Recall Questions Flashcards by Paul Timmons

What is the definition of perinatal mortality rate?

a. The total number of intrapartum stillbirths expressed as a percentage of all live-births
b. The total number of stillbirths and neonatal deaths within the first 7 days of life expressed per 1000 total births
c. The total number of neonatal deaths within the first 28 days of life expressed per 1000 live births
d. The total number of stillbirths and late terminations of pregnancy (>24 weeks) expressed as a percentage of all live and still-births
e. The total number of stillbirths and neonatal deaths within the first 28 days of life expressed as a percentage of all live births

B - The total number of stillbirths and neonatal deaths within the first 7 days of life expressed per 1000 total births

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A 32 year old patient with severe learning difficulties is brought to the gynaecology clinic with severe heavy menstrual bleeding which has proven refractory to medical treatment. Her family are keen for her to undergo a hysterectomy and while you believe this may indeed prove a sensible option, have some concern regarding obtaining valid consent for such a procedure. How should you proceed in such a case?

a. Obtain a court order
b. Proceed with a hysterectomy without consent in the ‘best interests’ of the patient
c. Obtain consent from first degree relative
d. Proceed on the basis of inferred consent if the patient is not obviously resistant to undergoing such surgery
e. Contact a welfare guardian to give consent on the patient’s behalf

A - Obtain a court order

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What is the role of the Caldecott Guardian?

a. Act as an intermediary in any dispute between a patient and their care giver in a healthcare institution
b. Advocate on behalf of a patient lacking capacity to consent to medical procedures
c. Protect the confidentiality of patient information in a healthcare institution
d. Responsibility for the safeguarding of vulnerable patients during an inpatient admission
e. Independently review all patient healthcare records to ensure information is up to date and accurate

C - Protect the confidentiality of patient information in a healthcare institution

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What is the definition of positive predictive value?

a. The likelihood that a given intervention will produce the desired effect
b. The probability that a patient with a positive screening test will actually have the disease screened for
c. The likelihood that a patient will test negative for a condition they do not have
d. The likelihood that a patient who suffers from a disease will test positive for that disease on screening
e. The number of healthy people in a given sample correctly identified as such on screening

B - The probability that a patient with a positive screening test will actually have the disease screened for

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A patient makes a formal complaint to her healthcare provider after she develops necrotising fasciitis following a hysterectomy for heavy menstrual bleeding. She insists she was not told of this potential complication during consenting. Which principle of consent could the hospital rely up on here in defence?

a. Montgomery
b. Bolam
c. Fraser
d. Gillick
e. Material risk

B - Bolam

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What type of data do given responses to a pain score represent?

a. Nominal
b. Ordinal
c. Integral
d. Interval
e. Ratio

B - Ordinal

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A patient is noted to have sustained a fourth degree tear during a forceps delivery for prolonged second stage. How should the anorectal mucosa be repaired?

a. Interrupted using PDS
b. Continuous using PDS
c. Interrupted using Vicryl
d. Continuous using Vicryl
e. Interrupted or continuous Vicryl

E - Interrupted or continuous Vicryl

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A patient sustains a perineal tear requiring suturing following a normal delivery. You are supervising a trainee performing the repair under local anaesthetic. How long after infiltration with lidocaine is its anaesthetic effect felt?

a. Under one minute
b. 2 minutes
c. 5 minutes
d. 10 minutes
e. 20 minutes

B - 2 minutes

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How long after infiltration of lidocaine do blood levels peak (assuming not inadvertently injected intravascularly)?

a. 1-5 minutes
b. 6-10 minutes
c. 10-25 minutes
d. 25-45 minutes
e. >45 minutes

C - 10-25 minutes

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What is the incidence of wound infection following an emergency caesarean section?

a. <5%
b. Up to 10%
c. Up to 15%
d. Up to 20%
e. Up to 25%

B - Up to 10%

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Which of the following correctly describes the optimum sites of local anaesthetic infiltration for a para-cervical block?

a. 3, 6 and 9 o’clock
b. 4 and 8 o’clock
c. 12 and 6 o’clock
d. 3, 6, 9 and 12 o’clock
e. 10, 6 and 2 o’clock

D - 3, 6, 9 and 12 o’clock

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A patient undergoes a complex caesarean section at full dilation. Bilateral extensions of the uterine incision are sutured though there is concern following return to the ward about the patient’s urinary output. She is reviewed by the surgeon who performed the procedure who is concerned about the possibility of a ureteric injury. What is the best investigation to help in making such a diagnosis?

a. Cystogram
b. MRI urinary tract
c. CT urogram
d. USS KUB
e. Cystoscopy

C - CT urogram

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A Para 3 (1 caesarean section, 2 vaginal births) is seen on the early pregnancy unit with a missed miscarriage and opts for manual vacuum aspiration. Scan has revealed a fetal pole with a CRL of 35mm as well 2 intramural fibroids measuring 3cm each in diameter. You note from her record that 5 months earlier she completed a course of antibiotics for chlamydial infection. What feature in this history renders MVA an unacceptable choice for this patient?

a. Previous Caesarean
b. History of Chlamydia
c. Uterine fibroid
d. Multiparity
e. CRL 35mm

E - CRL of 35mm

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Aside from a reduction in operating time, what is the advantage of the blunt ‘Joel-Cohen’ entry technique for Caesarean section compared with ‘sharp’ entry?

a. Improves haemostasis
b. Improves recovery time
c. Less post-op febrile morbidity
d. Less adhesion formation
e. Less visceral injury

C - Less post-op febrile morbidity

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A 13 year old patient attends the clinic alone requesting a termination of pregnancy. On discussion around the procedure she is deemed to be Fraser competent. Who can sign her consent form for the termination?

a. The patient herself
b. Her parent or guardian
c. A court-appointed advocate
d. The practitioner undertaking the procedure
e. The medical director

A - The patient herself

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A 29 year old primigravida with known sickle cell disease presents at 32/40 complaining of acute onset chest pain and shortness of breath. On auscultation of the chest there are bi-basal crepitations and bronchial breath sounds present. CXR demonstrates a new, large infiltrate on the left lung field. What is the most likely diagnosis?

a. Myocardial infarction
b. Pneumonia
c. Pulmonary Embolism
d. Acute chest syndrome
e. Pulmonary tuberculosis

D - Acute chest syndrome

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A patient attends the EPAU for a viability scan after experiencing some light vaginal bleeding around 6 weeks since her last menstrual period. A transvaginal scan demonstrates an empty gestational sac within the uterine cavity with dimensions 30 x 20 x 25mm. What management plan is most appropriate here?

a. Beta-hCG now and in 48 hours
b. Second opinion by sonographer to confirm miscarriage
c. Diagnose miscarriage and initiate management
d. Pipelle endometrial biopsy
e. Repeat scan in 7 days

B - Second opinion by sonographer now to diagnose miscarriage

Where the MSD is 25mm or greater, miscarriage may be diagnosed

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A patient is readmitted 36 hours following a normal vaginal delivery feeling generally unwell with a high temperature, tachycardia and hypotension. On examination the abdomen is tender to palpation and offensive vaginal discharge is noted per speculum. High vaginal swabs are taken and sent for microscopy and sensitivity. What is the most likely causative organism?

a. Staph. Aureus
b. H. Influenzae
c. C. Trachomitis
d. Group B Streptococcus
e. Group A Streptococcus

E - Group A Streptococcus

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A patient attends the gynaecology ward overnight after experiencing cramping lower abdominal pain around 7 weeks since her last menstrual period. You perform a transvaginal scan which demonstrates an intrauterine gestational sac containing a yolk sac and fetal pole measuring 7mm in CRL with no evidence of cardiac activity on colour doppler. The patient is clinically well. What management is appropriate here?

a. Diagnose and initiate management of missed miscarriage
b. Measure beta-hCG now and again in 48 hours
c. Repeat scan in 7 days
d. Administer progesterone pessaries
e. Reassure the patient and discharge

C - Repeat scan in 7 days

Where the CRL is 7mm or less and no fetal cardiac activity is present, a repeat scan should be undertaken after an appropriate interval prior to making a diagnosis

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A patient admitted to the gynaecology ward with hyperemesis gravidarum is found to be tachycardic. Her biochemistry results demonstrate a high T4 and low TSH on thyroid function testing. What management is most appropriate here?

a. Carbimazole
b. Propylthiouracil
c. Thyroxine
d. Propranolol
e. Do nothing

E - Do nothing

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A patient is referred to fetal medicine after her routine fetal anomaly scan. The sonographer is concerned that the aorta and pulmonary trunk appear to leave the heart as one common vessel (truncus arteriosus). What chromosomal defect is most commonly associated with this abnormality?

a. Monosomy X
b. 5p deletion
c. 22q11 deletion
d. Trisomy 13
e. Triple X syndrome

C - 22q11 deletion

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Levels of which of the following clotting factors are decreased in normal pregnancy?

a. Factor VIII
b. vWF
c. Protein C
d. Protein S
e. Factor V

D - Protein S

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A primigravida presents to the antenatal clinic at 6/40. She is referred on account of her history of chronic hypertension for which she usually takes enalapril. Aside from this and asthma she has no other medical history of note. What drug do you advise for management of her hypertension in pregnancy?

a. Continue on enalapril
b. Labetalol
c. Methyldopa
d. Captopril
e. Hydralazine

C - Methyldopa

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A patient with bipolar disorder is seen in the antenatal clinic. She is anxious about developing puerperal psychosis as her mother, who also suffers from bipolar, developed this after childbirth. What do you advise is her risk of puerperal psychosis?

a. 1 in 2
b. 1 in 3
c. 1 in 4
d. 1 in 5
e. 1 in 8

A - 1 in 2

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A primigravida with bipolar disorder is seen in the antenatal clinic. You discuss the implications of this on pregnancy and the postnatal period. What do you advise is the risk of her developing puerperal psychosis in this pregnancy? a. 1 in 2 b. 1 in 3 c. 1 in 4 d. 1 in 10 e. 1 in 20

C - 1 in 4

You see a couple in the gynaecology clinic who are planning a pregnancy. They are concerned however regarding Zika Virus as the male partner has recently returned from Bolivia and developed a mild viral illness for a few days after returning. How long if at all should they be advised to take preventative measures against pregnancy (including use of barrier contraception)? a. No prevention needed b. 6 weeks c. 8 weeks d. 12 weeks e. 24 weeks

E - 24 weeks

You see a couple in the gynaecology clinic who are planning a pregnancy. They are concerned however regarding Zika Virus as the female partner has recently returned from Bolivia. How long if at all should they be advised to take preventative measures against pregnancy (including use of barrier contraception)? a. No prevention needed b. 6 weeks c. 8 weeks d. 12 weeks e. 24 weeks

C - 8 weeks

Which of the following drugs is associated with an increased risk of developing GDM in pregnancy? a. Citalopram b. Lithium c. Olanzapine d. Levothyroxine e. Venlafaxine

