Sba 1 Obstetric

Question 1

You see a 20-year-old G1P0 with a diagnosis of genital herpes in pregnancy. What is the
gestational age at which a primary infection occurs that the risk of transmission to the
baby is greatest?

Answer 1

Third trimester (34–40weeks)

Question 2

You admit a woman at 40weeks of gestation in labour with confirmed genital herpes.
Thisis thought to be a primary infection. Sheis offered an emergency CS that she refuses.
How will you manage this patient?

Answer 2

Commence her on intravenous aciclovir and also offer the neonate intravenous aciclovir

Question 3

An elective caesarean section is being performed on a 30-year-old Rhesus D negative
pregnant woman at 37weeks of gestation for placenta praevia (major). Arrangements
were made and she is receiving intraoperative cell salvage (ICS) transfusion. What would
be the plan with regard to Rhesus D prophylaxis in this woman assuming the baby’s
blood group is unknown?

Answer 3

Administer 1500IU anti-D Ig and then take a sample of maternal blood 30–45min after
ICS infusion

Question 4

What is the recommended regimen for anti-D prophylaxis for a 26-year-old Rhesus D
negative woman who is notsensitized?
A. 500IU Ig at 28weeks of gestation
B. 500IU Ig anti-D at 34weeks of gestation
C. 1000IU Ig anti-D at 28weeks gestation
D. 1500IU Ig anti-D at 28weeks gestation
E. 1500IU Ig anti-D at 28 and 34weeks of gestation

Answer 4

1500IU Ig anti-D at 28weeks gestation
OR : two-dose regimen of 500IU Ig given at 28 and 34weeks

Question 5

A 20-year-old RhD negative woman presents with bleeding at 11 weeks of gestation.
When will you consider administering anti-D Ig prophylaxis to this woman?
A. Shegoes on to have a complete miscarriage
B. Thebleeding is heavy but is stopping
C. Thebleeding is repetitive or associated with pain
D. Thebleeding is small and painless
E. If this is a threatened miscarriage and the bleeding is stopping

Answer 5

Thebleeding is repetitive or associated with pain

Question 6

A28-year-old primigravida was admitted with an undiagnosed breech and opted to try
for a vaginal delivery after counselling. What is the best indication that a cephalic-pelvic
disproportion is unlikely to happen?
A. Aclinically adequate pelvis
B. An estimated fetal weight that is less than 3800g
C. Afrank breech presentation
D. Good progress to full dilatation
E. Simultaneous easy passage of the fetal thighs and trunk through the pelvis

Answer 6

Simultaneous easy passage of the fetal thighs and trunk through the pelvis
* Afrank presentation is the best type of breech presentation for a successful vaginal birth followed
by a complete breech. Afootling or kneeling breech is a contraindication for a vaginal breech birth

Question 7

You have been called to the delivery of a 30-year-old primigravida who is pushing.
Thebaby is in the breech position. Themidwife is conducting the breech delivery and the
head of the baby is trapped behind the cervix, which is only 8 cm dilated. What action
will you take to deliver the head?

Answer 7

Incise the cervix at 3 and 7o’ clock positions
* Other options are symphysiotomy or CS, but these are only applicable where the cervix is fully dilated

Question 8

You have counselled a 30-year-old primigravida at 35weeks of gestation with a breech
presentation, and she agrees to an external cephalic version. You have scheduled this
procedure at 36weeks of gestation. What success rate will you give this woman?

Answer 8

38%–45%
* Multipara> nullipara

Question 9

What is the Lovset’s manoeuvre in breech vaginal delivery ?

Answer 9

rotation of the trunk of the foetus during a breech birth to facilitate delivery of the extended foetal arms and the shoulders

Question 10

Inthe conduct of a breech vaginal delivery, what manoeuvre should be used in delivering
the arms?

Answer 10

Lovset’s manoeuvre

Question 11

What is the Mauriceau–Smellie–Veit manoeuvre in breech vaginal delivery ?

Answer 11

suprapubic pressure by one obstetrician on the mother/uterus, while another obstetrician inserts left hand in vagina, palpating the fetal maxilla using the index and middle finger and gently pressing on the maxilla, bringing the neck to a moderate flexion.

Question 12

What is the Burns-Marshall technique in breech vaginal delivery ?

Answer 12

allowing the breech to ‘hang’ by its weight until the nape of the neck (or the ‘hair-line’) is visible

Question 13

What is the Bracht manoeuvre in breech vaginal delivery ?

Answer 13

After the arms are delivered, the infant is grasped by the hips and lifted with two hands toward the mother’s stomach

Question 14

Aschool teacher who is 10weeks pregnant reports contact with one of her pupils who has
chickenpox. When would you say this child was infectious?

Answer 14

48h before the rash appeared and until it crusted (usually after 5days)

Question 15

What advice would you give a 20-year-old woman from Nigeria at her booking visit at
12weeks of gestation who has a history of nothaving had chickenpox in the past?
A. To avoid contacts with anyone with chickenpox
B. To contact her GP if she has a rash
C. Reassure her as she is likely to have had the infection without knowing about it
D. To undertake serum screening for VZV immunoglobulin G (IgG)
E. To immediately inform a healthcare worker of a potential exposure to chickenpox

Answer 15

To undertake serum screening for VZV immunoglobulin G (IgG)

Question 16

Apregnant woman in her 24th week of gestation reports contact with a friend who previously has shingles/herpes zoster. What type of shingles poses the greatest risk to this
woman if she is susceptible ?

Answer 16

Ophthalmic shingles

Question 17

A29-year-old G3P1 delivered a full-term male infant 3days after she developed a chickenpox rash. Shewas commenced on oral aciclovir soon after the rash appeared. How will
you manage the baby?
A. Advise against breastfeeding for 4days
B. Administer VZIG IgG to the baby
C. Administer VZIG IgG to the baby with or without oral aciclovir
D. Educate the mother on the warning signs of varicella infection in the neonate and discharge

Answer 17

Administer VZIG IgG to the baby with or without oral aciclovir
* Breastfeeding is notcontraindicated in mothers who are on aciclovir.

Question 18

You are running an antenatal clinic for women with epilepsy with a neurologist and a
midwife. You are counselling a patient about the risk of epilepsy in pregnancy and the
importance of complying with the medications. What is the strongest risk factor for sudden unexpected death in epilepsy?

Answer 18

Uncontrolled tonic-clonic seizures

Question 19

What advice should be given to a 26-year-old woman suffering from epilepsy that has
been well controlled (with no seizures for the past 2years) on sodium valproate who has
attended for pre-conception counselling?

Answer 19

Change AED to the lowest effective and least teratogenic AED dose and commence on
folic acid 5mg/day for at least 3months before pregnancy
🚫 Not necessarily lamotrigine

Question 20

A26-year-old woman was admitted into the obstetrics unit at 20weeks of gestation feeling generally unwell and with diarrhoea. Shewas being treated as a case of gastroenteritis. Shefailed to respond to treatment on admission and on the third day deteriorated
rapidly and died. Apost-mortem showed that she had died from sepsis. What has been
identified as the most common aspect of substandard care in the management of pregnant women with sepsis that results in severe morbidity or mortality?
A. Delay in instituting appropriate antibiotic therapy
B. Failure to institute appropriate antibiotic therapy
C. Failure to institute appropriate resuscitative measures
D. Failure of recognition of signs of sepsis
E. Failure of recognition of symptoms of sepsis

Answer 20

Failure of recognition of signs of sepsis ( not 🚫 symptoms)

Question 21

Awoman died from genital sepsis that occurred at 30weeks of gestation. Whatis the
most common site of infection associated with septic shock in pregnancy?
A. Ascending genital tract
B. Gastrointestinal
C. Pharyngeal
D. Pulmonary
E. Urinary tract

Answer 21

Urinary tract
* Urinary tract infection and chorioamnionitis are common infections associated with septic shock in the pregnant patient

Question 22

A 26-year-old pregnant woman presents with very severe constant abdominal pain of
3days duration at 30weeks of gestation. Sheis examined and found to have abdominal
tenderness. Thereare no specific localized signs. Sheis tachycardic, but her blood pressure
is normal. Theuterus is irritable, but the fetal heart is normal on cardiotocography (CTG).
Urinalysis is negative for protein, glucose, and nitrites. Sheis administered pain killers, but
the pain has remained unchanged after 24h. What is the most likely cause of the pain?
A. Degenerating uterine fibroids
B. Genital tract sepsis
C. Ovarian torsion/haemorrhage
D. Placental abruption
E. Pyelonephritis

Answer 22

Genital tract sepsis

Question 23

What recommendation does NICE make about measuring the fetal heart rate in labour?
A. That CTGs should be discontinued after 30min where it has been normal
B. That CTGs should be performed on all women in suspected or established labour
C. That CTGs should be discontinued once they have been confirmed to be normal
D. That intermittent auscultation of the fetal heart should occur every 10–15min
E. To record accelerations and decelerations if heard

Answer 23

To record accelerations and decelerations if heard
* intermittent auscultation : every 15 to 30 minutes in active labor and every 5 minutes in the second stage of labor.
*

Question 24

Themidwife is admitting a woman into the alongside midwifery unit in your maternity
hospital. What feature in her initial assessment will warrant a transfer of this low-risk
woman to an obstetric unit?
A. Apulse of over 110beats/min on two occasions 30min apart
B. Asingle diastolic reading of 100mmHg or more or raised systolic BP of 150mmHg or more
C. Either raised diastolic BP of 90mmHg or more or raised systolic BP of 140mmHg or
more on 2consecutive readings taken 30min apart
D. Rupture of fetal membranes 12h before onset of established labour
E. Thepresence of single strands of meconium

Answer 24

Either raised diastolic BP of 90mmHg or more or raised systolic BP of 140mmHg or
more on 2consecutive readings taken 30min apart
* Apulse of over 120beats/min on two occasions 30min apart
* Asingle diastolic reading of 110mmHg or more or raised systolic BP of 160mmHg or more
* Rupture of fetal membranes 24h before onset of established labour
* Thepresence of significant meconium
* a temperature of 38°C or above on a
single reading or 37.5°C or above on 2consecutive readings 1h apart

Question 25

What are the fetal features in the initial assessment will warrant a transfer of a low-risk
woman to an obstetric unit?

