Reproductive Health SAQs and SBAs

Question 1

A 21-year-old nulliparous woman has been diagnosed as having a left sided Ectopic pregnancy. She is going to have a laparoscopic left salpingectomy.

a) You have been asked to obtain informed consent for the procedure. Please list four operative complications that you will have to talk to the patient about.

Answer 1

i. anaesthetic risk
ii. haemorrhage
iii. infection
iv. visceral/vascular injury

Question 2

What is the number one cause of ectopic pregnancy in the UK?

Answer 2

chlamydial PID

Question 3

The patient undergoes surgery for her ectopic pregnancy; the surgeon converts to an open procedure because of multiple adhesions. On the third postoperative day you are asked to see her because of increasing abdominal pain and abdominal distension.

She looks unwell, her temperature is 38.5oC, and her pulse is 124 bpm. What are your differential diagnoses?

Answer 3

i. Bowel injury
ii. Peritonitis
iii. Pelvic haematoma

Question 4

Contraceptive advice for someone who has just had surgery for an ectopic pregnancy?

Answer 4

avoid IUCD
avoid progestogen only contraception

Question 5

1. A 30-year-old G3 P2 presents for a routine Antenatal Clinic visit at 22 weeks gestation. She is very well and the pregnancy has been progressing in a satisfactory fashion. Her last recorded pre-pregnancy blood pressure was 138/85 mm Hg. Today her BP is 88/50 mm Hg.

What is the relevant physiological adaptation mechanism?

Answer 5

Decrease in peripheral vascular resistance

Question 6

A 42-year-old G1 P0 seeks your advice regarding antenatal screening and diagnosis. She is currently nine weeks pregnant. She would like to know whether or not her baby has Down’s syndrome, and would like a test at the earliest possible opportunity.

What is the most appropriate test?

Answer 6

Chorionic villous sampling

This patient wants to know whether or not her baby is affected, that means you need to offer her a diagnostic rather than a screening test. She wishes to have a test as soon as possible; a chorionic villous sample (CVS) can be taken after 10 weeks gestation, whereas an amniocentesis is offered from 15 weeks onwards. An earlier CVS carries a risk of limb reduction defects, whereas an amniocentesis performed before 15 weeks has a higher risk of miscarriage.

Question 7

A 27-year-old nulliparous woman is undergoing investigations for infertility. Her doctor wishes to perform a blood test to confirm ovulation.

What is the most appropriate hormone to test?

Answer 7

progesterone

If ovulation occurs, the corpus luteum begins to secrete progesterone; a rise in plasma progesterone levels in the midluteal phase is therefore suggestive of an ovulatory cycle. In longer cycles the best timing for the test is one week before expected menstruation.

Question 8

A 25 year old woman presents at 30 weeks gestation with a one week history of generalised pruritus without a rash. The itching is worse at night, particularly on her hands and feet.

What first line laboratory investigations should be requested?

Answer 8

LFT and Bile acids are the first line investigations.

Further investigations areperformed if LFT and/or bile acids are abnormal

Question 9

A 33 year old primigravida is diagnosed with severe obstetric cholestasis at 36 weeks gestation. She is offered induction of labour at 37 weeks.

Which investigation should she be offered in the postnatal period?

Answer 9

postnatal LFT test
10 days after delivery.

Question 10

A 30 year old woman is 16 weeks into her second pregnancy.In her last pregnancy she was diagnosed with Obstetric Cholestasis at 36 weeks gestation.

What is her risk of OC recurrence in this pregnancy?

Answer 10

50%

Question 11

What is the increase in risk of developing VTE in pregnancy compared to the general population?

Answer 11

5 x greater risk

Question 12

Does delivery increase risk of VTE?

Answer 12

vaginal birth itself does not but instrumental delivery and C sections do

Question 13

A 39 year old woman develops left sided calf swelling and localised tenderness three days after a forceps delivery. Doppler Ultrasound confirms the diagnosis of DVT. She is commenced on appropriate treatment.

What additional advice should she be given?

Answer 13

In a future pregnancy, she should be started on thromboprophylaxis (LMWH as DOACs should be avoided in pregnancy)

Question 14

What would be the most appropriate first line management for PPH due to atony after ABCDE approach?

Answer 14

Empty bladder, rub up contraction, commence Oxytocin infusion

Question 15

A 24 year old primigravida is undergoing an emergency Caesarean section, but is bleeding excessively. She is managed with bi-manual compression, oxytocin, Ergometrine, and a Bakri Balloon is inserted before her abdomen is closed.
As the bleeding is still ongoing, further drug treatment is required.

Which of the following drugs is LEAST LIKELY to reduce the bleeding?