C - Olanzapine

A 36 year old with known heterozygous Factor V Leiden is referred to the antenatal clinic at booking. Her booking BMI is 32 though she has no other significant medical history. What, if any prophylactic LMWH does she require in pregnancy? a. From booking and 6/52 postnatally b. From 28/40 and 6/52 postnatally c. 6/52 postnatally d. 10/7 postnatally e. None unless additional risk develops

B - From 28/40 and 6/52 post-natally

A woman who has just had her mid-trimester anomaly scan returns to the antenatal clinic to discuss the results. On the scan it is stated that there is complete anhydramnios. The fetus is in a flexed breech presentation. Neither kidney could be identified on the scan with no evidence of renal arteries on colour flow Doppler bilaterally. Within the limitations of the scan, the rest of the fetal anatomy appears normal and biometry supports a gestation of 20 weeks. The woman states that there is no history of leaking per vagina. a. Counsel the woman that the scan findings are incompatible with life and offer termination of pregnancy b. Discharge to midwife led-care c. Offer a further scan at 28/40 to confirm the diagnosis and reassure that the oligohydramnios may well be transient d. Offer amniocentesis to exclude an underlying chromosomal abnormality e. Refer to antenatal triage for a sterile speculum examination to exclude PPROM

A - Counsel the woman that the scan findings are incompatible with life and offer termination of pregnancy

A woman returns to the antenatal clinic following her mid-trimester anomaly scan. On the scan it states that there is an abdominal wall defect present. There is herniation of the small bowel to the right of the cord insertion. The bowel does not appear to be membrane covered and is free floating in the liquor. Fetal biometry appears normal but liquor is subjectively reduced. The rest of the fetal anatomy appears normal. a. The findings are consistent with a limb-body wall defect; offer termination of pregnancy b. The findings are consistent with exomphalos and likely to be associated with chromosomal abnormalities; offer a termination of pregnancy c. The findings are consistent with gastroschisis; offer to arrange serial growth scans and review at the tertiary fetal medicine unit to discuss the prognosis with the neonatal surgeons d. The findings are consistent with physiological herniation of the bowel that resolves in the vast majority of cases; arrange a follow-up ultrasound scan at 28 weeks e. The findings are likely associated with a chromosomal abnormality; arrange an amniocentesis for the woman

C - The findings are consistent with gastroschisis; offer to arrange serial growth scans and review at the tertiary fetal medicine unit to discuss the prognosis with the neonatal surgeons

A patient attends labour ward in spontaneous labour at 7cm. The midwife who performs the initial assessment asks you to reviews as she suspects a face presentation. What dimension of the fetal skull is relevant to a face presentation? a. Subocciptobregmatic b. Mentovertical c. Submentobregmatic d. Occiptofrontal e. Bitemporal

C - Submentobregmatic

A patient attends labour ward in spontaneous labour at 7cm. The midwife who performs the initial assessment asks you to reviews as she suspects a face presentation. What is the dimension (in cm) of a face presentation? a. 9.5cm b. 10cm c. 11cm d. 12cm e. 13.5cm

A - 9.5cm

A patient attends labour ward in spontaneous labour at 7cm. The midwife who performs the initial assessment asks you to reviews as she suspects a brow presentation. What dimension of the fetal skull is relevant to a brow presentation? a. Subocciptobregmatic b. Mentovertical c. Submentobregmatic d. Occiptofrontal e. Bitemporal

B - Mentovertical

A patient attends labour ward in spontaneous labour at 7cm. The midwife who performs the initial assessment asks you to reviews as she suspects a face presentation. What is the dimension (in cm) of a brow presentation? a. 9.5cm b. 10cm c. 11cm d. 12cm e. 13.5cm

E - 13.5cm

A midwife on labour ward asks you to review a patient with a prolonged second stage following an induction for macrosomia. She suspects the presentation may be deflexed OP. What dimension of the fetal skull is most applicable to a deflexed OP presentation? a. Subocciptobregmatic b. Mentovertical c. Submentobregmatic d. Occiptofrontal e. Bitemporal

D - Occiptiofrontal

A midwife on labour ward asks you to review a patient with a prolonged second stage following an induction for macrosomia. She suspects the presentation may be deflexed OP. What are the fetal skull dimensions (in cm) of a deflexed OP presentation? a. 9.5cm b. 10cm c. 11.5cm d. 12.5cm e. 14cm

C - 11.5cm

You are taking an ST1 trainee through a straightforward ventouse ‘lift-out’ delivery for prolonged second stage. The fetus is in a direct OA, vertex presentation. What dimension of the fetal skull is relevant to a DOA vertex presentation? a. Subocciptobregmatic b. Mentovertical c. Submentobregmatic d. Occiptofrontal e. Bitemporal

A - Suboccipitobregmatic

B - 9.5cm

A 17 year old primigravida gives birth vaginally to a baby boy at term weighing 3750g. Postnatally you review the results of a swab taken at 35/40 during an admission with threatened preterm labour on which C. Trachomitis was grown. This seems to have been missed during the antenatal period and on discussing the result with the mother, she was not informed and thus not treated. What is the risk of her baby developing ophthalmia neonatorum secondary to chlamydial infection? a. 10% b. 25% c. 50% d. 66% e. 80%

B - 25%

A 19 year old Para 1 gives birth vaginally to a baby boy at term weighing 3250g. Postnatally you review the results of a swab taken at 36/40 during an admission with ?SROM on which C. Trachomitis was grown. This seems to have been missed during the antenatal period and on discussing the result with the mother, she was not informed and not treated. What is the risk of her baby developing chlamydia pneumonitis? a. <5% b. 15% c. 20% d. 30% e. 45%

B - 15%

How soon after treated for chlamydial infection in pregnancy should a test of cure be performed? a. Immediately b. 1-2 weeks c. 3-4 weeks d. 5-6 weeks e. 9-10 weeks

D - 5-6 weeks

What is the incidence of early-onset GBS disease in the UK without screening? a. 0.1% b. 0.5% c. 1% d. 1.5% e. 2%

B - 0.5%

A mother with beta-thalassaemia major wishes to restart her iron chelation therapy Desferrioxamine postnatally thought also wishes to breastfeed her infant. What is the risk to the newborn associated with desferrioxamine in breastfeeding mothers? a. Anaemia b. Neutropenia c. Thrombocytopenia d. Agranulocytosis e. No risk

E - No risk Desferrioxamine is not orally absorbed thus, despite being secreted in small amounts in breast milk is not harmful to the newborn

Which of the following rare complications of pregnancy is more common in mothers carrying a male fetus? a. Acute fatty liver of pregnancy b. Amniotic fluid embolism c. Vasa praevia d. Hypertrophic cardiomyopathy e. Obstetric cholestasis

A - Acute fatty liver of pregnancy

A mother undergoes a TORCH screen after polyhydramnios and fetal echogenic bowel is detected on her fetal anomaly scan. Which of the following would indicate recent, primary CMV infection in pregnancy? a. Raised IgG and IgM b. Urine CMV PCR c. Low avidity IgG d. High avidity IgG e. Fourfold rise in IgG compared with booking bloods

C - Low avidity IgG IgM may remain positive for up to 9-12 months after acute infection. IgG avidity testing is therefore of great use in differentiating between acute or chronic infection. In acute infection, avidity of IgG is low while in recurrent infection it is high.

A patient in the latent phase of labour has been using paracetamol for pain relief though is now struggling to cope with this alone and requests further analgesia. She explains that she is emitophobic and does not wish to take anything which may increase the likelihood of her vomiting. What do you suggest? a. Pethidine b. Epidural c. Diamorphine d. Immersion in water e. Entonox

D - Immersion in water

What is the circulating blood volume of a newborn delivered at term? a. 20-40ml/kg b. 50-70ml/kg c. 80-100ml/kg d. 120-150ml/kg e. 180-200ml/kg

C - 80-100ml/kg

A low risk primigravida presents to the delivery suite at 39 weeks of gestation stating that she has been experiencing painful contractions every 10-15 minutes for the last 12 hours. On vaginal examination she is found to be 2cm dilated and fully effaced. Abdominally, the presentation is cephalic and 2/5 are palpable. What do you advise? a. Remain on ward and repeat VE in 4 hours assuming contraction frequency remains the same b. Advise to go home and come back when contraction frequency increases c. Advise to go home but return in 24 hours for induction of labour if not in spontaneous labour d. Perform artificial rupture of membranes e. Perform artificial rupture of membranes and commence syntocinon infusion

B - Advise to go home and come back when contraction frequency increases

A patient with a history of spinal cord injury develops a sudden headache in labour. On review she is tremulous and noted to be flushed with clammy skin and experiencing involuntary muscular spasm. Blood pressure is 145/95mmHg and her pulse is 55bpm. Spinal cord lesions above what level are known to cause autonomic dysreflexia in labour? a. Any level b. L2 c. T6 d. T4 e. C5

C - T6

Which of the following factors is likely to decrease the likelihood of a patient requiring an instrumental delivery? a. Continuous support in labour b. Use of routine syntocinon for the second stage c. Epidural analgesia d. Lithotomy position for delivery e. Upright positioning in labour

A - Continuous support in labour

You are called to review a patient on the post-natal ward who has developed sudden onset breathlessness and pleuritic chest pain, 6 hours following a rotational forceps delivery in theatre. A chest x-ray requested by the ward SHO is normal. She does not report any additional symptoms and there are no other clinical findings on systematic examination. What is the diagnostic investigation of choice in this scenario? a. ECG b. Lower limb doppler c. V/Q scan d. CTPA e. Arterial blood gas

C - V/Q scan Where there is no clinic suggestion of a DVT (in which lower limb doppler may be appropriate to diagnose PE by proxy) choice of diagnostic imaging should be based on the CXR - if normal, VQ is preferred, if abnormal, CTPA.

A patient attends for antenatal care in her first pregnancy. She is known to be Hepatitis B positive. On review of her serology you find that she is HBsAg positive but HBeAg negative. What is the likelihood of vertical transmission to the neonate? a. Up to 15% b. Up to 25% c. Up to 50% d. Up to 65% e. Up to 95%

A - Up to 15% e-Ag positive; transmission up to 95%; e-Ag negative; transmission up to 15%

A patient attends for antenatal care in her first pregnancy. She is known to be Hepatitis B positive. On review of her serology you find that she is HBsAg and HBeAg positive. What is the likelihood of vertical transmission to the neonate? a. Up to 15% b. Up to 25% c. Up to 50% d. Up to 65% e. Up to 95%

E - Up to 95% e-Ag positive; transmission up to 95%; e-Ag negative; transmission up to 15%

At what stage of pregnancy and the puerperium is vertical transmission of Hepatits B most likely to occur? a. First trimester b. Second trimester c. Third trimester d. Delivery e. Postnatally – breastfeeding

D - Delivery The majority of infection occurs at delivery - only 5% of cases are thought to be due to transplacental passage

It is recommended that all neonates born to women with either acute or chronic hepatitis B should be given both hepatitis B immunoglobulin and HBV vaccine within 24 hours of birth as this is up to 95% effective in preventing both infection and the chronic carrier state. Which of the following is the only exception to this guidance? a. Infants born to HBeAg positive mothers should not receive HBV vaccine b. Infants born to HBeAg negative mothers should not receive HBV vaccine c. Infants born to anti-e positive mothers should not receive HBV immunoglobulin d. Infants born to anti-e positive mothers should not receive HBV vaccine e. Infants weighing <1500g should not receive HBV immunoglobulin

C - Infants born to anti-e positive mothers should not receive HBV immunoglobulin All infants should receive HBV vaccine and immunoglobulin except those where the mother is anti-e antibody positive who should receive only the HBV vaccine.

