suspected chorioamnionitis or sepsis, or a temperature of 38°C or above
• severe hypertension 160/110 mmHg or above
• oxytocin use
• the presence of significant meconium
• fresh vaginal bleeding that develops in labour - this was a new point added to the guidelines in 2014

Question 127

How does uterine hyperstimulation present? [2]
Name two risks of uterine hyperstimulation [2]

Answer 127

Prolonged and frequent contractions

Complications include:
- Uterine rupture
- Interupted blood flow and fetal hypoxia

Question 128

Which vitamin is important to avoid in pregnancy and why? [1]
Name a food that has a high dose [1]

Answer 128

Vitamin A: causes birth defects
Liver has lots of vitamin A

Question 129

What is important to note about the presentation of placenta praevia? [1]

Answer 129

Painless (generally)

Question 130

What is the first line tx for PPH? [2]

Answer 130

Uterine massage AND emptying bladder (via a catheter)

Question 131

What is the range of weeks that you would give c/steroids if preterm rupture of membranes is imminent? [1]

Answer 131

34-36 weeks

Question 132

Name a key risk factor for placenta accreta [1]

Answer 132

Previous C-section