A. Carboprost
B. Mefenamic acid
C. Misoprostol
D. Recombinant factor VIII
E. Tranexamic acid

Answer 15

Mefenamic acid - no role in PPH mx

Question 16

A 29 year old primigravida presents to the Maternity Assessment Unit at 33 weeks because she feels she has been leaking clear fluid. Fetal movements are reported to be normal.
On speculum examination the cervix appears to be dilated to around 4 cm, and liquor is seen to be pooling in the posterior fornix.

Which first line treatment should be offered as soon as possible?

Answer 16

Maternal corticosteroids for fetal lung maturation

Question 17

A 22 year old primigravida is referred to the Antenatal clinic by her midwife, because of a symphysis fundal height (SFH) of 24 cm at 28 weeks gestation.
Fetal movements are reported to be normal.
She has no significant personal or family history. Her BMI is 18. Her BP is 122/74 mmHg, urinalysis is clear.

What would be the most appropriate next step in her management?

Answer 17

An ultrasound scan for fetal growth

Inpatient monitoring is unlikely to be of benefit unless there is a fetal concern identified on USS, such as abnormal umbilical artery Doppler or oligohydramnios.

Question 18

Baseline investigations for mild hypertension and proteinuria in pregnancy?

Answer 18

FBC, U&E, LFT, Protein/creatinine ratio

A coagulation profile may be appropriate in moderate to severe hypertension

Question 19

A 44 year old woman is referred to MAU having just had a fetal growth USS. The estimated fetal weight is on the 4th customised centile for gestational age. She is currently 28 weeks pregnant.
The ultrasound scan was arranged as part of her GROW Pathway, because she had a small baby in her last pregnancy.

What further basic information do you require before you can generate a management plan to discuss with a senior Obstetrician?

Answer 19

Maternal perception of fetal movements (? reduced), BP and urinalysis (? pre-eclampsia), fetal amniotic fluid volume, fetal Doppler (fetal wellbeing)

this will help you determine whether outpatient or inpatient care is required

Question 20

How many antenatal visits with her midwife should women have over the course of pregnancy?

Answer 20

7 visits for low risk multiparous woman and 9 visits for nulliparous woman

Question 21

A 23 year old woman is booking for antenatal care at 9 weeks gestation in her first pregnancy. She is fit and well and has no significant PMHx. Her midwife discusses her antenatal care plan and visits with her.

When will she be seen by an Obstetrician?

Answer 21

She will be referred for obstetric led care if there is any concern

For low risk healthy women with uncomplicated pregnancies, Midwife- and GP-led models of care should be offered

Question 22

A 35 year old nulliparous woman attends the antenatal department at her local hospital at 12+2 weeks gestation for a combined screening test.
What are the components of the test she is being offered?

Answer 22

Serum B-HCG, PAPP-A, Nuchal translucency

Question 23

A 40 year old primigravida chooses to have antenatal screening for Down’s syndrome. She is offered the combined test at 11+4 weeks gestation - the result suggests a Down’s syndrome risk of 1:100.
She is very concerned and wants to find out as soon as possible whether her baby actually does have Down’s syndrome.

What would be the most appropriate advice for this patient?

Answer 23

She should be offered chorionic villous sampling.

Amniocentesis is offered after 15 weeks of pregnancy as early amniocentesis is associated with higher complication rates. Given that she wishes to have a definitive answer as soon as possible, a CVS can be offered sooner (from 10 weeks gestation).

Question 24

A woman is diagnosed with breech presentation at 36 weeks gestation in her second pregnancy. She had a previous uncomplicated vaginal delivery.On USS the placenta is not low and there are no concerns about fetal growth.

How should she be managed?

Answer 24

All low risk women with breech presentations should be offered ECV after 36 weeks. If the woman declines ECV or if ECV is not successful, she should be offered CS at 39 weeks.
Induction of labour is contraindicated for breech presentation.

Question 25

Commonest causes of secondary PPH?

Answer 25

Endometritis and retained placental or membrane tissue

Question 26

Which is the appropriate advice regarding management of labour at home?

Answer 26

Mum will be offered intermittent auscultation of the fetal heart in first and second stage of labour

USS assessment is not required before labour unless there is uncertainty regarding presentation

Continuous CTG is offered in complicated pregnancies only

Question 27

What is the added risk of miscarriage with amniocentesis beyond the background population risk?

Answer 27

1:100

Question 28

Intra-partum bleeding or meconium stained liquor suggests need for what?

Answer 28

Continuous CTG to monitor for foetal compromise

Question 29

A 32 year old nullipara is in spontaneous labour at term. She has made good progress since admission to the Labour Ward, and the cervix is now 8 cm dilated.

On CTG, late decelerations have been observed over a period of 30 minutes.

What would be the next step in the management of her case?