A primigravida is keen to breastfeeding after delivering preterm at only 30 weeks of gestation. She finds she is struggling to produce sufficient breast milk to meet the nutritional needs of her infant who is on the neonatal unit. Which of the following medications has been shown to increase breast milk production amongst mothers who delivery preterm infants? a. Chlorphenamine b. Domperidone c. Bromocriptine d. Cabergoline e. Metaclopramide

B - Domperidone

You attend a delivery of an un-booked primigravida who presents in spontaneous preterm labour at 36 weeks of gestation. On inspection following delivery, the infant is noted to have multiple structural abnormalities including only one eye positioned centrally, holoencephaly and omphalocoele. What is the most likely underlying genetic syndrome to account for this combination of abnormalities? a. Edward’s syndrome (Trisomy 18) b. Cri-du-chat c. Triple X syndrome d. Patau’s syndrome (Trisomy 13) e. VACTERL complex

D - Patau's syndrome (Trisomy 13)

For how long following birth and newborn infants protected by the influenza vaccine their mother receives during pregnancy? a. 1 month b. 3 months c. 6 months d. 9 months e. 12 months

C - 6 months

A patient with known diabetes mellitus type 1 is admitted to the labour ward with vomiting and abdominal pain. On further questioning she reveals that she had omitted to take her long acting insulin the previous evening as she was feeling unwell and not eating. What blood ketone level is diagnostic of diabetic ketoacidosis in pregnancy? a. >0.6 b. >1.2 c. >1.8 d. >2.6 e. >3.0

E - >3.0

Which of the following is an indication for routine testing of blood sugar in the neonate following birth? a. Maternal BMI >40 b. Forceps delivery c. Maternal age >35 d. Gestational age at delivery >42/40 e. SFGA

E - SFGA

A 52 year old presents to the gynaecology clinic complaining of symptoms suggestive of virilisation including cliteromegaly and male pattern body hair growth which have come on somewhat rapidly over the preceding 6 months. Her blood tests show normal levels of DHEA and 17-hydroxyprogesterone though very high testosterone. What is the most likely diagnosis? a. PCOS b. Androgenic adrenal tumour c. Late onset congenital adrenal hyperplasia d. Ovarian hyperthecosis e. Sertoli-Leydig tumour

E - Sertoli-Leydig tumour Rapid onset of symptoms suggestive of a tumour; more insidious onset is suggestive of hyperthecosis

A young woman is accompanied to the gynaecology clinic by her mother who is concerned that she has not started her periods yet aged 17. A pelvic ultrasound is performed which demonstrates an absent uterus and pelvic examination reveals a short, blind ending vagina. Secondary sexual development and the external genitalia are otherwise completely normal. Karyotyping is performed and is reported as 46XX. What is the most likely diagnosis? a. Congenital adrenal hyperplasia b. Mayer-Rokitansky-Kuster syndrome c. Kallman’s syndrome d. Androgen insensitivity syndrome e. Cystic fibrosis

B - Mayer-Rokitansky-Kuster syndrome

A nulliparous 27 year old with known polycystic ovarian syndrome, managed with metformin 500mg TDS, undergoes ovulation induction therapy with clomiphene citrate for 3 cycles at doses of 50mg, 50mg and 100mg respectively. Day 19 progesterone levels taken during each cycle however suggest that even with stimulation, she does not appear to be ovulating. Her pregnancy test in clinic is negative. What is the most appropriate next step in her management? a. Continue with clomiphene for a further 3 cycles b. In-vitro fertilisation c. High dose gonadotrophin therapy d. Increase her daily dose of metformin to 1 gram TDS e. Arrange laparoscopic ovarian drilling

E - Arrange laparoscopic ovarian drilling

On what days of the menstrual cycle should clomiphene citrate be taken for purposes of ovulation induction? a. Day 1-14 b. Day 2-6 c. Day 9-12 d. Day 18-24 e. Day 24-28

B - Days 2-6

A 59 year old, fit and well, Para 4 undergoes a pelvic ultrasound to investigate lower abdominal discomfort. This demonstrates reassuringly normal appearances of the pelvic viscera though the endometrium is incidentally noted to appear thickened and measured 10mm in AP diameter. On direct questioning she states that she has had no vaginal bleeding since her periods came to an abrupt halt 8 years earlier. What is the most appropriate course of action here? a. Advise oral high-dose progesterone b. Pipelle endometrial biopsy c. Hysteroscopy and endometrial biopsy d. Reassure and discharge e. Repeat scan in 6 months

D - Reassure and discharge The online RCOG query bank references the Canadian college guidelines suggesting incidental ET thickening only requires further scrutiny if 'over 11mm'

A 27 year old commences the Depo-Provera progesterone injection for contraception though returns to the clinic after 3 months as she is experiencing unpredictable breakthrough bleeding which is impacting on her usual enjoyment of swimming. She is otherwise quite fit and well with no significant past medical history. Assuming there are no other contraindications to any of the options given, which is the most appropriate management option? a. Concurrent prescription of the combined pill for 3 months b. Tranexamic acid c. Mefenamic acid d. Double dose of Depo-Provera e. Norethisterone

A - Concurrent prescription of the combined pill for 3 months

A patient is referred by her GP with genetic counselling owing to a strong family history of female malignancy. Which of the following puts her at the highest risk of developing a malignant neoplasm of the breast? a. BRCA1 mutation b. BRCA2 mutation c. Lynch syndrome d. 2 first degree relatives with history of breast cancer e. MEN type 1 syndrome

A - BRCA1 mutation

What is the mechanism of action of Mirabegron? a. Beta-2 adrenoreceptor agonist b. Beta-3 adrenoreceptor agonist c. Anti-muscarinic d. Acetylcholine receptor antagonist e. Selective oestrogen receptor modulator

B - Beta-3 adrenoreceptor agonist

A 52 year old patient with post-menopausal bleeding undergoes a pipelle biopsy of the endometrium which is reported as demonstrating endometrial hyperplasia without atypia. She is unsure whether or not she wishes to have hormonal treatment. What do you advise is the risk of endometrial hyperplasia without atypia progressing to endometrial cancer? a. <1% b. 2% c. 4% d. 8% e. 20%

C - 4% The risk of progression to endometrial cancer with hyperplasia without atypia is 4% over 20 years; for hyperplasia with atypia, rates are much higher: 8% in 4 years, 12% in 9 years and 27% in 19 years

A patient is seen in the antenatal clinic at booking. She has had three previous caesarean sections following an initial section in her first pregnancy for placenta praevia. She wishes to know the risk of placenta praevia in this pregnancy as she experienced a massive obstetric haemorrhage with her first and is anxious about this occurring again. What is the risk of placenta praevia in patients with 3 previous caesarean sections? a. 3% b. 10% c. 30% d. 50% e. 60%

A - 3% The risk of subsequent praevia is 1%; 1.7% and 3% after 1, 2 and 3 caesarean sections respectively.

A patient who’s first delivery was complicated by a shoulder dystocia is anxious about the risk of recurrence. What is the risk of shoulder dystocia in patients with a history of this problem relative to the general population risk? a. Equivalent b. 2-fold c. 3-fold d. 5-fold e. 10-fold

E - 10-fold

What time interval following delivery is the risk of developing puerperal psychosis highest? a. 24-48 hours b. 2-7 days c. 1-3 weeks d. 4 weeks e. 6 weeks

D - 4 weeks

A woman comes to the preconception counselling clinic. Her husband is known to suffer from haemophilia A. She herself has been tested and is not a carrier. They wish to know the likelihood of their offspring being affected by the condition? a. No increased risk b. 1 in 2 c. 1 in 4 d. 1 in 8 e. 1 in 16

A - No increased risk Be careful with these questions (haemophilia in particular seems to be a favourite topic) - remember as an X-linked condition it can generally only be passed from mother > son so be sure to check what the question is asking - i.e. 'what is the risk of her daughter being affected?' would be 0% even if the mother was a carrier.

A hospital wishes to compare its stillbirth rate against the national average. What is the rate of stillbirth in the UK? a. 0.5 in 1000 b. 1 in 1000 c. 2 in 1000 d. 5 in 1000 e. 10 in 1000

D - 5 in 1000

A patient undergoes a laparoscopic resection of endometriosis. The following morning she complains of abdominal tenderness and flank pain. She has a fever, tachycardia and urine output is almost negligible. You suspect a ureteric injury. What proportion of ureteric injuries are missed at the time of laparoscopy? a. 10% b. 20% c. 30% d. 40% e. 60%

E - 60% As many as 2/3 of ureteric injuries are missed at the time of laparoscopy

A patient undergoes a laparoscopic resection of severe endometriosis. The following morning she complains of abdominal tenderness and flank pain. She has a fever, tachycardia and urine output is almost negligible. You suspect a ureteric injury. What is the risk of ureteric injury at laparoscopy for severe endometriosis? a. 1 in 5 b. 1 in 10 c. 1 in 20 d. 1 in 50 e. 1 in 100

A - 1 in 5 Risk of ureteric injury is high for such procedures - consideration may be given to preoperative stenting in high risk cases

You perform a ventouse delivery in a primigravidae for prolonged second stage. The baby requires some assistance with his breathing following the birth. What are acceptable pre-ductal oxygen saturations in the neonate 2 minutes following birth? a. 55-60% b. 65-70% c. 75-80% d. 85-90% e. 95-100%

B - 65-70% Normal neonatal pre-ductal (right hand or either foot) oxygen saturations immediately after birth are as follows: ``` 1 minute: 60-65% 2 minutes: 65-70% 3 minutes: 70-75% 4 minutes: 75-80% 5 minutes: 80-85% 10 minutes: 85-95% ```

You take consent from a primigravida for an instrumental delivery in theatre for fetal malposition and prolonged second stage. She is anxious about the risk of obstetric anal sphincter injury with forceps delivery as her friend experienced such a complication following her own first delivery. What do you advise is the risk of a 3rd/4th degree perineal tear with forceps delivery? a. 1-2% b. 3-4% c. 5-7% d. 8-12% e. 15-20%