Answer 25

1- Thefetal indications include any abnormal
presentation, including cord presentation, transverse or oblique lie .
2- high (4/5–5/5 palpable) or
free-floating head in a nulliparous .
3- suspected anhydramnios or polyhydramnios .
4- fetal heart rate
below 110bpm or above 160bpm, a deceleration in FHR heard on intermittent auscultation .
5- reduced fetal movements in the last 24h reported by the woman

Question 26

You have admitted a primigravida at 41weeks of gestation contracting regularly for the
past 3h. Fetal membranes are intact. Thishas been an uncomplicated pregnancy. What is
the recommendation for monitoring the fetal heart rate as part of the initial assessment?
A. Auscultate the fetal heart at the first contact with the woman in labour and at each further
assessment
B. Auscultate the fetal heart for a minimum of 30s immediately after a contraction and
record it as a single rate (record for at least 1min)
C. Give the woman the option of having a continuous or intermittent monitoring of the fetal
heart
D. Palpate the maternal pulse to differentiate between the maternal and fetal heart if the fetal
heart rate is at a rate similar to maternal heart rate
E. Perform a CTG on admission as low-risk women in suspected or established labour to first
establish a normal heart rate

Answer 26

Auscultate the fetal heart at the first contact with the woman in labour and at each further
assessment ( hourly)
* for a minimum of 1min immediately after a
contraction
* not performing a CTG on admission for low-risk women in suspected or established labour

Question 27

A low-risk woman was admitted into the alongside midwifery unit in spontaneous
labour at 42weeks of gestation. Sheruptured her membranes spontaneously at 6cm
dilatation, and there was liquor containing lumps of meconium. She was therefore
transferred to the obstetrics unit. What precautions should be taken with this woman’s
labour and birth?

Answer 27

Ensure availability of a healthcare worker trained in advanced neonatal life support at the
time of birth
* + ensure that healthcare professionals trained
in fetal blood sampling ( not necessary taking sample)

Question 28

A25-year-old woman presents with absent fetal movements for 24h. What would be the
best method of diagnosing an intrauterine fetal death (IUFD) in this woman?
A. Acardiotocography showing an absent fetal heartbeat
B. Auscultation of the fetal heart with a sonicaid
C. Doppler ultrasound scan
D. Real-time ultrasound scan
E. Real-time ultrasound with colour Doppler

Answer 28

Real-time ultrasound with colour Doppler

Question 29

A27-year-old woman who is known to be a group B haemolytic Streptococcus carrier
has been diagnosed with an intrauterine fetal death at 34weeks of gestation. Sheis being
induced with prostaglandins and mifepristone. What management would you recommend for her group B haemolytic Streptococcus carrier status?

Answer 29

No antibiotics are indicated

Question 30

Themidwife referred an unaccompanied 30-year-old primigravida at 36weeks of gestation because she could nothear the fetal heart with a sonicaid in the community. You
have seen the patient and diagnosed an intrauterine fetal death. What would be the next
step in her management?

Answer 30

Offer to call her partner or relative or friend

Question 31

What will make you classify a 26-year-old female haemophilia carrier as obligate?

Answer 31

Her father is affected or she has an affected son and an affected relative in the maternal
line

Question 32

You see a 23-year-old woman and her 29-year-old partner who has haemophilia A.
Thereis uncertainty as to the severity of his haemophilia. What is the main difference
between the severe and the mild/moderate forms of haemophilia with regard to clinical
manifestations?

Answer 32

Those with severe haemophilia bleed spontaneously into muscles and joints, while those
with the mild/moderate forms may bleed following trauma or invasive procedures

Question 33

A26-year-old woman attends with her partner who has severe haemophilia A. Sheis
now7weeks pregnant. What advice should they be given? 🤷🏻‍♀️🤷🏻‍♀️

Answer 33

Offer fetal sexing by free fetal DNAanalysis from 9weeks of gestation

Question 34

A22-year-old woman visits for her routine anomaly ultrasound scan at 20weeks and
informs the team that her partner has severe haemophilia B. Thedetailed scan is normal, and she is informed that the fetus is a male. What advice should be offered to this
woman ? 🤷🏻‍♀️🤷🏻‍♀️

Answer 34

Prenatal diagnosis by means of amniocentesis in the third trimester
* Ideally before 34 w

Question 35

Approximately what proportion of twin pregnancies in the UK are monochorionic?

Answer 35

30 %

Question 36

Itis well recognized that monochorionic monoamniotic twin pregnancies have a higher
perinatal loss rate than monochorionic diamniotic twin pregnancies. What gestations
carry the greatest risk of perinatal loss?

Answer 36

Before 24weeks of gestation

Question 37

What type of vascular anastomoses in monochorionic twin pregnancies is most commonly associated with twin-to-twin transfusion syndrome (TTTS)?

Answer 37

Unilateral artery-vein anastomoses

Question 38

What proportion of monochorionic pregnancies are complicated by TTTs ?

Answer 38

15 %

Question 39

Atwhat gestational age is TTTS most likely to develop in monochorionic twin pregnancies?

Answer 39

16 w
* Uncommon after 26 w

Question 40

A20-year-old woman is seen at 30weeks of gestation with generalized pruritus especially
of the palms of the hands and soles of the feet. Adiagnosis of obstetric cholestasis is suspected. How common is this complication of pregnancy in theUK?

Answer 40

7–8/1000pregnancies

Question 41

A 38-year-old G1P0 presents at 31 weeks of gestation with generalized pruritus that is
notassociated with a rash. Theitching which is worse at night is on her palms and soles. Her
stools have slowly become paler, but she is notjaundiced. You suspect obstetric cholestasis
and request for a liver function test that includes bile acids. These come back as abnormal,
thus confirming the diagnosis. How often should her liver function test be monitored?

Answer 41

Every 7days

Question 42

A37-year-old woman who was diagnosed with obstetric cholestasis at 34weeks of gestation had a spontaneous induced vaginal delivery at 36weeks and 5days. Thebile acid
levels then were 45mmol/L. Shehas come back for follow-up at 8weeks post-delivery.
What should you tell her about the risk of recurrence?

Answer 42

Up to 90%

Question 43

Ithas been recognized that various events during the intrapartum period are known to
reduce the risk of operative vaginal delivery. What is the single most important factor that
has been shown to help avoid operative vaginal delivery in a 29-year-old primigravida?
A. Appropriate analgesia during labour
B. Continuous support during labour
C. Effective uterine contractions
D. Ensuring adequate maternal hydration during labour
E. Regular pelvic examination and monitoring of progress of labour

Answer 43

Continuous support during labour

Question 44

Ithas been recognized that various events during the intrapartum period are known to
reduce the risk of operative vaginal delivery. What is the single most important factor that
has been shown to help avoid operative vaginal delivery in a 29-year-old primigravida?
A. Appropriate analgesia during labour
B. Continuous support during labour
C. Effective uterine contractions
D. Ensuring adequate maternal hydration during labour
E. Regular pelvic examination and monitoring of progress of labour

Answer 44

Continuous support during labour

Question 45

A 32-year old primigravida went into spontaneous labour at 40 weeks of gestation.
Shehas an epidural for pain relief. What is the effect of delaying pushing for 1–2h on
delivery?

Answer 45

Decreased risk of rotational operative interventions

Question 46

You have examined a 28-year-old primigravida who went into spontaneous labour at
39weeks of gestation following an uncomplicated pregnancy. Shehas been fully dilated
for the past 3 h, and you feel that her labour should be expedited. The fetal head is
1/5palpable per abdomen and there is caput at 2 cm below the spines. What is the level of
the biparietal diameter in this baby?

Answer 46

Atleast 1cm above the spines

Question 47

A35-year-old primigravida whose BMI is 37kg/m2 had an uncomplicated pregnancy
and went into spontaneous labour at 39+5weeks of gestation. An epidural was sited
for pain relief. Shehas been fully dilated for the past 3.5h, actively pushed for 1.5h,
and nowappears completely exhausted. You have been asked to perform an assisted
vaginal delivery. What factor will increase the risk of her having a failed instrumental
delivery?
A. Estimated weight of 3600g
B. Her BMI
C. Right occipito-anterior position
D. Station at spines +1 and 0/5vertex palpable per abdomen
E. Two pluses of caput

Answer 47

Her BMI (< 30 )
* Estimated weight of > 4000g
* occipito-posterior position
* 1/5vertex palpable per abdomen

Question 48

AFoundation Year 2doctor sustains a needle stick injury, while you were taking her
through the suturing of an episiotomy in a woman who has just had a normal vaginal
delivery. If this woman is HIV positive, what would be the estimated risk of this trainee
acquiring the infection?