Answer 29

Perform fetal blood sampling to exclude foetal compromise

Question 30

A 36 year old woman attends her GP surgery three weeks after giving birth, because of excessive tiredness and difficulty sleeping. She is a single mother, as her partner left her 2 weeks before the baby’s birth. She is concerned that she is not a good mother.

The GP notes in her records that she has a history of mild depression, and that she attended the surgery in the previous week and expressed the same concerns.

Which is a red flag in the patient’s history?

Answer 30

Repeated expression of incompetency as a parent -persistent expressions of inadequacy is a red flag for a Perinatal Mental Health illness.

Question 31

A 32 year old woman presents to the Emergency Department with SOB, abdominal discomfort and vomiting. She is undergoing IVF treatment and had an embryo transfer one week ago.
What is the most likely diagnosis?

Answer 31

Ovarian hyperstimulation syndrome which is known complication of assisted reproductive technique .

Release of vasoactive substances such as interleukins,
tumor necrosis factor-α, endothelin-1, and VEGF
secreted by the ovaries results in increased capillary permeability resulting in ascites, ovarian enlargement and in severe cases pleural effusion.

Question 32

A 31 year old woman who is a Para 2 presents to her GP to discuss family planning. She plans to go travelling for a few weeks and wants to have reliable contraception. She admits that she is forgetful with pills. Her last pregnancy was unplanned and occurred whilst she was using a coil. Her recent pelvic scan was reported to be normal.
What would be the best contraceptive for her?

Answer 32

Depo Provera injection which provides effective contraception for 3 months with no increased risk of thrombosis which could easily be administered at her GP surgery.

Question 33

A 25 year old woman presents to the Emergency Department because of vaginal bleeding. She is 6 weeks into her first pregnancy.
Whilst she is being admitted, she feels a large gush of blood and starts feeling dizzy and faint. Her blood pressure 88/49 mmHg and her pulse is 48 bpm.
She is immediately cannulated, and bloods are taken for FBC and G&S.

What is immediate management steps should be taken next?

Answer 33

Start IV fluids and remove clots from cervix.

POC and clots lodged in the cervical canal induce a vasovagal response, resulting in hypotension and bradycardia (so called cervical shock).

Immediate action to remove any clot or tissue from the cervix will result in rapid resolution of the symptoms.

Question 34

A 40 year old primigravida attends EPAU at 8 weeks gestation, having had some light, painless spotting.
She undergoes a pelvic ultrasound scan. The report reads as follows:

“The uterus is enlarged and cavity is distended with diffusely thickened tissue with cystic appearance, ? placenta. There is no obvious gestational sack. Both ovaries appear normal.”

What is the USS diagnosis of her condition?

Answer 34

Molar pregnancy

Question 35

A 27 year old woman is attending EPAU with a two day history of left sided pelvic pain. She had PID at 18 years of age but has no other medical history.

Her pelvic ultrasound scan report suggests a normal sized uterus with normal endometrium. Both ovaries are normal. Next to left ovary there is 3 cm mass with a doughnut shaped structure within. There is minimal free fluid in pelvis.

What is the dx?

Answer 35

Ectopic pregnancy

Empty uterus and an adnexal mass with doughnut shaped structure is diagnostic of ectopic pregnancy. It is unruptured which is why there is not much fluid in the pelvis.

Question 36

A 25 year old woman presents to GAU with acute onset of pelvic pain in her LLQ. She had episodes of short lasting, milder pain over the last 24 hours, but 4 hours ago the pain suddenly became constant and severe. Simple analgesia made no difference to the pain. She is feeling nauseous, but has no bowel symptoms.

Her menstrual cycles are regular with 5/28 pattern. Her last period was 18 days ago.

What would be the most likely cause of her pain?

Answer 36

Ovarian cyst torsion.

Pain is most likely due to adnexal torsion- typically there would be intermittent pain preceding the constant pain of torsion, as the cyst may rotate somewhat before full torsion occurs.

Question 37

What is the most effective long acting reversible contraceptive? (LARC)

Answer 37

Nexplanon Progestogen only implant
<1 in 1000 over 3 years

Question 38

True or false: HSV Type 2 infection recurs more frequently than HSV Type 1 in the first 12 months following a primary episode

Answer 38

True

Question 39

True or false: Urinary retention is a potential complication of primary Herpes infection

Answer 39

True

Question 40

True or false: Genital herpes cannot be passed on if no ulcers are present

Answer 40

False

Question 41

Is partner notification required for genital warts?

Answer 41

No

Question 42

True or false: A woman with a clinical diagnosis of PID who has persistent pelvic pain after 3 days of treatment should have her IUD removed

Answer 42

True

Question 43

A 19 year old gay man presents to the Sexual Health Clinic with a three-day history of yellow muco-purulent urethral discharge and dysuria. The Gram-film of urethral smear shows excess polymorphs and Gram-negative intracellular diplococci.

What treatment should commence whilst awaiting infection testing results?