D - 8-12% The approximate risk of OASIS following instrumental delivery is 1-4% with ventouse and 8-12 with forceps

A patient is delivered by forceps in theatre for pathological CTG following a long labour and induction for reduced fetal movement. The baby is delivered in poor condition and admitted to the neonatal unit with low APGARs, profound acidaemia and raised lactate on cord gases. How long following this birth should the CTG be stored as part of the medical record? a. 5 years b. 10 years c. 20 years d. 25 years e. Indefinitely

E - Indefinitely Under normal circumstances, the NICE guideline on IP Care states that CTG traces should be stored - ideally electronically - for 25 years. In cases where there is concern that the baby may experience developmental delay: "photocopy cardiotocograph traces and store them indefinitely in case of possible adverse outcomes"

What is the main basis of most medical litigation cases where an abnormal CTG is concerned? a. Failure to act b. Failure to recognise c. Failure to monitor d. Failure to escalate e. Inappropriate oxytocin usage

B - Failure to recognise

An infant is admitted to the neonatal unit with poor APGAR scores following a ventouse delivery. On examination of the fetal scalp there is a prominent diffuse swelling with poorly defined edges. What is the most likely diagnosis? a. Cephalhaematoma b. Subgaleal haematoma c. Caput d. Intracranial haemorrhage e. Chignon

B - Subgaleal Haematoma

You are about to undertake a ventouse delivery for a fetal bradycardia for a patient who has just arrived on labour ward and has no analgesia on board. You decide to perform a pudendal nerve block prior to commencing the procedure. What is the maximum dose of Lidocaine without adrenaline you can use here? a. 1mg/kg b. 3mg/kg c. 5mg/kg d. 7mg/kg e. 10mg/kg

B - 3mg/kg 3mg/kg w/out adrenaline; 7mg/kg with Usual concentration is 10mg/ml therefore for a 60kg patient, 18ml would be the maximum volume of 1% lidocaine

A patient with systemic lupus erythematous is worried about the potential risks her condition poses to her unborn infant. What of the following tests is the most important predictor of fetal outcome in patients with SLE? a. Antiphospholipid syndrome antibodies b. Lupus anticoagulant c. Sjörgen’s syndrome antibodies A and B d. Anti-dsDNA antibody e. Antinuclear antibody

C - Sjörgen’s syndrome antibodies A and B Previously known as 'anti-Ro/La'

A patient with HIV on cART has an undetectable viral load at 36 weeks of gestation. She has come to the antenatal clinic however concerned about the appearance of blisters around the external genitalia, which on inspection you suspect are suggestive of genital herpes simplex. She does not believe she has ever had such blisters previously. What is the most appropriate plan for delivery in this case? a. Induction of labour at 39 weeks b. Caesarean section at 39 weeks c. Await spontaneous onset of labour – IV acyclovir in labour d. Oral acyclovir now – allow vaginal delivery if blisters healed by onset of labour; otherwise for caesarean delivery e. Caesarean section immediately

B - Caesarean section at 39 weeks The lead in on the patient's HIV status here is a red-herring. While in the absence of genital HSV, vaginal delivery may be appropriate, the appearance of primary HSV in the third trimester mandates a need for caesarean birth

A 39 year old patient with a family history of breast cancer presents in the second trimester of pregnancy with a suspicious lump in the right breast. What is the first line investigation in a bid to secure a diagnosis here? a. Mammogram with fetal shielding b. Ultrasound c. Fine needle aspiration for cytology d. MRI e. CT

B - Ultrasound

A patient is diagnosed with breast cancer at 26 weeks of gestation. Following MDT discussion it is determined that she would benefit from a course of chemotherapy. What is the most likely chemotherapy agent to be appropriate here? a. Methotrextae b. Cisplatin c. Etoposide d. Paclitaxel e. Anthracycline

E - Anthracycline

A 36 year old patient from Rwanda has tested positive in her antenatal screening for syphilis serology. Which of the following tests should be performed to confirm the diagnosis? a. VDRL test b. Treponema Pallidum Agglutination assay c. Treponema fluorescence test d. Lesion smear for PCR e. RPR test

B - Treponema Pallidum Agglutination assay

A patient attends the antenatal clinic following her dating scan which confirms a monochorionic, diamniotic twin pregnancy. You explain the risks of monochorionicity including that of twin-to-twin transfusion syndrome. From what gestation should women with monochorionic twin pregnancies begin serial scanning in order to detect TTTS? a. 12 weeks b. 16 weeks c. 18 weeks d. 20 weeks e. 24 weeks

B - 16 weeks

A primigravida with known HIV on cART presents with premature, pre-labour rupture of membranes at 35 weeks of gestation. The liquor draining is clear and inoffensive. She is well in herself and is afebrile. The CTG is normal. Viral load was checked on admission and is undetectable. What is the most appropriate next step in her management? a. Immediate delivery by caesarean section b. Steroids and antibiotics now and caesarean section at 36 weeks c. Immediate induction of labour d. Steroids and antibiotic cover now, induction of labour at 36 weeks e. Antibiotics now, caesarean section at 39 weeks

C - Immediate induction of labour

A Para 2 with a history of gestational diabetes in both her previous pregnancies presents to her midwife at 7 weeks since her last menstrual period. When should she undergo screening for GDM in this pregnancy? a. At booking and if negative, repeat at 26-28 weeks b. At booking and if negative repeat at 16-18 weeks c. At booking and if negative, reassure d. At 26-28 weeks e. At 26-28 weeks and if negative, repeat at 34-36 weeks

A - At booking and if negative, repeat at 26-28 weeks Those with a personal history of GDM in a previous pregnancy should have two GTTs - at booking and again in the late second/early third trimester

A primigravida undergoes induction of labour for severe pre-eclampsia and HELLP syndrome at 36 weeks of gestation. 4 hours postnatally you are called to review as she has become gradually more breathless over the course of the previous 30 minutes. Oxygen saturations are 91% on room air and she is tachycardic with a pulse of 110bpm. On auscultating the chest there are bibasal crepitations. Urine output has been only 10ml since delivery. What is the most likely diagnosis? a. Pulmonary embolism b. Myocardial infarction c. Pneumonia d. Pulmonary oedema e. Amniotic fluid embolism

D - Pulmonary oedema Care must be taken in women with severe pre-eclampsia to avoid fluid overload in the immediate postnatal period - fluid restriction may be necessary

A para 3 with a history of chronic hypertension is brought to A&E at 36 weeks of gestation after collapsing at home. Her Glasgow Coma Scale on admission is 3 and her blood pressure markedly elevated at 200/120mmHg. Her husband states that she had reported a severe headache for the last 2 days prior to collapse. What is the most likely diagnosis? a. Pre-eclampsia b. Idiopathic intracranial hypertension c. Interventricular haemorrhage d. Cerebral venous sinus thrombosis e. Subarachnoid haemorrhage

E - Subarachnoid haemorrhage

A major obstetric haemorrhage occurs during a caesarean section for placenta praevia. 6 units of red blood cells have been ordered and are being currently transfused. The latest blood results are as follows: Platelet Count 85; APTT 1.3; Fibrinogen 1.2. What additional blood component does this patient require? a. Fresh frozen plasma b. Cryoprecipitate c. Platelets d. Factor VIII e. Fibrinogen concentrate

B - Cryoprecipitate Cryoprecipitate should be used here to raise fibrinogen to >2. Fibrinogen concentrate is not licensed for use in obstetric practice in the UK and should not be employed out-with a clinical trial

The emergency buzzer is pulled on labour ward by a midwife who has returned to the room to find her patient collapsed on the bed and unresponsive. The woman had a normal delivery 30 minutes earlier and was using a remifentanyl PCA for analgesia in labour which remains in situ. On examination she has pinpoint pupils, respiratory rate is 9 breaths/min, pulse 95/min and she is hypotensive with a blood pressure of 80/40mmHg,. Oxygen saturations are normal. What therapy is indicated here? a. Adrenaline b. Naloxone c. Atropine d. DC cardioversion e. Intralipid infusion

B - Naloxone The clinical findings and history of reminfentanyl use suggest opioid overdose for which naloxone is the antidote

You are fast-bleeped to accident and emergency to see a woman at 26 weeks of gestation who has been brought in by ambulance with severe chest pain and breathlessness. She is haemodynamically unstable upon admission and struggling to maintain acceptable oxygen saturations even with 15L administered via a non-rebreathe mask. Shortly after you arrive she loses cardiac output and the cardiac arrest team are called. How soon following a cardiac arrest should a Perimortem caesarean section be undertaken? a. Immediately b. 2 minutes c. 4 minutes d. 5 minutes e. 6 minutes

C - 4 minutes Perimortem caesarean should be commenced after 4 minutes with a view to delivering the infant by 5 minutes in pregnancies beyond 20/40 gestation. It is performed exclusively in the maternal interest to facilitate resuscitation, though infant survival is a possibility and neonatologists should be on-hand for delivery where possible.

A patient with protracted nausea and vomiting is admitted at 11 weeks of gestation as she is unable to tolerate oral fluids and is severely ketotic on testing. What is the first line anti-emetic which should be used in nausea and vomiting of pregnancy? a. Cyclizine b. Metaclopramide c. Ondansetron d. Corticosteroids e. Domperidone

A - Cyclizine

A patient who is Rhesus negative receives a transfusion of 2 pools Rhesus positive FFP during a major postpartum haemorrhage. How much anti-D prophylaxis should she be given to cover this transfusion? a. 250iU b. 500iU c. 1000iU d. 1500iU e. No anti-D necessary

E - No anti-D necessary FFP and cryoprecipitate should ideally be of the same group as the recipient. If unavailable, FFP of a different ABO group is acceptable providing that it does not have a high titre of anti-A or anti-B activity. There is no need for anti-D cover with FFP or cryoprecipitate. If mismatched platelets are given however anti-D cover is indicated though 250iU of anti-D will cover 5 pools of platelets transfused within a 6 week period.

A woman who is known to be a haemophilia A carrier attends delivery suite in early labour, contracting 1-2 in 10, at 38 weeks of gestation. She is ‘unbooked’ and received no antenatal care in this pregnancy. On vaginal examination, the cervix is fully effaced and 2cm dilated. What is the most appropriate immediate management plan? a. Delivery by caesarean section Cat. 1 b. Delivery by caesarean section Cat. 2 c. Check factor VIII levels d. Aim for vaginal delivery; avoid fetal blood sampling and instrumental delivery e. Commence oxytocin infusion in order to expedite delivery

B - Delivery by caesarean section Cat. 2 In this scenario there is 1 in 4 chance of the fetus being affected by haemophilia (50% likelihood of being male, 50% likelihood of being affected if so). Infants known to be affected by haemophilia should not be exposed to the risks of vaginal birth and delivery by LSCS should occur.