Answer 48

3per 1000injuries

Question 49

Amidwife in the unit was suturing an episiotomy of a woman who is known to be HIV
positive and sustains a needle injury. Within which period of commencing PEP is it likely
to be most effective?

Answer 49

Within 1 h of the exposure
Not beyond 72 h
* pep : post exposure prophylaxis: is the use of antiretroviral drugs after a single high-risk event to stopHIVseroconversion.

Question 50

The rationale for post-exposure prophylaxis is that viral replication can be inhibited
shortly following the exposure. Once the mucosal barrier has been breached, how long
does it take the virus to be detected in blood?

Answer 50

Up to 120h blood
* Lymph nodes 72 h

Question 51

A35-year-old primigravida complained of a breast lump when she attended the antenatal clinic for her routine visit at 24 weeks of gestation. Further investigations have
confirmed that this is indeed a malignancy. What is the impact of the pregnancy on the
prognosis of the cancer?

Answer 51

Ithas no impact on prognosis

Question 52

A36-year-old woman who is 30weeks pregnant has been referred by the midwife to the
consultant-led antenatal clinic with a lump in her left breast. You have examined and
found a discrete lump on the left breast with features suspicious of malignancy. What
should be the most appropriate investigation to offer to this woman?
A. Fine needle aspiration biopsy
B. Fluid aspiration for cytology
C. Mammography
D. Ultrasound-guided biopsy
E. Ultrasound scan

Answer 52

Ultrasound scan
( as a first step)
* Then : Tissue diagnosis is performed with ultrasound-guided
biopsy for histology rather than cytology as proliferative changes during pregnancy render cytology

Question 53

What advice should a woman who had breast cancer and wishes to conceive after completing her course of tamoxifen but has been found on imaging to have suspicious metastases in the lungs be given?

Answer 53

To avoid pregnancy as life expectancy is limited and treatment of metastasis will be
compromised

Question 54

A 24-year-old woman is admitted at 30weeks of gestation with regular uterine contractions. Thisis her first pregnancy and until nowthe pregnancy has been uncomplicated.
Sheis examined, and the cervix is found to be soft with a closed os. Adecision is taken
to give her a course of corticosteroids and to commence her on the tocolytic nifedipine.
What is the benefit of giving her nifedipine?

Answer 54

Prolongs the pregnancy by 2–7days

Question 55

Awoman books for antenatal care at 8weeks of gestation in her first pregnancy. What is
the recommendation with regard to testing for blood group and antibodies?
A. Test blood group and antibody at booking and then at 28weeks of gestation
B. Test blood group and antibody at booking and then antibody at 28weeks
C. Test blood group and antibody at booking, 28 and 36weeks
D. Test blood group and antibody at booking and then blood group at 28weeks
E. Test blood group and antibody at booking and 28weeks and then antibody at 36weeks

Answer 55

Test blood group and antibody at booking and then at 28weeks of gestation

Question 56

What is severe postpartum haemorrhage?

Answer 56

Blood loss of more than 2000mL
minor (500–1000 mL) or major (>1000mL)
Major ; subdivided into moderate (1001–2000 mL) and severe (>2000mL).

Question 57

What is the most common cause of primary postpartum haemorrhage?

Answer 57

Disorders of tone
* Causes of PPH can be grouped under the ‘four Ts’, which include tone, tissue, thrombin and trauma.

Question 58

A35-year-old primigravida presents with a sudden onset of epigastric pain that is radiating to the back. Prior to this, she had been seen repeatedly with right hypochondrial
pain. Sheis now30weeks pregnant. Her BP at the last antenatal clinic visit was normal.
Sheis apyrexial, but tachycardic (pulse: 110bpm) and hypotensive (BP=80/50mmHg).
What is the most likely diagnosis?
A. Abruptio placenta
B. Hepatic rupture
C. Pre-eclampsia
D. Rupture of aortic aneurysm
E. Splenic rupture

Answer 58

Hepatic rupture

Question 59

An ST4 is performing an elective CS at 39weeks of gestation with assistance by a FY2 on
a G2P1. Theindication for the CS is breech presentation. On opening the abdomen and
exposing the uterus, she discovers that the lower segment is extremely vascular. Theplacenta had been localized to be anterior and notlow on ultrasound scan at 20 weeks of
gestation. What action should she take?

Answer 59

Call consultant before proceeding to make an incision on the uterus

Question 60

What is the most important risk factor for postpartum sepsis?
A. Asymptomatic bacteriuria
B. Caesarean section
C. Manual removal of the placenta
D. Pre-labour rupture of fetal membranes
E. Prolonged labour

Answer 60

Caesarean section

Question 61

Acouple are anxious about the risk of their baby being born with an inherited autosomal
recessive condition. Their anxiety stems from the fact that their relative recently had a
baby with an autosomal recessive condition. Theywant to know what the most common
autosomal recessive condition worldwide is?

Answer 61

Beta-thalassaemia

Question 62

Theywant to know what the most common
autosomal recessive condition among Caucasians in Europe is?

Answer 62

cystic fibrosis.

Question 63

You are counselling a patient about pre-implantation genetic diagnosis (PGD). Theyhave
been told that there is a risk of them having a baby with an autosomal recessive condition.
What is a characteristic of an autosomal recessive condition?
A. Both parents have to carry the abnormal gene for their children to be affected
B. Half of the offspring will be affected by the condition
C. Theytend to be less severe and life-threatening
D. Theaffected individual needs to have only one copy of abnormal gene for the disease to
be expressed
E. Therisk to the offspring of an affected parent is 1:4

Answer 63

Both parents have to carry the abnormal gene for their children to be affected

Question 64

A27-year-old primigravida is admitted at 35weeks of gestation with a blood pressure
of 110/110 mmHg, severe proteinuria and brisk reflexes. She also has headaches and
visual disturbances. She had a kidney transplant 2 years ago and was switched from
an angiotensin-converting enzyme inhibitor (ACEi) in early pregnancy to labetalol. You
have decided to commence her on magnesium sulphate (MgSO4) having sent a blood
sample for an urgent renal function test because she has hardly voided in the last 6h.
What would be the regimen you will start with?

Answer 64

4g loading dose followed by 0.5g/h
* Theloading dose (4g) should be given irrespective of the renal function but maintenance infusion levels should be halved in those with significant renal impairment and/or oliguria.

Question 65

You are planning to induce a renal transplant recipient at 38weeks of gestation. Shehas been
taking 10mg of prednisolone throughout pregnancy. Her renal function is stable and her BP
is well controlled on labetalol. What additional precautions should you take in labour?

Answer 65

Commence her on intravenous hydrocortisone at a dose of 50–100mg every 6–8h
* Women taking more than 7.5 mg prednisolone per day for more than 2 weeks during pregnancy require intravenous hydrocortisone (50–100 mg every 6–8h) during labour and until they
are able to tolerate oral medication.

Question 66

A25-year-old woman who had kidney transplant 2years ago wishes to embark on pregnancy.
Her graft function has been stable but she has significant proteinuria and is on an ACEi for
the control of hypertension. What advice should she be given?
A. Continue to ACEi until a positive pregnancy test and then reassess need for treatment and
if required offer a non-teratogenic option
B. Continue with ACEi until a positive pregnancy test, switch to a non-teratogenic option but
recommence after 12–14weeks
C. Stop the ACEi
D. Stop ACEi and recommence after 12weeks of gestation
E. Switch from the ACEi to another antihypertensive that is notteratogenic

Answer 66

Continue to ACEi until a positive pregnancy test and then reassess need for treatment and
if required offer a non-teratogenic option
* Thenon-proteinuria hypertensives can switch to alternative antihypertensives prior to pregnancy, but those with significant proteinuria maybe reluctant to lose their renal
protection for the unknown length of time it takes to successfully conceive

Question 67

A30-year-old woman has been diagnosed with acute kidney injury following an obstetric
complication. What is the most common cause of acute kidney injury in obstetrics?

Answer 67

Pre-eclampsia ( 1.4 % of the cases )
HEIIP ( 14 % of the cases)

Question 68

A30-year-old G3P0 type I diabetic who has been on an insulin pump from 4 months
before pregnancy is admitted for induction of labour at 38 weeks of gestation. What
would be management plan once she is in established labour?
A. Allow labour to progress without the need to monitor as the pump adjusts her insulin
requirement
B. Commence her on an insulin sliding scale
C. Continue with the insulin pump but monitor blood glucose when appropriate
D. Discontinue the insulin pump
E. Increase the basal insulin dose and continue with the maintenance dose

Answer 68

Continue with the insulin pump but monitor blood glucose when appropriate

Question 69

A 36-year-old woman who suffers from ulcerative colitis (UC) that was refractory to
standard treatment was commenced on the biologic agent infliximab. Shecontinued with
this medication throughout the pregnancy. What is the main impact of this on the management of the mother and baby after delivery?