Answer 43

Ceftriaxone 1g I/M stat

hx suggests gonorrohea

Question 44

small, dome shaped papules on genitalia with central depression = ?

Answer 44

Genital Molluscum contagiosum

caused by a pox virus infection, spread by contact, so can be, but is not always, a sexually transmitted infection.

Question 45

genital warts, that are typically single or multiple painless, flesh coloured lesions = ?

Answer 45

Condyloma acuminata

Question 46

highly-infectious wart like lesions suggestive of secondary syphilis = ?

Answer 46

Condylomata lata

Question 47

non-pathological, visible
sebaceous glands on the genital area = ?

Answer 47

Fordyce spots

Question 48

Chances of natural conception for a patient with no medical hx, with regular unprotected intercourse, after one year of trying?

Answer 48

80%

Question 49

Most common causes of infertility in the UK?

Answer 49

30% = male factor
25 % = anovulation
25% = unexplained
20% = tubal factor

Question 50

How common is pain at Caesarean section scar site due to nerve entrapment?

Answer 50

Pfannenstiel scar pain due to nerve entrapment is reported as 3.7%.

Question 51

37 year old with amenorrhoea for a year with FSH ≥40 IU/L =?

Answer 51

Premature Ovarian Insufficiency

repeat FSH test 8 weeks later

Question 52

A 25 year old woman attends her GP surgery as she finds herself pregnant.
She does not wish to continue the pregnancy, as she has just started a new job and her relationship has broken down.

What would be the next step to take in her management?

Answer 52

Arrange to see a counsellor within a few days to discuss options, including continuation of pregnancy, and available support, before arranging an appointment with Gynaecology service in the following week.

Question 53

A 15 year old school girl, who is 6 weeks pregnant, is referred to Fertility control services by the Family planning clinic for termination of pregnancy. Her family is not aware of the pregnancy.

Which of the following is true regarding consent in this patient?

Answer 53

She can give consent according to Fraser guidelines

Question 54

A 42 year old woman attends the Gynaecology clinic because of some bleeding between her periods. She has regular menstrual cycles 5/28 with normal blood loss, that are not painful. She is not sexually active and is not using any contraception. She had a normal cervical smear last year.

What is the most likely cause of her intermenstrual bleeding?

Answer 54

Endometrial polyp

Question 55

Tx for patient struggling with menorrhgia due to fibroids who is trying to conceive?

Answer 55

Tranexamic acid

Question 56

most common congenital human bleeding disorder?

Answer 56

Von Willebrand disease

detected most commonly in younger women when investigating for idiopathic menorrhagia

Question 57

According to NICE, consider an LNG-IUS as the first treatment for HMB in women with:

Answer 57

no identified pathology
or
fibroids less than 3 cm in diameter, which are not causing distortion of the uterine cavity
or
suspected or diagnosed adenomyosis

Question 58

A 39 year old Para 3 with a long standing history of menorrhagia is attending the Gynaecology clinic for follow up after dx of mutliple fibroids.
She was managed with Tranexamic and Mefenamic acid, with no success. She has been sterilised and is not keen for hormonal treatment of her condition.

What would be the most appropriate and least invasive long-term treatment option for her?

Answer 58

Fibroid Embolisation

Least invasive management is fibroid embolisation via interventional radiology.
Almost 90 % of women experience either significant or complete resolution of their fibroid-related symptoms following embolisation.

Question 59

A 14 year old girl is brought to the Emergency Department by her mother because of severe abdominal pain.
She has not started her period yet, but on examination she has normally developed secondary sexual characteristics. On genital inspection there is a bulging bluish membrane is visible at the vaginal introitus.

Dx?

Answer 59

imperforate hymen

Imperforate hymen resulting in collection of blood in vagina usually presents with cyclical pain against a background of primary amenorrhoea. Due to pressure effects on bladder and rectum, it can present also with urinary retention/ diarrhoea /constipation.

Question 60

How do you calculate RMI for ovarian cancer?

Answer 60

U x M x CA125

U is 1 for 0–1 abnormal USS findings and 4 for 2 or more abnormal USS findings

M=1 in pre-menopausal women and 4 for post-menopausal women

The serum level of CA125 is directly entered in the formula

Question 61

Patient presents with vulval pruritus. On clinical examination her vulva has an atrophic appearance, with loss of architecture and fusion of the labia over the clitoris.

most likely dx?

Answer 61

lichen Sclerosus et atrophicus

LSA is an autoimmune chronic inflammatory skin disorder that most commonly affects women before puberty or after menopause

most common distribution is a figure of 8 involving the vulva and perianal area

increased risk of vulval cancer

Question 62

Which combination of tumour markers should be performed in a patient with suspected dermoid cyst?

Answer 62

Alpha fetoprotein , LDH and HCG