A woman with Type III von Willebrand disease experiences a bleed during labour. Administration of what therapy may be of benefit here? a. Factor VII concentrate b. Recombinant Factor VIII c. Platelet transfusion d. Desmopressin e. Cryoprecipitate

D - Desmopressin

A patient with known asthma is reviewed in the antenatal clinic at 31 weeks of gestation. She is taking her regular salbutamol inhaler as well as her corticosteroid inhaler though feels her asthma remains poorly controlled. What is the next most appropriate step in her management? a. Long acting beta-agonist b. Oral corticosteroids c. Theophilline d. Leukotriene receptor antagonist e. Magnesium sulphate

A - Long acting beta agonist

A patient with a history of renal transplant attends for pre-pregnancy counselling. Her condition is stable and renal function is normal. Which of the following medications should she be advised to stop prior to conception? a. Ciclosporin b. Prednisolone c. Azathioprine d. Tacrolimus e. Ramipril

E - Ramipril

A patient presents with a new-onset severe headache in the third trimester of pregnancy. She has no other symptoms and is systemically well. There is no neurological deficit on examination. Which of the following imaging modalities is most appropriate first line? a. CT head with contrast b. CT head without contrast c. MRI with gadolinium contrast d. MR venogram e. Skull x-ray

D - MR Venogram

A primigravida with a BMI of 42 is found dead at home 3 weeks following a caesarean section for breech presentation. A post-mortem examination reveals a large saddle pulmonary embolus to be the cause of death. In terms of MBBRACE classification, how should this death be considered? a. Early, direct maternal death b. Late, direct maternal death c. Early, indirect maternal death d. Late, indirect maternal death e. This death is not reportable to MBBRACE

A - Early, direct maternal death Death from venous thromboembolism is the leading cause of direct maternal death (causes of death directly attributable to pregnancy). A death is considered 'early' if it occurs during or in the first 6 weeks following pregnancy.

A Para 1 is readmitted from home day days postnatal following an uneventful pregnancy and delivery. She has been complaining of lower abdominal pain for the last 12 hours and has a temperature of 39.1C. On arrival she is tachycardiac, tachypnoeic and hypotensive. You diagnose sepsis. Which of the following analgesic options is not suitable here? a. Oral morphine sulphate b. Diclofenac c. Codeine Phosphate d. Paracetamol e. Diamorphine

B - Diclofenac NSAIDs should be avoided in patients with puerperal sepsis

A primigravida attends delivery suite at 26 weeks and 2 days of gestation with absent fetal movements for 24 hours. Sadly an ultrasound scan confirms fetal demise. Which of the following regimens should be used for induction of labour? a. Mifepristone 200mg; Misoprostol 25 micrograms 4 hourly b. Mifepristone 200mg; Misoprostol 50-micrograms 4 hourly c. Misoprostol 50-micrograms 4 hourly d. Mifepristone 200mg; Misoprostol 100-micrograms 6 hourly e. Misoprostol 100-micrograms 6 hourly

D - Mifepristone 200mg; Misoprostol 100-micrograms 6 hourly The dosages of agents used for induction of labour for IUFD vary depending on gestation: - 100 micrograms 6-hourly before 26+6 weeks - 25–50 micrograms 4-hourly at 27+0 weeks or more Given until a total of 24 hours therapy complete or delivery; whichever is sooner

A primigravida attends delivery suite at 27 weeks and 2 days of gestation with absent fetal movements for 24 hours. Sadly an ultrasound scan confirms fetal demise. Which of the following regimens should be used for induction of labour? a. Mifepristone 200mg; Misoprostol 25-50 micrograms 4 hourly b. Misoprostol 50-micrograms 4 hourly c. Mifepristone 200mg; Misoprostol 100-micrograms 6 hourly d. Misoprostol 100-micrograms 6 hourly e. Mifepristone 200mg; Misoprostol 200-micrograms 8-hourly

A - Mifepristone 200mg; Misoprostol 25-50 micrograms 4 hourly The dosages of agents used for induction of labour for IUFD vary depending on gestation: - 100 micrograms 6-hourly before 26+6 weeks - 25–50 micrograms 4-hourly at 27+0 weeks or more Given until a total of 24 hours therapy complete or delivery; whichever is sooner

A couple are both known to be carriers for cystic fibrosis. They wish to know what the likelihood of their offspring being affected by the condition is. What do you advise them is the risk of an affected child? a. 100% b. 50% c. 25% d. 10% e. 5%

C - 25% Cystic fibrosis is an autosomal recessive condition therefore in a couple who are both carriers who had four hypothetical children, the make up would be as follows: - 1 affected child - 2 carriers - 1 unaffected

A patient with known epilepsy requests contraception as she has recently started a new relationship. Concurrent use of the combined oral contraceptive pill may lead to a reduction in serum concentrations of which of the following anti-epileptic drugs? a. Phenytoin b. Leviteracitem c. Lamotrigine d. Sodium Valproate e. Lorazepam

A - Phenytoin As an enzyme inducer, serum levels of phenytoin may be reduced by concurrent use of the COCP. Carbamazepine and phenobarbitone are the other commonly used enzyme inducing AEDs.

A 23 year old patient is seen in the gynaecology admissions unit complaining of a painless fleshy lesion which has appeared on the labia in the last few days. She has recently started a new relationship and is not using contraception. What is the most likely pathogen to be responsible for such an appearance? a. Treponema Pallidum b. Herpes simplex c. C. Trachomitis d. N. Gonorrhoea e. Human Papillovirus

E - Human Papillovirus

What is the most common site for uterine perforation during surgical evacuation? a. Fundus b. Anterior wall c. Posterior wall d. Cervix e. Lateral wall

B - Anterior wall

A patient is seen in the urogynaecology clinic with a vaginal vault prolapse. What is the most common symptom reported amongst patients with vault prolapse? a. Vaginal bulge b. Stress urinary incontinence c. Constipation d. Voiding dysfunction e. Sexual dysfunction

A - Vaginal bulge

A 29 year patient with a history of a previous midline laparotomy is consented for laparoscopic salpingectomy after a diagnosis is made of tubal ectopic pregnancy. What is the incidence of peri-umbilical adhesions in patients with a previous midline laparotomy scar? a. 10% b. 25% c. 40% d. 50% e. 70%

D - 50% Up to 50% with a previous midline, up to 25% with a previous low transverse (i.e. Pffanenstiel) incision

A 46 year old woman with a history of heavy menstrual bleeding is found to have multiple large uterine fibroids and elects to undergo a total abdominal hysterectomy. She enquires about the complications of such a procedure. What do you advise is the most common serious complication of abdominal hysterectomy? a. Pulmonary embolism b. Urinary tract injury c. Bowel injury d. Ovarian failure e. Haemorrhage requiring transfusion

E - Haemorrhage requiring transfusion

A couple with primary subfertility have undergone investigations. No male factor is identified though the female partner is known to have endometriosis. After what period of infertility should they be offered IVF? a. Immediately b. 6 months c. 12 months d. 24 months e. 36 months

D - 24 months

A 23 year old patient is diagnosed with a tubal ectopic pregnancy and is consented for a laparoscopy. What is the most common site of tubal ectopic pregnancy? a. Infindibulum b. Isthmus c. Ampulla d. Cornua e. Equivalent rate across each of the above

C - Ampulla

A woman with a history of bipolar disorder is seen in the antenatal clinic at booking. You counsel her regarding the implications of such a diagnosis in pregnancy, particularly around the puerperium. What is the incidence of postpartum psychosis amongst patients with a personal history of bipolar disorder? a. >90% b. 50% c. 33% d. 25% e. 10%

D - 25% Increased to 50% if a family history

A primigravida is seen in the antenatal clinic at 28 weeks of gestation. She is considering paying for a private screening test for Group B Strep infection as she has seen an item on the evening news about the condition and is anxious her baby will be affected. What do you advise her is a incidence of early-onset GBS infection in the UK amongst un-screened women? a. 0.5 in 1000 b. 1 in 1000 c. 2 in 1000 d. 5 in 1000 e. 10 in 1000

A - 0.5 in 1000 1 in 2000 babies in the UK are affected by EOGBS disease in the absence of a national screening programme

What is the increase in maternal mortality amongst multiple pregnancies relative to singletons? a. Equivalent risk b. 1.5x c. 2.5x d. 4x e. 5x

B - 1.5x

A low-risk primigravida is considering a home-birth. She wishes to know the risks associated with this compared with hospital birth. What is the incidence of serious adverse outcomes in the infant amongst such women who chose to labour at home? a. 1 in 1000 b. 2 in 1000 c. 5 in 1000 d. 9 in 1000 e. 15 in 1000

D - 9 in 1000 There is a table in the NICE guideline on intrapartum care which outlines the risk of 'serious medical problems' in the neonate per 1000 births across each birth setting in low-risk primi- and multigravidae respectively. For primigravida the risk is 9 in 1000 (0.9%) for homebirth and 5 in 1000 (0.5%) for obstetric or midwifery led inpatient units. For multigravidae the risk is 3 in 1000 (0.3%) across all settings except a co-located midwifery-led unit in which the risk is slightly lower at 2 in 1000 (0.2%)

A low-risk primigravida is considering a home-birth. She wishes to know the risks associated with this compared with hospital birth. What is the incidence of serious adverse outcomes in the infant amongst primiparous women who deliver in either an obstetric or midwifery led setting? a. 1 in 1000 b. 2 in 1000 c. 5 in 1000 d. 9 in 1000 e. 15 in 1000

C - 5 in 1000 There is a table in the NICE guideline on intrapartum care which outlines the risk of 'serious medical problems' in the neonate per 1000 births across each birth setting in low-risk primi- and multigravidae respectively. For primigravida the risk is 9 in 1000 (0.9%) for homebirth and 5 in 1000 (0.5%) for obstetric or midwifery led inpatient units. For multigravidae the risk is 3 in 1000 (0.3%) across all settings except a co-located midwifery-led unit in which the risk is slightly lower at 2 in 1000 (0.2%)

A low-risk multipara is considering a homebirth. She is anxious about the prospect however of delivering in a non-medical environment ‘in case something goes wrong with the baby’. You explain that the risk of adverse outcomes for low-risk multiparae is equivalent whether they deliver at home or in hospital – what is that risk? a. 0.5 in 1000 b. 1 in 1000 c. 3 in 1000 d. 5 in 1000 e. 9 in 1000

C - 3 in 1000 There is a table in the NICE guideline on intrapartum care which outlines the risk of 'serious medical problems' in the neonate per 1000 births across each birth setting in low-risk primi- and multigravidae respectively. For primigravida the risk is 9 in 1000 (0.9%) for homebirth and 5 in 1000 (0.5%) for obstetric or midwifery led inpatient units. For multigravidae the risk is 3 in 1000 (0.3%) across all settings except a co-located midwifery-led unit in which the risk is slightly lower at 2 in 1000 (0.2%)

A low-risk primigravida is found to have a breech presentation at 36 weeks and undergoes a successful ECV to cephalic. She enquires about the likelihood of the baby spontaneously reverting to breech prior to labour. What is the risk of spontaneous reversion following ECV? a. <5% b. 7-8% c. 10-12% d. 14-15% e. 20-25%

A - <5% Following a successful ECV, the quoted likelihood of reversion to breech is low at 3%

You are consenting a 19 year old with a diagnosis of missed miscarriage at 8 weeks of gestation for a surgical evacuation. What do you advise her is the risk of uterine perforation associated with this procedure? a. 1 in 1000 b. 2 in 1000 c. 5 in 1000 d. 8 in 1000 e. 10 in 1000

A - 1 in 1000 Some older texts may quote numbers as high as 1 in 200 as this previously appeared on the RCOG consent advice - the latest version however states the risk quoted should be 1 in 1000 for first trimester ERPC

A 40 year old woman undergoes a risk-reducing laparoscopic BSO procedure after she is identified as a carrier of the BRCA1 mutation. What is the risk of finding an occult malignancy during this procedure? a. <1% b. 3% c. 5% d. 10% e. 20% f. 40%

C - 5% From TOG - 4-8% risk in women under 40, rising to 20% in over 40s.