Answer 69

No live vaccines should be administered to the baby for the first 6months
( Should ideally be discontinued at 32w of Pregnancy)

Question 70

A 30-year-old woman who suffers from an active inflammatory bowel disease (IBD)
reports that she is pregnant. Sheis currently taking sulfasalazine therapy. What is the
likely course of the IBD in the pregnancy?
A. Itis likely to become more active during pregnancy
B. Itis likely to remain active
C. Itis likely to respond better to treatment than outside pregnancy
D. Thecourse tends to be fluctuating between remission and active disease
E. Thereis a higher chance of remission

Answer 70

Itis likely to remain active
*( It’s better to be in remission for 6 months before conception)
* Rheumatoid arthritis 👉 Thereis a higher chance of remission
* systemic lupus 👉 Itis likely to become more active during pregnancy

Question 71

What is the estimated detection rate for trisomy 21 when nuchal translucency, absence
of the nasal bone, raised ductus venosus Doppler, tricuspid regurgitation and maternal
serum biomarkers are combined at 11–13weeks of gestation?
A. 88% for a false positive rate of 5%
B. 90% for a false positive rate of 5%
C. 95% for a false positive rate of 3%
D. 97% for a false positive rate of 3%
E. 99% for a false positive rate of 5%

Answer 71

95% for a false positive rate of 3%
* biochemistry (serum free-β-hCG and PAPP-A), + soft markers
* Biochemistry alone 5% false positive

Question 72

A29-year-old woman with twins is seen for her combined first-trimester aneuploidy scan
at 12weeks of gestation. Why will the false positive rate of her test be twice as high as in
singleton pregnancies?
A. One of the twins is hydropic
B. Thetwins are dichorionic
C. Thetwins are monochorionic
D. Thereis demise of one twin
E. Thereis a significant difference in CRL measurements

Answer 72

Thetwins are monochorionic
* Indichorionic twins, an individual risk is given for each fetus, but in monochorionic twins, the risk is calculated for each fetus and an average of the two is given for the whole pregnancy .

Question 73

Atwhat ferritin level should chelation be considered in a 30-year-old woman with a haemoglobinopathy who has had repeated blood transfusions and wishing to become pregnant?

Answer 73

> 1000µg/L
* Chelation therapy may start after 10–20 transfusions or when the serum ferritin level exceeds
1000µg/L

Question 74

After approximately how many transfusions should chelation be considered in a 33-yearold woman with haemoglobinopathy who is desirous of starting a family?

Answer 74

10–20

Question 75

Which hormone is responsible for reducing the water content of stools during pregnancy
and thus making them harder?
A. High circulating aldosterone
B. High circulating oestrogen levels
C. Motilin
D. Renin
E. Somatostatin

Answer 75

High circulating aldosterone

Question 76

A20-year-old woman is seen at 8weeks of gestation complaining of chronic constipation since she missed her last period. Her bowels open twice a week and furthermore
she strains for more than 25% of the time when she defaecates. Shehas been prescribed
a hyperosmolar laxative. What is the most unwanted side effect of this medication for
this woman?

Answer 76

Abdominal bloating and flatulence

Question 77

A30-year-old woman with three previous mid-trimester miscarriages has been referred
for the assessment for an abdominal cerclage. What will be the indication for an abdominal cerclage in this patient?
A. Previous failed McDonald suture
B. Previous failed Shirodkar suture
C. Shehas a short vaginal cervix
D. Shehas had a previous cone biopsy
E. Thecervix is grossly disrupted

Answer 77

Thecervix is grossly disrupted
* or an absent vaginal cervix. Apreviously failed vaginal cerclage may be an indication .

Question 78

A29-year-old woman who has had two mid-trimester miscarriages had a transabdominal
cerclage with a posterior knot at 11weeks of gestation. She presents at 19weeks of gestation with a brownish vaginal loss and disappearance ofpregnancy signs of 3days duration. An ultrasound scan confirms an intrauterinefetal death of 18weeks of gestation.
How best will she be managed?
A. Hysterotomy and leave stitch in-situ
B. Posterior colpotomy to remove stitch and offer suction evacuation
C. Remove the stitch by laparotomy and induce delivery
D. Remove the stitch by posterior colpotomy and induce delivery
E. Remove the stitch laparoscopically and induce delivery

Answer 78

Remove the stitch by posterior colpotomy and induce delivery

Question 79

You are seeing a 29-year-old woman in the clinic for counselling. She has had four
mid-trimester miscarriages and the last two followed a failed vaginal cerclage (one a
McDonald suture and the other a Shirodkar suture). When she was examined at her last
clinic visit, there was very little vaginal cervix. Sheis now6weeks pregnant. What would
be the approach to minimize the risk of miscarriage in this woman?

Answer 79

Offer a transabdominal cerclage at 10–11weeks

Question 80

A30-year-old woman attends at 12weeks for a nuchal translucency measurement as part
screening for aneuploidy. What approximate detection rate for trisomy 21using nuchal
translucency alone will you quote to this woman?

Answer 80

77 %
* 85%–90% for a combined first-trimester
test using measurement of NT and placental protein markers, free β-hCG and pregnancy-associated
plasma protein (PAPP-A) for a false positive rate of approximately 5%

Question 81

A33-year-old primigravida is seen for booking at 10weeks gestation. Following counselling, she opts for the integrated test for aneuploidy. What is the main advantage of this
test over the first-trimester screening test?
A. Ithas a lower false-positive rate
B. Ithas a higher detection rate for aneuploidy
C. Itis more cost-effective
D. Ithas a better acceptance by patients
E. Itis less time-consuming

Answer 81

Ithas a lower false-positive rate
*. integrated test : combines first-trimester maternal serum PAPP-A and fetal nuchal translucency with second-trimester quad screening

Question 82

An ultrasound is performed at 14weeks of gestation in a 27-year-old primigravida, and
it shows a singleton viable pregnancy and an adnexal mass. What feature on this ultrasound scan will be helpful in distinguishing between an invasive and a benign cystic
adnexa mass?

Answer 82

Thepresence of the ‘ovarian crescent sign’

Question 83

A24-year-old woman is seen at 18weeks of gestation having been inadvertently treated
by her GP with the tetracycline derivative doxycycline for a suspected infection in the
first trimester. Sheis anxious about this treatment. What should she be told about the
risk of this treatment to the pregnancy?

Answer 83

Itis notassociated with an increased risk as used in the first trimester
* Thetetracycline doxycycline is contraindicated beyond the 15th week of pregnancy as it causes tooth
and bone discolouration and inhibits bone growth. Inadvertent use of tetracycline in the first trimester is notassociated with an increased risk of congenital malformations

Question 84

What is the most common adnexal cystic lesion diagnosed after 16weeks of gestation?
A. Corpus luteum cyst
B. Follicular cyst
C. Haemorrhagic cysts
D. Luteoma of pregnancy
E. Matured cystic teratoma

Answer 84

Matured cystic teratoma ( dermoid )
* < 6 cm asymptomatic
6-8 cm are prone to torsion

Question 85

Approximately what percentage of women of child-bearing age is affected by epilepsy?
A. 0.1%–0.5%
B. 0.5%–1.0%
C. 1.0%–1.5%
D. 1.5%–2.0%
E. 2.0%–2.5%

Answer 85

0.5%–1.0%

Question 86

What is the effect of epilepsy on maternal mortality?
A. Itdoubles the maternal mortality
B. Increases it by up to 5times
C. Increases it by up to 10times
D. Increases it by up to 3times
E. Increases it by up to 6–7times

Answer 86

Increases it by up to 10times

Question 87

A 25-year-old woman on high doses of sodium valproate reports that she has unexpectedly fallen pregnant. Sheis currently 8weeks pregnant. What would be your next
management plan?
A. Commence her on high-dose folic acid (5mg daily), stop the sodium valproate and commence on lamotrigine
B. Commence on high-dose folic acid (5mg daily), stop sodium valproate and commence on
levetiracetam
C. Commence on high-dose folic acid (5mg daily), stop sodium valproate and commence on
levetiracetam and refer for urgent neurological review
D. Commence on high-dose folic acid (5mg daily), stop sodium valproate and refer to neurologist for review
E. Commence on high-dose folic acid (5mg daily) and recommend continuation of sodium
valproate but refer urgently to neurological review of medication

Answer 87

Commence on high-dose folic acid (5mg daily) and recommend continuation of sodium
valproate but refer urgently to neurological review of medication

Question 88

A20-year-old primigravida has been diagnosed with diabetes insipidus at 20weeks
of gestation. What is the most likely biochemical abnormality associated with this
condition?

Answer 88

Hypernatraemia
* Diabetes insipidus is the failure of the renal tubules to conserve water. If notcorrected, this can lead to symptoms of polydipsia and dilute polyuria and can result in hypernatraemic dehydration

Question 89

A30-year-old pregnant woman has had a cardiac arrest and is undergoing cardiopulmonary resuscitation (CPR). When should a perimortem caesarean section be considered in
this woman?