A patient develops a post-dural puncture headache the morning after a normal delivery. There was some difficulty in siting an epidural in labour and the consultant anaesthetist had to be called from home to assist. She is counselled towards undergoing a ‘blood patch’ procedure. What is the likelihood that she will gain relief from this procedure? a. Up to 10% b. Up to 25% c. Up to 50% d. Up to 70% e. Up to 90%

E - Up to 90%

A patient is readmitted with collapse 2 days following a normal delivery. On admission she is noted to have a temperature of 39.5C, pulse of 135bpm, respiratory rate of 35 and un-recordable blood pressure. Her GCS is 11. You suspect septic shock and initiate the ‘septic six’ pathway. What lactate result would support your diagnosis? a. >1.5 b. >2 c. >3 d. >4 e. >8

D - >4

What is the earliest gestation at which a fetal heart rate may reasonably be expected to be seen on transvaginal ultrasound scanning? a. 21 days b. 28 days c. 35 days d. 42 days e. 49 days

C - 35 days The fetal cardiac system is known to be established by approximately 5 weeks of gestation

A woman in her first pregnancy develops primary genital herpes simplex at 35 weeks of gestation. She is counselled regarding the risks of vaginal delivery and advised to delivery by caesarean section, but wishes to press ahead with vaginal birth against medical advice. What, do you advise, is the risk of neonatal HSV infection in such a scenario? a. 0-3% b. 10% c. 25% d. 40% e. 65%

D - 40% Risk with primary infection in the third trimester - 40% Risk with secondary infection is 0-3%

A 22 year old woman undergoes genetic testing after both her mother, aunt and grandmother developed ovarian cancer in their early 40s. She is found to be a carrier for the BRCA1 mutation. What do you advise is her lifetime risk of ovarian cancer? a. 1.3% b. 17% c. 25% d. 40% e. 60%

D - 40% Rather starkly different figures for this risk appear in various sources - given the timing of this paper, a TOG article from 2014 from which another question is clearly drawn seems to be the reference thus 40% is the most likely answer in this case. A scientific impact paper on RR surgery in BRCA carriers quotes over 60% however. The risk is unquestionably far higher with BRCA1 than BRCA2 however

A 54 year old presents to the urogynaecology clinic with urinary symptoms. Following completion of a bladder diary and review of her history, overactive bladder is felt to be the problem and she wishes to consider treatment. She undergoes bladder training though finds the response to such therapy suboptimal. Which of the following medication should be tried in this woman first line? a. Darifenacin b. Solifenacin c. Duloxetine d. Mirabgeron e. Transdermal oxybutynin

A - Darifenacin Tolterodine would be an alternative option if listed, as would oral oxybutynin

What is the most commonly seen variant of urinary incontinence amongst women in the UK? a. Stress b. Urge c. Mixed d. Unclassifiable e. Iatrogenic post-surgical

A - Stress

A patient is discovered to have sustained a ureteric injury on CT urogram some 48 hours following a laparoscopic resection of rectovaginal endometriosis. What is the most common type of ureteric injury following a therapeutic laparoscopy? a. Crush b. Resection c. Transection d. Angulation e. Thermal

C - Transection

Significant intra-abdominal bleeding is noted at laparoscopy immediately following insertion of the primary trocar through an umbilical port with the Veress needle technique. What is the most common vascular injury at primary umbilical trachar insertion? a. Abdominal aorta b. Inferior epigastric artery c. Internal iliac artery d. Umbilical artery e. Common iliac artery

E - Common iliac artery

Which of the following statements regarding the anatomical course of the ureter is correct? a. The ovarian vessels run posterior to the ureter b. The ureter runs superior to the uterine artery c. The normal length of the ureter in the adult female is approx.. 40cm d. The ureter runs medial to the bifurcation of the common iliac artery e. The ureter runs medial to the internal iliac artery

E - The ureter runs medial to the internal iliac artery

A check hysteroscopy following a blind uterine polypectomy identifies a small perforation in the anterior uterine wall. There is no evidence of bleeding. What is the most appropriate immediate management? a. Laparotomy b. Laparoscopy c. Attempt hysteroscopic repair d. Antibiotics and observation e. Observation alone

D - Antibiotics and observation Where there is a small perforation with no suggestion of visceral injury in a well patient, an initial management plan of antibiotic cover and observation is acceptable first line management

A patient is referred to the 2-week wait clinic with a suspect vulval lesion. On testing she is found to be positive for HPV 16. What subtype of vulval carcinoma is associated with HPV infection? a. Adenocarcinoma b. Verroucus carcinoma c. Basaloid d. Paget’s disease e. Squamous cell carcinoma

C - Basaloid HPV is implicated in ~30% of vulval cancers though >70% of VIN

A patient undergoes testing prior to an IVF cycle. Her anti-Muellerian hormone level is noted to be elevated at 90. Within the context of IVF, what is the significance of this results? a. It is indicative of premature ovarian insufficiency b. It indicates a higher likelihood of developing ovarian hyperstimulation syndrome c. It indicates a lower likelihood of developing ovarian hyperstimulation syndrome d. Suggests a higher likelihood of a live birth following IVF e. Suggests a lower likelihood of a live birth following IVF

B - It indicates a higher likelihood of developing ovarian hyperstimulation syndrome High AMH indicates a high ovarian reserve. These patients are at increased risk of OHSS.

A patient with large uterine fibroids is keen to avoid invasive surgery and opts instead to undergo uterine artery embolisation. Which of the following is an absolute contraindication to uterine artery embolisation? a. Recent genital tract infection b. Bicornuate uterus c. Fibroid size >10cm d. Adenomysosis e. A desire for future fertility

A - Recent genital tract infection

A 55 year old woman is commenced on hormone replacement therapy as she is finding the vasomotor symptoms of menopause unbearable. 2 months later she presents anxious about unscheduled vaginal spotting. What management is appropriate here? a. Reassurance b. Hysteroscopy c. Ultrasound pelvis d. Outpatient endometrial biopsy e. Stop HRT

A - Reassurance Unscheduled bleeding in the first 3 months following initiation of HRT may be managed expectantly

142. An 19 year old patient is seen in the gynaecology clinic seeking contraceptive advise. She is epileptic and using carbamazepine for seizure control. Which of the following contraceptive options are appropriate for her? CHC POP DMPA IMPL LNG-IUS IUCD a. x x x x x x b. x c. x x d. x x x e. x x x x

D - Depo, IUS and IUCD

A 17 year old patient is referred to the adolescent gynaecology clinic with primary amenorrhoea. On examination she has normally developed secondary sexual characteristics though pelvic examination reveals a short, blind ending vagina. An ultrasound scan is performed which reveals an absent uterus. She undergoes karyotyping which is reported as 46XX. What is the diagnosis here? a. Late onset congenital adrenal hyperplasia b. Androgen insensitivity syndrome c. Mayer-Rokitansky-Kuster-Hauser syndrome d. Gonadal dygenesis e. Turner syndrome

C - MRKH Syndrome This is a common question - MRKH occurs in 46XX females and is characterised by a congenital absence of the uterus. Ovarian function is usually normal thus secondary sexual development occurs at expected timings. These patient present in their late teens with primary amenorrhoea.

A 19 year old girl is reviewed in the adolescent gynaecology clinic with primary amenorrhoea. She has a body mass index of 18 and explains that she has a part time job as a fitness instructor at the local gym. On examination, secondary sexual characteristics are poorly developed. Investigations reveal marked elevation in serum FSH and LH levels. Ultrasound scan is normal. Karyotyping is performed and a result of 46XX obtained. What is the most likely diagnosis here? a. Late onset congenital adrenal hyperplasia b. Androgen insensitivity syndrome c. Mayer-Rokitansky-Kuster-Hauser syndrome d. Exercise-related amenorrhoea e. Primary ovarian failure

E - Primary Ovarian Failure The marked elevation in gonadotrophin levels distinguish primary ovarian failure in this case from exercise induced amenorrhoea which is suggested by the lead-in

A 50 year old woman reports rapidly progressive virilising symptoms over the preceding 6 months. Her blood results demonstrate normal DHEAS and 17-hydroxyprogesterone levels with a markedly raised testosterone. What is the most likely diagnosis? a. PCOS b. Androgenic adrenal tumour c. Late-onset CAH d. Ovarian hyperthecosis e. Sertoli-Leydog tumour of the ovary

E - Sertoli-Leydig tumour Normal DHEAS levels point to an ovarian cause - DHEAS is produced only by the adrenal gland thus is not elevated in ovarian pathology. Rapid onset of symptoms suggests a tumour while hyperthecosis is associated with gradual onset over time

A couple present to the fertility service after 9 months of failure to conceive. The male partner’s semen analysis result is reviewed and is normal. On history taking the woman discloses a history of polycystic ovarian syndrome. Her body mass index is elevated at 37. What is the most appropriate first line management option for this couple? a. Clomiphene citrate b. Metformin c. Laparoscopic ovarian drilling d. Weight loss e. IVF

D - Weight loss This couple have only been trying for 9 months thus fertility treatment is not yet indicated. In any case, weight loss is first line in obese patients prior to any medical therapy.

A postmenopausal woman is on medication to reduce her risk of osteoporosis though has had to stop after she developed osteo-necrosis of the jaw. What drug is the most likely cause of this? a. Bisphosphonates b. Calcitonin c. Strontium d. Teriparatide e. Raloxifene

A - Bisphosphonates Osteonecrosis of the jaw is associated with bisphosphonate use though is not the most common side effect - oesophageal irritation is seen more frequently.