Answer 89

Sheis greater than 20🙌weeks pregnant, and correctly performed CPR has failed to result
in rapid return of spontaneous of circulation (ROSC) after 4 🙌min

Question 90

What is the ideal time within which a perimortem caesarean section should be completed
in the interest of the mother from the cardiac arrest?
A. 3min after a cardiac arrest
B. 4min after a cardiac arrest
C. 5min after a cardiac arrest
D. 6min after a cardiac arrest
E. 10min after a cardiac arrest

Answer 90

5min after a cardiac arrest

Question 91

A30-year-old woman has just had a cardiac arrest on the ward. You commenced CPR
and need to instruct your assistant to deliver continuous oxygen by face mask. What is
the recommended rate of delivery of oxygen to this woman?
A. 1–2litres per min
B. 2–4litres per min
C. 4–6litres per min
D. 6–10litres per min
E. 10–15litres per min

Answer 91

10–15litres per min

Question 92

A23-year-old woman suffered a cardiac arrest and was brought into the A&E where CPR
was initiated, and in the course of this a perimortem, CS was performed. Unfortunately
the patient failed to respond to CPR and was pronounced dead 30min after admission.
What would be the next step in her management?
A. Complete the perimortem CS and then inform the coroner and her relatives
B. Leave all intravenous access ports, lines, intubation and other equipment including the CS
in place and notify the coroner and relatives
C. Remove the placenta and send for examination but do notcomplete the procedure until the
coroner has been informed
D. Inform the relatives and seek permission to inform the coroner after which the abdomen
can be closed and the placenta sent for histological examination
E. Inform the coroner and seek permission to complete the procedure and then inform the
relatives

Answer 92

Leave all intravenous access ports, lines, intubation and other equipment including the CS
in place and notify the coroner and relatives

Question 93

A35-year-old woman with phenylketonuria (PKU) is pregnant. When during pregnancy
will the diagnosis of microcephaly be made?

Answer 93

When the HC measurement on USS is 5SD or more below the gestational age
* Microcephaly should be suspected if the HC falls 2 SD below the mean for gestational age. Adefinitive diagnosis can be made when the measurement is 5or more SD below the mean for gestational age.

Question 94

A 29-year-old woman presents at 24+6 weeks of gestation with mild contractions and
intact fetal membranes. A speculum examination is performed and the cervical os is
closed. What is the recommended management that is considered cost-effective?
A. Commence on tocolysis and a course of corticosteroids
B. Oncofetal fibronectin and corticosteroids
C. Transabdominal cervical length measurement followed by a course of corticosteroids
D. Translabial cervical length measurement followed by a course of corticosteroids
E. Transvaginal cervical length measurement followed by a course of corticosteroid

Answer 94

Commence on tocolysis and a course of corticosteroids
* Below 29+⁵ w no need to do tests or ultrasound for cervical measurement.. offer tocolysis & steroids instead

Question 95

You have admitted a 30-year-old woman in her second pregnancy at 26+3weeks of gestation with uterine contractions and intact fetal membranes. You suspect that she is in
preterm labour. What would be the recommended management for this woman?

Answer 95

Corticosteroids and nifedipine

Question 96

You are conducting an assisted vaginal breech delivery of a 32-year-old woman at
27 weeks of gestation, and this is complicated by head entrapment. What immediate
action will you take to deal with this complication?
A. Administer nifedipine
B. Administer terbutaline subcutaneously
C. Incise the cervix laterally
D. Perform an episiotomy
E. Proceed to a stat caesarean section

Answer 96

Incise the cervix laterally

Question 97

Approximately what percentage of all live births are twins?

Answer 97

3 %

Question 98

Approximately what percentage of twin pregnancies are delivered preterm (i.e. before
37completed weeks of gestation)?

Answer 98

50% (1:2)
* 34w-37w 👉 30%
* < 34w 👉 20%

Question 99

A28-year-old woman attends to book for antenatal care at 10weeks of gestation. Abooking ultrasound scan shows a monochorionic diamniotic twin pregnancy. What would be
the recommended test to predict the risk of spontaneous preterm birth in this woman?

Answer 99

Asingle cervical length measurement from 18weeks of gestation

Question 100

A29-year-old woman presents at 22weeks of gestation for routine antenatal assessment.
Acervical length measurement is performed, and this is reported as 22mm. What intervention has been shown to have the best benefit with respect to reducing the risk of preterm birth in this woman?
A. Cervical cerclage
B. TheArabin pessary
C. Thetocolytic nifedipine
D. None
E. Vaginal progesterone

Answer 100

None

Question 101

What is the most common non-genital cause of sensorineural deafness in children?

Answer 101

Congenital cytomegalovirus (CMV) infection

Question 102

A30-year-old primigravida at 14weeks of gestation was seen two days ago with myalgia,
rhinitis and a mild temperature. Shewas investigated and found to have an infection
with CMV. Assuming that this is a primary infection, what would be the estimated risk
of vertical transmission in this pregnancy?

Answer 102

Up to 50%
* Risk of congenital anomalies 40% - as herps

Question 103

A30-year-old woman has been diagnosed with a CMV infection at 16weeks of gestation.
Sheis known to have had a CMV infection in the past. What would be the vertical transmission rate for this woman?

Answer 103

1 -2 %

Question 104

When will you summon a multidisciplinary team of senior staff to attend a woman with
primary postpartum haemorrhage?
A. Shehas lost in excess of 500mL blood and bleeding is ongoing or she is in clinical
shock
B. Shehas lost in excess of 750mL blood and bleeding is ongoing or she is in clinical
shock
C. Shehas lost in excess of 1000mL blood and bleeding is ongoing or she is in clinical
shock
D. Shehas lost in excess of 1500mL blood and bleeding is ongoing or she is in clinical
shock
E. Shehas lost in excess of 2000mL blood and bleeding is ongoing or she is in clinical
shock

Answer 104

Shehas lost in excess of 1000mL blood and bleeding is ongoing or she is in clinical
shock

Question 105

When will you investigate a 19-year-old woman in her first pregnancy for anaemia?
A. Her Hb is ≤110g/L at 28weeks of gestation
B. Her Hb is ≤105g/L at booking
C. Her Hb is ≤100g/L at 28weeks of gestation
D. Her Hb is <110g/L at first contact in the first trimester
E. Her Hb is <105g/L at any time in pregnancy

Answer 105

Her Hb is <110g/L at first contact in the first trimester

Question 106

You are performing an elective caesarean section on a 33-year-old woman for breech
presentation at 39weeks of gestation. What would be the best prophylactic drug for the
prevention of primary postpartum haemorrhage in this woman?

Answer 106

Intravenous oxytocin (5IU, slowly)
* IF vaginal delivery 👉 IM oxytocin 10 IU

Question 107

A28-year-old schoolteacher is attending for counselling about the risk of CMV as she
plans to start a family. Sheis anxious about the risk of CMV to the pregnancy as this is a
common infection in her school. What is the matrix to whose exposure she has the greatest risk of acquiring the infection?

Answer 107

Urine of an infected child
* Or saliva

Question 108

A30-year-old woman has been diagnosed with primary CMV infection. An amniocentesis has been performed, and this confirms vertical transmission of the infection. What
proportion of babies infected in utero are symptomatic at birth?

Answer 108

10%–25% ( 10 - 15 % )

Question 109

You are about to see a couple in the pre-conception clinic for counselling about the
risk of viral infections in pregnancy. When if infected is she at the greatest vertical
transmission?
A. Periconception (8weeks before and up to 6weeks after conception)
B. Pre-gestation (12months to 8weeks before conception)
C. Thefirst trimester (up to 13weeks)
D. Thesecond trimester
E. Thethird trimester

Answer 109

Thethird trimester

Question 110

A25-year-old woman is seen for pre-pregnancy counselling. As a child, she underwent
treatment for cancer, which involved chemotherapy with doxorubicin and radiotherapy
to her chest and abdomen. What would be the essential screening test to perform prior to
her embarking on a pregnancy?
A. Chest X-ray
B. Echocardiogram
C. Liver function test
D. Lung function test
E. Renal function test

Answer 110

Echocardiogram

Question 111

A 25-year-old woman had Hodgkin’s lymphoma and was treated with chemotherapy
only. With respect to her cancer treatment, she is at a slightly increased risk of which
pregnancy complication?

Answer 111

Preterm delivery
* ( Radiation: stillbirth/ SGA)

Question 112

A 29-year-old woman is diagnosed with postural tachycardia syndrome (PoTS) at
20weeks of gestation. What conservative treatment would be considered for this patient
in the first instance?
A. Increase caffeine intake
B. Increase fluid and salt intake
C. Increase fluid intake
D. Application of compression stockings
E. Initiate aerobic exercises

Answer 112

Increase fluid and salt intake

Question 113

A 29-year-old woman is diagnosed with postural tachycardia syndrome (PoTS) at
20weeks of gestation. What conservative treatment would be considered for this patient
in the first instance?
A. Increase caffeine intake
B. Increase fluid and salt intake
C. Increase fluid intake
D. Application of compression stockings
E. Initiate aerobic exercises

Answer 113

Increase fluid and salt intake

Question 114

A37-year-oldprimigravida is admitted in established labour at 29+4weeks of gestation.
Shehas been prescribed magnesium sulphate for neuroprotection. What is the correct
dose to be administered?

Answer 114

Asingle 4g infusion IV over 30min and then a 1g infusion per hour until she delivers

Question 115

A 27-year-old woman is diagnosed with monochorionic diamniotic twin pregnancy at
an ultrasound scan performed at 10weeks of gestation. Atwhat gestational age should
monitoring for twin to twin transfusion syndrome (TTTS) be started?

Answer 115

16weeks

Question 116

How common is a dural tap as a complication of epidural analgesia in labour?

Answer 116

0.5 - 2.5 %
* approximately 50–60% of women experience postdural puncture headache

Question 117

A28-year-old woman is suspected to have severe sepsis following a normal vaginal delivery at 35weeks of gestation. Shehad presented with spontaneous rupture of membranes
12h before being induced. Ablood test is performed as part investigation. What lactate
level will influence your care of this patient?

Answer 117

4mmol/L
* With serum levels
>4mmol/L, an initial minimum of 20mL/kg of crystalloid or equivalent should be administered.
Vasopressors should be given for hypotension that does notrespond to initial resuscitation

Question 118

Aprimigravida who has had an uncomplicated pregnancy elects to have a home delivery
after appropriate counselling. What will be her approximate risk of transfer to the hospital in labour as per NICE guidelines?

Answer 118

35% ( Indeed: 450/1000👉 45 % )

Question 119

A30-year-old woman is seen with vague generalized aches and feeling generally unwell.
Shehad complained of a sore throat and body aches a few days before. Sheis a schoolteacher and reports that one of the children in her class has recently been diagnosed with
parvovirus B19. Ablood test is performed and shows a positive result for IgM but a negative result for IgG for parvovirus. Sheis 15weeks pregnant. What is the risk of vertical
transmission in this patient?

Answer 119

25%–35%
* < 15w 👉 15%

Question 120

An ultrasound scan is performed on a 23-year-old primigravida at 11weeks of gestation.
Thisshows herniation of the gut with the umbilical cord inserted at the centre of the hernia sac. What is the most likely diagnosis?
A. Exomphalos/omphalocele
B. Gastroschisis
C. Omphalomesenteric duct remnants
D. Physiological hernia
E. Umbilical cord hernia

Answer 120

Exomphalos/omphalocele
* most physiological hernias do nothave the cord inserted at the centre of
the hernia sac.
* Ventral wall hernias are best diagnosed after 12weeks of gestation when physiological hernias in most cases have resolved.

Question 121

A41-year-old woman attends at 13+4weeks of gestation. What would you consider to be
the most appropriate screening test for Down syndrome for her?
A. Combined test (MA+NT+biochemistry)
B. NT and biochemical test in the first and second trimesters
C. NT measurement
D. Triple test
E. Quadruple test

Answer 121

Combined test (MA+NT+biochemistry)
* MA 👉 detection rate: 30%
MA + NT 👉 detection rate: 75-80%
NT+combined test 👉 detection rate: 85%
MA+NT+combined test 👉 detection rate: 85-95% , false positive rate 5%

Question 122

You see a 30-year-old woman who is unsure of her dates. An ultrasound scan is performed,
and the measurements are as follows: CRL=90mm, HC=120mm, BPD=36mm,
FL=20mm, AC=98mm. What measurement should be used to determine her gestational age?

Answer 122

HC
* CRL < 84 👉 determined by CRL

Question 123

A25-year-old Somalian woman who recently came to the UK admits genital cutting as a
child. Sheis 26weeks pregnant. You examine and find infibulation. What is the type of
female genital mutilation (FGM) that this woman has?

Answer 123

FGM type 3
* Type 1 is partial or total removal of the clitoris and/or
the prepuce (Clitoridectomy)
* type 2 is partial or total removal of the clitoris and the labia minora
* type 3 is narrowing of the vagina orifice
with creation of a covering seal by cutting and appositioning the labia minora and/or the labia
majora, with or without excision of the clitoris (infibulation)
* type 4 is all other harmful procedures to the female genitalia for non-medical purposes, for example, pricking, piercing

Question 124

A30-year-old woman who has just had a normal vaginal delivery at term sustains a perineal tear that involves 50% of the external anal sphincter. You are called to suture this
tear. How will you classify the degree of the tear?

Answer 124

3a degree
* 1 degree: laceration of the vaginal epithelium or perineal body.
2 degree: primary muscle but notanal sphincter tear.
3 degree: 3a, <50% thickness of the external sphincter
3b, >50% of thickness of the external sphincter torn
3c, internal sphincter also torn
4 degree: tear with disruption of the anal epithelium

Question 125

A 24-year-old primigravida goes into spontaneous labour at 39+6 weeks of gestation
following an uncomplicated pregnancy. She progresses to 8 cm dilatation but fails to
dilate any further. You have examined and found that the baby is in the deflexed occipitoposterior position. What will be diameter of the presenting part in this baby

Answer 125

Occipito-frontal

Question 126

What will be diameter of the presenting part in each case :
1- fully flexed occipito-anterior presentation
2- deflexed vertex
3- brow presentation
4- face presentation

Answer 126

1- fully flexed occipito-anterior presentation 👉 sub-occipito bregmatic = 9.5
2- deflexed vertex 👉 occipito-frontal = 11.5
3- brow presentation 👉mento-vertical = 13.5
4- face presentation 👉 sub-mento bregmatic = 9.5

Question 127

A32-year-old woman in her second pregnancy was induced at 40weeks because of gestational diabetes that is well controlled with metformin. Shehad prostaglandin gel and 3 h
later had an artificial rupture of fetal membranes. Shortly after, she started contracting
and progressed to full dilatation after 7h. Sheremained fully dilated for 2h and then
started pushing. Thehead was delivered but was noticed to be receding (i.e. there was a
turtleneck appearance). You were called and arrived after 2min. What would be the next
step to take in her management?
A. Apply suprapubic pressure
B. Insert your hand in the vagina and deliver the posterior arm
C. Place her in all fours
D. Perform an episiotomy and the attempt to deliver the shoulders
E. Place her in the McRoberts position

Answer 127

Place her in the McRoberts position : which is successful in as many as 90% of cases.
( maternal pushing should be discouraged )
* If this fails, the next manoeuvre should be the application of supra-pubic pressure followed by internal manoeuvres

Question 128

Aprimigravida is diagnosed with an intrauterine fetal death at 26weeks of gestation.
Following counselling, she books for induction of labour. What would be the appropriate
dose of misoprostol and mifepristone to use to induce labour?

Answer 128

Mifepristone 200mg, misoprostol 50µg qd for a total of 5doses
* given six
times hourly up to a maximum of five doses per course.
* Thevaginal route is the gold standard with
the oral and sublingual routes reserved for those women at risk of malabsorption related to vaginal
discharge or bleeding

Question 129

A36-year old woman who had breast cancer and has been free of any recurrence and has
also just completed her five-year course of tamoxifen wishes to know when can she start
trying to conceive?

Answer 129

After 3months

Question 130

You see a 31-year-old woman at 10 weeks of gestation for booking. She is on antituberculosis treatment. What is the most relevant monthly test you need to perform
on this patient?

Answer 130

Liver function test

Question 131

You suspect myocardial infarction in a pregnant woman at 24weeks of gestation. An
ECG is performed. What finding on the ECG would be highly suspicious (i.e. which is the
most sensitive and specific change) of an acute myocardial infarction (AMI)?

Answer 131

ST elevation

Question 132

A primigravida develops eczematous skin eruptions at 30 weeks of gestation. These
are associated with itching and on examination are found to be located mainly within
abdominal striae. What is the most likely diagnosis?
A. Atopic eruption of pregnancy
B. Eczema of pregnancy
C. Obstetric cholestasis
D. Pemphigoid gestationis
E. Polymorphic eruption of pregnancy (PEP)

Answer 132

Polymorphic eruption of pregnancy (PEP)
👉( abdominal striae.) + sparing the belly button (umbilicus)

Question 133

Aprimigravida is seen at 28weeks of gestation for an ultrasound scan for suspected fetal
growth restriction. Thisis confirmed on ultrasound scan measurement of the various
biometric indices, and there is oligohydramnios and reduced end-diastolic flow (REDF)
on umbilical artery Doppler. Thebaby is known to be a boy. What is the most likely cause
of the oligohydramnios?
A. Placenta insufficiency
B. Polycythemia
C. Posterior urethral valve
D. Renal agenesis
E. Renal hypoperfusion

Answer 133

Renal hypoperfusion

Question 134

A30-year-old lady who suffers from a major depressive disorder and has recently been
admitted but is nowwell controlled on fluoxetine 40mg has just found that she is pregnant. Thisis an unplanned pregnancy, and she is worried about the effects of the drug on
the baby. What advice should she be given?
A. Explain that the risk of malformation is low and recommend continuation of the medication
B. Stop medication and replace it with a tricyclic antidepressant
C. Stop medication and resume after delivery
D. Stop medication and resume after the end of the first trimester
E. Stop medication immediately

Answer 134

Explain that the risk of malformation is low and recommend continuation of the medication

Question 135

A25-year-old woman who is known to have beta-thalassaemia major has just delivered.
Sheis on desferrioxamine. Themother plans to breastfeed and is worried about the effect
of the drug on the baby. What should she be told ?
A. Advise against breastfeeding
B. Advise that breastfeeding is safe
C. Change to another iron-chelating agent and allow her to breastfeed
D. Recommend to continue medication and breastfeed as long as she understands the risk
E. Stop the medication and breastfeed

Answer 135

Advise that breastfeeding is safe
* Desferrioxamine is secreted in breast milk but is notorally absorbed and therefore notharmful

Question 136

An elective caesarean section has been performed on a primigravida with a breech
presentation at 39 weeks of gestation. Her weight is 110 kg. What is the dose of lowmolecular-weight heparin (Dalteparin) that you would give her as thromboprophylaxis?