A 29 year old woman undergoing fertility investigations reports severe cyclical pelvic pain. An ultrasound scan is highly suggestive of a 4cm right-sided endometrioma. Which of the following is the most appropriate first line management option? a. Laparoscopic aspiration of the cyst b. Laparoscopic ovarian cystectomy c. Laparoscopic oophorectomy d. Trial of combined oral contraceptive pill e. Reassurance

B - Laparoscopic cystectomy

An ST5 trainee conducts a small study comparing the effects of two different prostaglandin preparations on the success of induction of labour in two different groups. Which of the following statistical tests is most appropriate to determine the difference? a. Chi-squared b. Student’s t test c. Mann-Whitney U test d. ANOVA e. Kruskall-Wallace

A - Chi-squared

What is the role of the Caldicott guardian? a. To ensure patients are aware of their rights in a healthcare setting b. To monitor and ensure regular audit is occurring within a hospital c. To protect the interests of staff from litigation or complaints d. To protect patient confidentiality e. To provide support in making litigation claims to patients who feel unfairly treated

D - To protect patient confidentiality

What are acceptable pre-ductal oxygen saturations on a baby two minutes following birth? a. 60-65% b. 65-70% c. 75-80% d. 85-90% e. >90%

B - 65-70% There is 5% stepwise increase from 60% in the first 5 minutes of life to pre-ductal SpO2

A primigravida is delivering on the midwifery-led birthing unit and elects to use Entonox (nitrous oxide) for analgesia. What is the mechanism of action of entonox? a. Inhibits COX breakdown b. Smooth muscle relation in the uterus c. Inhibition of neurotransmission blocking sodium channels in nociceptors d. Actives central opioid receptors e. Increases concentration of endogenous endorphins, corticotrophins and dopamine

E - Increases concentration of endogenous endorphins, corticotrophins and dopamine

The emergency buzzer is pulled on labour ward. A primigravida has just had an amniotomy for failure to progress at 9cm followed by a cord prolapse which is confirmed on examination. The vertex is at +1 in a DOA position. The CTG is still running and is normal. Which of the following is the most appropriate management option? a. Cat. 1 CS b. Cat. 2 CS c. Forceps delivery in the room d. Forceps delivery in theatre e. Manual replacement of the cord

B - Cat. 2 CS In the context of a normal CTG, a Cat. 2 caesarean is appropriate here. Instrumental delivery can be considered in fully dilated patients though obviously not at 9cm. An abnormal CTG would mandate a Cat. 1 caesarean. Manual replacement of the cord is associated with vasospasm and should not be attempted.

A multigravida who is a known carrier of the BRCA1 mutation attends at 20 weeks of gestation with a lump in her left breast. What is the most appropriate first line investigation? a. Ultrasound breast b. Mammography c. CT chest d. MRI breast e. Needle guided aspiration for cytology

A - Ultrasound breast

A woman attends for genetic counselling. Which of the following places her at the highest risk of developing a breast carcinoma? a. BRCA1 b. BRCA2 c. Lynch syndrome d. MEN type 1 e. 2 first degree relatives with a history of breast cancer

A - BRCA1

A woman with known Turner’s syndrome is planning an IVF pregnancy. What is the most important investigation from the list below which should be performed prior to embarking on pregnancy? a. Glucose tolerance test b. DEXA bone scan c. Ultrasound pelvis d. Echocardiography e. Lunch function testing

D - Echocardiography Turner's syndrome is associated with coarctation of the aorta - an echo should be performed pre-conceptually to exclude this

What is the increased risk of autism amongst infants born to mothers using sodium valproate in pregnancy compared with the general population? a. Equivalent risk b. 3x c. 5x d. 10x e. 20x

B - 3x

A newborn infant is admitted to the neonatal unit 12 hours following a normal vaginal birth with suspected sepsis. What is the most likely causative organism? a. Staph. Aureus b. Strep. Pyogenes c. Strep. Agalactiae d. H. Influenzae e. E. Coli

C - Strep. Agalactiae Strep. Agalactiae is also known as 'Group B' strep. Strep. Pyogenes is 'Group A'

A patient is referred to fetal medicine for consideration of invasive testing after he anomaly scan was suggestive of truncus arteriosus. With which of the following chromosomal abnornalities is truncus arteriosus most commonly associated? a. Trisomy 13 b. Trisomy 18 c. Trisomy 21 d. 22q11 deletion (DiGeorge syndrome) e. Monosomy X (Turner’s syndrome)

D - 22q11 deletion Truncus arteriosus is associated with DiGeorge syndrome (22q11 deletion)

A pregnant woman is diagnosed with a cerebral venous sinus thrombosis. What is the most common presenting symptom of a CVST? a. Diplopia b. Confusion c. Fits d. Headache e. Motor weakness in lower limbs

D - Headache

A woman presents in late pregnancy complaining of a severe generalised headache, neck stiffness, confusion and visual disturbance. Blood pressure on admission is 140/90mmHg. There is no proteinuria. MRI is reported as showing a posterior ‘filling defect’. What is the most likely diagnosis? a. Posterior reversible encephalopathy syndrome b. Impending eclampsia c. Cerebral venous sinus thrombosis d. Migraine with aura e. Idiopathic intracranial hypertension

C - Cerebral venous sinus thrombosis

In which of the following scenarios is routine blood sugar testing of the neonate indicated? a. Forceps delivery b. SFGA fetus c. Maternal BMI >40 d. Maternal age >35 e. Baby born >40+14

B - SFGA fetus

A pregnant patient attends with symptoms suggestive of a myocardial infarction – central crushing chest pain radiating to the jaw and left arm. Which of the following diagnostic tests should be considered first line? a. ECG b. Chest x-ray c. Echocardiogram d. Cardiac enzyme testing e. Arterial blood gas

A - ECG

A grand multiparous woman with a history of polyhydramnios (AFI 28cm) is about to undergo a Category 1 caesarean section for cord prolapse. Which of the following risk factors is associated with the greatest risk of post-partum haemorrhage? a. Emergency Caesarean b. Polyhydramnios c. Grand-multiparity d. EFW 4.2kg e. Amniotomy

B - Polyhydramnios

A patient is reviewed in the antenatal clinic at booking in her second pregnancy. Her first pregnancy 5 years ago was complicated a left popliteal DVT at 32 weeks which was treated with LMWH and warfarin for a total of 3 months. What plan should be put in place for thromboprophylaxis in this pregnancy? a. Commence LMWH immediately and for 6 weeks postnatal b. Commence LMWH at 28 weeks and for 10 days postnatal c. Commence LMWH at 28 weeks and for 6 weeks postnatal d. 10 days postnatal LMWH e. 6 weeks postnatal LMWH

A - Commence LMWH immediately and for 6 weeks postnatal

A primigravida with anorexia nervosa presents at 35 weeks of gestation with a 6 week history of worsening pain in her right hip which has now reached the point she can no longer weight bear. Which imaging modality should be used first line in a bit to reach a diagnosis? a. CT b. DEXA c. X-ray with fetal shielding d. MRI e. No investigation necessary

C - X-ray with fetal shielding

Hydrops fetalis is diagnosed at 22/40 in a Rhesus D +ve woman. The patient has a past history of hospital admission and blood transfusion in Bangladesh several years earlier. What is the most likely red-blood cell antigen to be responsible for the development of fetal hydrops in this case? a. C b. D c. E d. K e. Fy

D - Anti-K

A woman develops confirmed falciparum malaria in pregnancy though is treated and makes a good recovery. What testing is indicated in the infant? a. Microscopy of thick and thin blood films at birth and weekly for 28 days b. Microscopy of thick and thin blood films at birth and daily for 7 days c. Microscopy of thick and thin blood films at birth only d. Placental histology to detect parasites with no further action required id negative e. Placenta and cord films for malaria parasites

A - Microscopy of thick and thin blood films at birth and weekly for 28 days

A primigravida in her first pregnancy develops acute fatty liver of pregnancy (AFLP) and is delivered by caesarean section at 35 weeks of gestation. She has come to antenatal clinic at booking, now pregnant again, wishing to know her risk of developing AFLP again this time round. What do you advise her is the recurrence risk of AFLP? a. 10% b. 25% c. 50% d. 75% e. 90%

B - 25% The recurrence rate of AFLP is considerable - at 25%

A primigravida with know lupus presents at booking. She is known to be Sjorgen’s syndrome antibody A&B positive (previous anti-Ro/La). What is the risk of congenital heart block in the baby? a. 2-3% b. 10% c. 15% d. 26% e. 42%

A - 2-3% Congenital heart block occurs in 2-3% of women with anti-Ro/La antibodies

A 58 year old woman is seen in the urogynaecology clinic with suspected pelvic organ prolapse– she wishes to known how common this is. What is the lifetime risk of developing pelvic organ prolapse? a. 2-5% b. 8-12% c. 18-25% d. 48-51% e. 68-70%

B - 8-12%

A patient develops a severe fronto-occipital headache which radiates to the neck 24 hours following a normal vaginal birth. She required an epidural for pain relief in labour and you speculate that a post-dural puncture headache may be a cause for her symptoms. What is the incidence of dural puncture in epidural insertion? a. 0.1-0.5% b. 0.5-2.5% c. 3-4% d. 5-10% e. Greater than 10%

B - 0.5-2.5%

A low risk primigravida is aiming for a home-birth. According to NICE guidelines on intrapartum care, what is the likelihood that she will require transfer to hospital prior to delivery? a. 4.5% b. 11.5% c. 25% d. 35% e. 45%

E - 45% Rates of transfer to hospital from home-birth is high at 45% in primigravida and 11.5% in multigravidae

A low risk multigravida is aiming for a homebirth. According to NICE guidelines on intrapartum care, what is the likelihood that she will require transfer to hospital prior to delivery? a. 4.5% b. 11.5% c. 25% d. 35% e. 45%

B - 11.5% Rates of transfer to hospital from home-birth is high at 45% in primigravida and 11.5% in multigravidae

A patient undergoing a vaginal birth is anxious about the risk of developing incontinence following delivery. What is the risk of developing stress urinary incontinence following one vaginal delivery? a. 2-3% b. 5% c. 10% d. 15% e. 20%

E - 20% Rates of SUI are 20% following vaginal birth and 5% following LSCS

A patient who’s mother suffers from severe stress incontinence requests an elective caesarean on grounds of maternal request as she is anxious about the risk of developing incontinence with vaginal birth. What do you advise her is the incidence of stress urinary incontinence after one caesarean section? a. <1% b. 2-3% c. 5% d. 8-9% e. 15%

C - 5% Rates of SUI are 20% following vaginal birth and 5% following LSCS

A woman with a diagnosis of biopsy proven lichen sclerosis returns to the gynaecology clinic following a trial of ultrapotent steroid therapy complaining that her symptoms are largely unchanged. What proportion of patients with lichen sclerosis will find their symptoms steroid resistant? a. 2-3% b. 4-10% c. 12-15% d. 20-24% e. 31-36%

B - 4-10% 4-10% of patients with lichen sclerosis will be steroid resistant and require second line therapy - tacrolimus

A primigravida comes to the clinic at 15 weeks of gestation. She is anxious as she works as a school teacher and after a child in her class developed ‘slapped cheek’, she herself has now come down with a mild viral illness. Assuming this is Parvovirus, what is the rate of vertical transmission at 15 weeks of gestation? a. 5% b. 15% c. 25% d. 50% e. 90%

C - 25% Rates of parvovirus transmission are 15% at <15/40; 25% at 15-20/40 and 70% at term

A young 23 year old woman is referred to the gynaecology clinic after an ovarian cyst is detected incidentally on an ultrasound scan to investigate a missing IUCD. She is extremely anxious as her grandmother died of ovarian cancer. What is the likelihood of an ovarian cyst in a premenopausal women representing a malignant pathology? a. 0.1% b. 0.2% c. 0.5% d. 1% e. 1.5%

A - 0.1% The likelihood of an ovarian cyst representing a malignant pathology in a pre-menopausal woman is low at 1 in 1000

A 45 year old patient undergoes a total abdominal hysterectomy for heavy menstrual bleeding. How long following such a procedure should she be on LMWH injections? a. 24 hours b. 5-7 days c. 10 days d. 2 weeks e. 6 weeks

B - 5-7 days

A 50 year old patient is referred to the Urogynaecology clinic with symptoms of voiding difficulty. What first line investigations should be performed? a. Urodynamics b. Urine culture c. Cystoscopy d. In-out catheter for PVR e. Bladder scan for PVR

E - Bladder scan for PVR

Which route of administration of misoprostol is associated with the quickest onset of action? a. Oral b. Buccal c. Sublingual d. Vaginal e. Rectal

A - Oral Timings of onset of misoprostol are as follows: - Oral: 8 minutes (duration 120m) - Sublingual: 11 minutes (180m) - Vaginal: 20 minutes (240m) - Rectal 100 minutes (240m)

A patient who is unsure of her dates attends for a dating scan. The following measurements are taken – CRL 90mm; HC 111mm; BPD 54mm; FL 67mm; AC 94mm. Which of these measurements should be used to date the pregnancy? a. CRL b. HC c. BPD d. FL e. AC

B - HC If the CRL is >84mm pregnancy should be dated by head circumference

A patient sustains an injury to the inferior epigastric artery during insertion of the secondary ports at a diagnostic laparoscopy. Which artery is the inferior epigastric a branch of? a. Femoral b. Internal thoracic c. Superior mesenteric d. Internal iliac e. External iliac

E - External iliac

A patient is diagnosed with a missed miscarriage at 8 weeks of gestation and opts to undergo surgical evacuation. What, do you advise her, is the most common complication of this procedure? a. Perforation b. Bleeding requiring blood transfusion c. Cervical injury d. Infection e. Reduction on future fertility

D - Infection

A patient undergoes an ultrasound scan of the pelvis for dysmenorrhoea which is reported as showing ‘diffuse adenomyosis’. What other ultrasound finding is most commonly seen alongside adenomysosis? a. Endometrial polyps b. Fibroids c. Endometrial hyperplasia d. Endometriosis e. Uterus didelphys

B - Fibroids

A 60 year old presents with post-menopausal bleeding. Endometrial thickness on scan is 7mm and she undergoes an outpatient endometrial biopsy which is reported as ‘hyperplasia without evidence of atypia’. What is the most appropriate management? a. Hysterectomy b. Hysterectomy and bilateral oophorectomy c. Levonorgestrel-IUS d. Oral progesterones e. Endometrial ablation

C - LNG-IUS

A patient with subfertility undergoes extensive investigation including a hysterosalpingogram which demonstrates complete uterus didelphys. Which of the following renal tract abnormalities is most commonly associated with this finding? a. Renal agenesis b. Pelvic kidney c. Horseshoe kidney d. Ectopic ureter e. Double ureter

A - Renal agenesis Renal agenesis is seen in up to 25% of women with with uterus didelphys

A couple attend the fertility clinic for investigation of secondary infertility. They already have one child together born by vaginal delivery 5 years earlier. All the woman’s investigations have returned normal results, though the male partner’s FSH is considerably reduced and semen analysis shows a sperm count of 0.5million/ml. Which of the following is the most likely cause? a. Kleinfelter’s syndrome b. Kallman syndrome c. Cryptorchidism d. Anabolic steroid use e. Androgen insensitivity syndrome

D - Anabolic steroid use Anabolic steroid use suppresses FSH/LH

A 27 year old couple who are otherwise fit and well have been trying to conceive for two and a half years. They have been extensively investigated and all investigations have been normal. What is the most appropriate management? a. Suggest continue to try for a further 6 months and review b. Repeat semen analysis and female hormone profile c. IVF d. Intra-uterine insemination e. Clomiphene citrate

C - IVF

A 23 year old patient presents to the clinic with menstrual irregularity and progressive hirsuitism. Ultrasound scan of the pelvis demonstrates a polycystic appearance of the ovaries. Testosterone level is raised 7 though the free-androgen index is normal. What is the next most appropriate investigation? a. DHEA b. DHEAS c. 17-(OH) Progesterone d. FSH/LH e. ACTH suppression test

C - 17-(OH) Progesterone

A 57 year old woman presents with post-menopausal bleeding and gradually worsening hirsuitism. Her husband who accompanies her to the clinic states that he feels her voice has also deepened over the last several months. Bloods reveal a testosterone level of 11. What is the most likely diagnosis in this case? a. PCOS b. Androgen secreting adrenal tumour c. Cushing’s syndrome d. Ovarian hyperthecosis e. Sertoli–Leydig tumour

D - Ovarian hyperthecosis

A patient presents with pre-menstrual syndrome seeking treatment. On discussion she discloses that she has never had any treatment for this thus far. She is not in a relationship at present and therefore not planning a pregnancy in the near future. Which of the following management options is most appropriate? a. Cognitive behavioural therapy b. Vitamin B1 c. High-dose SSRI d. Combined pill e. Estradiol patch with micronized progesterone

D - Combined pill First line in PMS is COCP, Vitamin B6 or low-dose SSRI. If there is a suggestion of psychological morbidity, CBT similarly may be appropriate

A 22 year old woman presents to the gynaecology clinic with heavy menstrual bleeding seeking management. She is not planning pregnancy in the near future. Which of the following options is most appropriate first line management? a. Combined pill b. Mefenamic acid c. Tranexamic acid d. Levonorgestrel IUS e. Depo-provera injections

D - Levonorgestrel IUS

An ST4 trainee takes a patient attempting VBAC to theatre at 4am for an emergency caesarean section for suspected scar rupture. The CTG has been abnormal for some 45 minutes now and there is fresh vaginal bleeding. Upon opening the peritoneal cavity, the presence of numerous tortuous veins covering the lower uterine segment are noted and placenta percreta is suspected. The report from her mid-trimester scan on placental position suggested it was ‘anterior not low’. What is the most appropriate management? a. Proceed with urgent delivery of the fetus b. Call obstetric consultant on-call and wait for their arrival prior to proceeding c. Call obstetric consultant on-call, attempt delivery of the baby through an upper segment incision while awaiting their arrival d. Perform on-table ultrasound to localise the placenta and open the uterus below its leading edge e. Call interventional radiologist to embolise internal iliac arteries prior to proceeding

B - Call obstetric consultant on-call and wait for their arrival prior to proceeding

A patient who has been on oxytocin in labour and postnatally is noted to have some electrolyte derangement on her bloods postnatally. Which of the following electrolyte imbalances is most commonly seen in patients on oxytocin? a. Hypernatremia b. Hyperkalaemia c. Hyponatraemia d. Hypokalaemia e. Hypocalcaemia

C - Hyponatremia

A medical student is learning about different modalities of analgesia in labour. She enquires about the mechanism of action of pethidine. Where in the brain are the majority of opioid receptors located? a. Basal ganglia b. Hippocampus c. Corpus callosum d. Periaqueductal grey mater e. Red nucleus

D - Periaqueductal grey matter

A patient with a history of breast cancer has just completed 5 years of tamoxifen treatment. She attends for pre-conceptual counselling as she now wishes to try for a pregnancy. When do you advise it would be appropriate to do so? a. Immediately b. 3 months c. 6 months d. 1 year e. 2 years

B - 3 months Pregnancy should be deferred for 3 months following cessation of tamoxifen therapy. The GTG does however state that pregnancy should be deferred for 2 years following completion of treatment of breast cancer treatment.

A patient with a history of schizophrenia for which she takes olanzapine attends the antenatal clinic at booking. Which complication of pregnancy is the most important consideration in patients taking olanzapine? a. Gestational diabetes b. Fetal anomalies c. IUGR d. Preterm labour e. Pre-eclampsia

A - Gestational diabetes

A patient with a history of renal transplant is seen in the pre-conceptual counselling clinic for a medication review. Which of the following drugs must be stopped prior to pregnancy? a. Azathioprine b. Ciclosporin c. Ramipril d. Prednisolone e. Lactulose

C - Ramipril

A 45 year old primigravida is admitted under the medical team at 37 weeks of gestation following an acute myocardial infarction. Where possible, how long should labour be delayed following acute MI? a. 48-72 hours b. 1-2 weeks c. 2-3 weeks d. 3-4 weeks e. 4-5 weeks

C - 2-3 weeks

Which of the following is the most consistent ECG finding amongst patients who suffer a myocardial infarction in pregnancy? a. ST elevation b. ST depression c. T wave inversion d. Q wave in infero-lateral leads e. Left axis deviation

A - ST elevation

A patient with hyperthyroidism presents to the day assessment unit complaining of a sore throat present for 2-3 days. Her observations are stable and she is afebrile. You note from her record that she is taking Carbimazole. What is the most important preliminary test to be performed on this patient? a. Throat swab b. Blood culture c. Thyroid function testing d. Sputum sample e. Full blood count

E - Full blood count A FBC is essential to exclude agranulocytosis in patients on carbimazole with evidence of infection

A patient with a history of severe depressive illness – including having been hospitalised twice with suicide attempts in the past – is seen in the antenatal clinic at 16 weeks of gestation. She is currently taking fluoxetine 40mg OD and reports that her mood is stable on this. What do you recommend with respect to her fluoxetine in pregnancy? a. Stop fluoxetine immediately, restart postpartum b. Suggest gradual dose reduction with a view to stopping by 28 weeks and restarting postnatally c. Stop immediately – restart from 28 weeks if mood unstable/deteriorating d. Suggest switch to sertraline 150mg e. Reassure of safety profile and continue

E - Reassure of safety profile and continue

A patient with known asthma develops persistent hypertension following a normal vaginal birth. She had no blood pressure problems during the antenatal period. She wishes to breastfeed her infant. Which of the following anti-hypertensives is most appropriate? a. Labetalol b. Nifedipine c. Ramipril d. Methyldopa e. Amlodipine

B - Nifedipine