Answer 136

7500IU
* 2500IU for women who weigh
<50kg,
5000IU for those weighing 50–90kg,
7500IU for those weighing 91–130kg,
10,000IU
for those weighing 131–170kg

Question 137

A29-year-old primigravida attends the clinic at 26weeks of gestation to discuss postpartum thromboprophylaxis. Sheis homozygous for factor V Leiden. Her mother had a
pregnancy-related thromboembolism. What would be the duration of thromboprophylaxis after her delivery?
A. 10days
B. 14days (2weeks)
C. 28days (4weeks)
D. 42days (6weeks)
E. 84days (12months)
30. What organism is known

Answer 137

42days (6weeks)
* family history of VTE in her mother as well as being homozygous factor V Leiden

Question 138

What organism is known to be the most common cause of sepsis in pregnancy?
A. Escherichia coli
B. Group B β haemolytic Streptococcus
C. Pseudomonas
D. Staphylococcus aureus
E. Streptococcus pyogenes

Answer 138

Escherichia coli
& Group A β haemolytic Streptococcus

Question 139

You are the specialist registrar on call for the unit and are performing an emergency lower
segment CS of a patient who has had one previous CS. An ultrasound scan performed at
20weeks had ruled out placenta praevia. Upon opening the peritoneum, you find engorged
bluish vessels on the lower uterine segment. What will be your course of action?
A. Call for the consultant immediately and wait until he/she arrives
B. Call for the consultant urgently but proceed with opening the lower segment
C. Call for the consultant urgently but proceed with opening the upper segment
D. Call the interventional radiologist and wait until catheters have been inserted
E. Crossmatch blood and then proceed to open the uterus– lower segment

Answer 139

Call for the consultant urgently but proceed with opening the lower segment
* this is emergency CS no time to wait the consultant or radiologist / classical CS associated with higher morbidity

Question 140

You have been called to see a 30-year-old woman with ITP who has been fully dilated for
over 3 h and pushing for the last one of these. You examine and find that the baby is in an
occipito-posterior position and at the level of the ischial spines (station zero). What would
be next step in the management of this patient?
A. Emergency CS
B. Kielland’s forceps delivery
C. Manual rotation and forceps
D. Neville-Barnes forceps delivery
E. Ventouse delivery

Answer 140

Emergency CS
1- will reduce the risk of intracranial haemorrhage
2 - An instrumental delivery is likely to be a difficult as the baby’s head is still at the level of the spines.

Question 141

You are about to see a 32-year-old woman in her third pregnancy at 12weeks of gestation. Her last baby suffered from haemolytic disease of the fetus and newborn (HDFN).
An antibody titre at this gestation is 8IU. Thefather is heterozygous for RhD. What
would be the next stage in her management?
A. Chorionic villus sampling for fetal genotype
B. ffDNAin maternal blood for fetal genotype
C. Refer to fetal medicine for serial MCADoppler monitoring
D. Serial titres weekly
E. Ultrasound scan for hydrops

Answer 141

ffDNAin maternal blood for fetal genotype
* Itis recommended that non-invasive fetal genotyping using maternal blood should be undertaken . Thisis possible for D, C, c, E, e and K

Question 142

primigravida presents with a chickenpox rash 3days after it was first noticed. Sheis
now18weeks pregnant. How will she be managed?
A. Arrange detailed scan with the fetal medicine unit after 5weeks
B. Arrange amniocentesis to exclude intrauterine infection
C. Commence on aciclovir 400mg tds for 5days
D. Reassure and discharge
E. Ultrasound scan for anomaly in 3weeks

Answer 142

Arrange detailed scan with the fetal medicine unit after 5weeks
* Oral aciclovir should be prescribed for pregnant women with chickenpox, if they present within
24h of the onset of the rash .
* referral to a fetal medicine specialist at 16–20weeks or 5weeks after infection

Question 143

A30-year-old G3P2 attends the VBAC clinic for counselling about mode of delivery.
Thisis an uncomplicated pregnancy and she had indicated after her mid-trimester scan
that she would like to try for a vaginal delivery. Shehad an emergency CS for her first
pregnancy because of fetal distress and then had a uterine rupture in the second pregnancy intrapartum. Theoutcome at surgery was a live birth. What is the risk of uterine
rupture that you will quote for this woman if she went for VBAC?

Answer 143

≥1:20 (5%) 👉 Aprevious uterine rupture is therefore considered a contraindication to VBAC

Question 144

A30-year-old G3P2 attends the VBAC clinic for counselling about mode of delivery.
Thisis an uncomplicated pregnancy and she had indicated after her mid-trimester scan
that she would like to try for a vaginal delivery. Shehad an emergency CS for her first
pregnancy because of fetal distress and then had a uterine rupture in the second pregnancy intrapartum. Theoutcome at surgery was a live birth. What is the risk of uterine
rupture that you will quote for this woman if she went for VBAC?

Answer 144

≥1:20 (5%) 👉 Aprevious uterine rupture is therefore considered a contraindication to VBAC

Question 145

What is the risk of uterine rupture in Women who have had a previous CS and are embarking on VBAC ?

Answer 145

1:200 ( 0.5 % )

Question 146

A27-year-old woman is being counselled about VBAC. Her CS was an emergency at 8cm
dilation for an abnormal fetal heart rate on CTG. Thebaby had normal Apgar scores
and pHat birth. Sheis now34weeks and the pregnancy is uncomplicated. What success
rate for VBAC will you quote for her?

Answer 146

71-75%
* After 2 CS = 62-75%

Question 147

A28-year-old who had a previous CS is being counselled about VBAC. What information
from her past obstetrics history would give her the best chance of a successful VBAC?
A. If she has had a previous vaginal delivery
B. If the previous CS was an elective CS for breech presentation
C. If the previous CS was for fetal distress in the late first state of labour
D. If the previous CS was for labour dystocia at 8cm or more dilatation
E. If the previous CS was for labour dystocia at less than 8cm dilatation

Answer 147

If she has had a previous vaginal delivery ( particularly previous VBAC )- single best predictor
* Asuccessful VBAC is more likely with a previous CS for fetal malpresentation compared with women with previous CS for either labour dystocia or fetal distress indications
* Asuccessful VBAC is more likely in women with a previous labour dystocia at 8cm or more compared to less than 8 cm

Question 148

A32-year-old multiparous woman went into spontaneous labour at 40weeks of gestation. Labour was progressing normally but at 8cm dilatation, when fetal membranes
ruptured spontaneously, she collapsed. What is the most likely cause of the collapse?

Answer 148

Amniotic fluid embolism ( 1.25-12.5/100,000)
* AFE presents as collapse during labour or within 30 min of delivery

Question 149

On what basis will you make a diagnosis of amniotic fluid embolism in a 30-year-old
G2P1 who laboured spontaneously but had syntocinon augmentation at 5 cm dilatation?
A. Bronchial lavage
B. Clinical features
C. Fetal squames in maternal circulation
D. Fetal squames in the pulmonary trees
E. Findings of a V/Q scan

Answer 149

Clinical features ( as there is no established accurate diagnostic test premortem. )

Question 150

A36-year-old woman is seen as an emergency at 34weeks of gestation with central chest
pain, which is mainly interscapular. Sheis found on examination to be breathless with a
systolic hypertension (BP=160/80mmHg) and a wide pulse pressure. What is the most
likely diagnosis in this woman?
A. Cardiomyopathy
B. Dissection of an aortic root aneurysm
C. Dissection of the coronary artery
D. Left ventricular failure
E. Myocardial infarction

Answer 150

Dissection of an aortic root aneurysm

Question 151

A 23-year-old primigravida whose pregnancy was complicated by gestational diabetes went into spontaneous labour at 40weeks of gestation. Shestarted pushing but had
shoulder dystocia after delivery of the head of the baby. What factor is likely to increase
the risk of brachial plexus injury (BPI) in the baby?

Answer 151

Theweight of the baby

Question 152

What is the most common cause of litigation related to shoulder dystocia in the UK?

Answer 152

Brachial plexus injury (BPI)

Question 153

A30-year-old woman whose labour was complicated by shoulder dystociaand brachial
plexus injury has come back for debriefing. Itis recognized that a significant number of
these injuries are associated with substandard care. Approximately what proportion of
these injuries are associated with substandard care?

Answer 153

45%–50%

Question 154

A42-year-old presents for booking at 10weeks of gestation. Sheis a smoker (smoking
8–10cigarettes per day). Her BMI is 28kg/m2. What would be the plan for screening/
monitoring for SGAin this woman?
A. Maternal serum-alpha protein at 14weeks of gestation
B. Maternal serum PAPP-Aat 12weeks of gestation
C. Serial uterine and umbilical artery Doppler from 20–24weeks of gestation
D. Serial growth ultrasound scan and umbilical artery Doppler from 26–28 weeks of
gestation
E. Uterine artery Doppler at 20–24weeks

Answer 154

Serial growth ultrasound scan and umbilical artery Doppler from 26–28 weeks of gestation
* These women are at high enough risk, and uterine artery Doppler is therefore notvery appropriate.
* Age is a major risk factor 👉 1 major: serial growth ultrasound scan
* Smoker < 11 is a minor risk factor 👉 1 minor : Uterine artery Doppler at 20–24weeks
* > 3 minor 👉 serial growth ultrasound scan

Question 155

A32-year-old G3P2 is referred at 28weeks of gestation for ultrasound scan because of
reduced fetal movements. Ultrasound measurements of both the head and abdominal circumference are below the 10th centile and the amniotic fluid index is 25cm. Theumbilical artery Doppler is normal. What single important investigation should be offered to
this woman?
A. Blood test for CMV and toxoplasmosis
B. Middle cerebral artery Doppler
C. Karyotyping
D. Oral glucose tolerance test with 75g glucose load
E. Uterine artery Doppler

Answer 155

Karyotyping
*SGA + polyhydramnios

Question 156

When Karyotyping should be offered in SGA cases ?

Answer 156

1- severe SGAwith structural abnormalities ( an EFW or AC <3rdcentile )
2- in those detected before 23weeks of gestation especially of the uterine artery Doppler is normal.
3- in Thepresence of polyhydramnios, symmetrical SGAand normal umbilical artery Doppler

Question 157

Inthe absence of group-specific blood, what should a 25-year-old woman who is having a
major postpartum haemorrhage be transfused with?
A. Blood group O, Rhesus (D) negative
B. Blood group O, Rhesus (D) negative and CMV negative
C. Blood group O, Rhesus (D) negative and K-negative
D. Blood groups O, Rhesus (D) negative, K-negative and CMV negative
E. Blood group O, Rhesus (D) negative, K-negative, CMV and CJD negative

Answer 157

Blood group O, Rhesus (D) negative and K-negative

Question 158

A27-year-old woman is on the list for an elective CS at 37weeks of gestation for placenta
praevia. Sherequests for intraoperative cell salvage. What are the components of intraoperative cell salvage?
A. Blood collection and transfusion
B. Blood collection, filtering and transfusion
C. Blood collection, filtering, washing and transfusion
D. Blood collection, filtering, washing and irradiation
E. Blood collection, filtering, washing and treating prior to transfusion

Answer 158

Blood collection, filtering, washing and transfusion

Question 159

You are managing a 24-year-old primigravida who has just had an emergency CS in
the second stage and is bleeding heavily. Shehas lost in total about 1500mL of blood
and continues to bleed. Transfusion has commenced and her haemostatic test results are
being awaited. What will be the indication for administering fresh frozen plasma (FFP)
to this woman?
A. Her fibrinogen level is less than 2g/L
B. Her haemostatic test results are unavailable
C. Her platelets were low at the onset of labour
D. Shehas had 4units of red blood cells
E. Sheis being transfused with fresh blood

Answer 159

Shehas had 4units of red blood cells ( in the guidelines 6 units)
* FFP should be guided by the aim of keeping PT & PTT ratios at less than 1.5 x normal.
* Cryoprecipitate : guided by fibrinogen results, aiming to keep levels above 1.5 g/l

Question 160

What is the estimated percentage reduction in venous thromboembolism (VTE) risk by
low-molecular-weight heparin (LMWH) in medical and surgical patients, respectively?

Answer 160

60% and 70%

Question 161

Atwhat stage in pregnancy is the risk of VTE highest in a 33-year-old woman who is
having her first baby and reports that her mother had a deep vein thrombosis (DVT)
while on the combined hormonal contraceptive pill at the age of 35years?
A. Inlabour
B. Inthe first trimester
C. Inthe first three weeks postpartum
D. Inthe second trimester
E. Inthe third trimester

Answer 161

Inthe first three weeks postpartum

Question 162

A37-year-old mother of 3who smokes 10cigarettes per day books for antenatal care at
10weeks of gestation. Thiswas an IVF pregnancy. You have examined and found that her
BMI is 29kg/m2. What recommendation will you offer her about thromboprophylaxis?
A. Commence on LMWH for 10days after delivery
B. Commence on LMWH from 28weeks of gestation until 6weeks post-delivery
C. Commence on LMWH from 28weeks until 10days post-delivery
D. Commence on LMWH nowand until 10days post-delivery
E. Commence LMWH nowand until 6weeks post-delivery

Answer 162

Commence LMWH nowand until 6weeks post-delivery
4 risk factors: smoker+ age > 35 y + IVF + parity
* ( BMI should be> 30 to be a risk factor)

Question 163

You are booking a 26-year-old in her first pregnancy at 6weeks of gestation. Shewas
referred for advice on thromboprophylaxis because she had a DVT three years ago and
was investigated and found to be heterozygous for factor V Leiden. TheGP had stopped
her warfarin and commenced her on 5000IU of Fragmin daily. What would be your plan
for her management?
A. Commence on a higher dose (either 50%, 75% or full treatment dose) of LMWH until
6weeks postpartum
B. Commence on a higher dose (either 50%, 75% or full treatment dose) of LMWH until
12weeks postpartum
C. Commence on a higher dose (either 50%, 75% or full treatment dose) of LMWH until
6weeks postpartum or until warfarin is re-commenced
D. Continue with the LMWH until 6weeks after delivery
E. Continue with the standard dose of LMWH until 6weeks postpartum or until warfarin is
re-commenced

Answer 163

Continue with the standard dose of LMWH until 6weeks postpartum or until warfarin is
re-commenced
* Women with a previous VTE associated with other heritable thrombophilic defects other than
antithrombin III are at a lower risk of recurrence and can be managed with standard doses
* High dose : recurrent DVt ot 2A : antphospholipid or antithrombin III or homozygous or 2 heterozygous ( compound)

Question 164

What is the estimated prevalence of diagnosed pulmonary embolism in pregnancy in
women with suspected PE?

Answer 164

2-6% ( 6%)

Question 165

What is the estimated prevalence of diagnosed pulmonary embolism in pregnancy in
women with suspected PE?

Answer 165

2-6% ( 6%)

Question 166

A30-year-old primigravida attends the Pregnancy Triage Unit with pain in her left leg. Sheis
examined and DVT is suspected; the level of clinical suspicion is graded as high. Sheis commenced on therapeutic doses of dalteparin– an LMWH. Acompression duplex ultrasound
scan is performed and this is negative. What should be the next step in her management?

Answer 166

Stop the LMWH and repeat the ultrasound scan on days 3 and 7 to ensure that it is indeed
nota DVT ( don’t continue except for PE continue and repeat CT)

Question 167

A33-year-old G2P1 presents at 29weeks of gestation with sudden onset chest pain and
difficulties breathing. Shealso reports that she has had a swollen and painful left leg for
the past one week. You suspect that she has a PE as well as a left DVT. Sheis commenced
on therapeutic doses of LMWH pending confirmation of diagnosis. What would be the
most appropriate investigation to perform in this woman?
A. Chest X-ray
B. Compression duplex ultrasound scan
C. Computed tomography pulmonary angiogram (CTPA)
D. Electrocardiogram (ECG)
E. Ventilation-perfusion (V/Q) lung scan

Answer 167

Compression duplex ultrasound scan

Question 168

A40-year-old mother of three in her fourth pregnancy at 30weeks of gestation is admitted into the emergency unit with a suspicion of PE. Shehas otherwise been asymptomatic
and there are no symptoms of DVT. Sheis commenced on therapeutic doses of LMWH
pending confirmatory tests. What should be next test to undertake in this woman?

Answer 168

Chest X-ray (CXR) followed by V/Q scan or CTPA

Question 169

A40-year-old mother of three in her fourth pregnancy at 30weeks of gestation is admitted into the emergency unit with a suspicion of PE. Shehas otherwise been asymptomatic
and there are no symptoms of DVT. Sheis commenced on therapeutic doses of LMWH
pending confirmatory tests. What should be next test to undertake in this woman?

Answer 169

Chest X-ray (CXR) followed by V/Q scan or CTPA

Question 170

A23-year-old woman presents with reduced fetal movements at 33weeks gestation. Thefetal
heart could notbe heard with a sonicaid; hence, she was referred for an ultrasound scan.
Thescan has confirmed an intrauterine fetal death (IUFD). Approximately what percentage
of women presenting with an intrauterine fetal death have reduced fetal movements?

Answer 170

55%

Question 171

A19-year-old primigravida has been referred to the Maternity Triage with suspected
reduced fetal movements at 35weeks of gestation. You have taken a history from her and
are assured that she does nothave reduced fetal movements. Thisis an uncomplicated
pregnancy. What will your managementof this patientbe?
A. Check her BP and urine and then perform a cardiotocography and if all findings are normal, discharge her with a kick chart
B. Check her BP and urine and then perform a cardiotocography and if all findings are normal, discharge her with the advice to contact the maternity unit if she has concerns
C. Check her BP and urine, perform a cardiotocography and arrange an ultrasound scan and
discharge if all findings are normal with the advice to contact the maternity unit if she has
concerns
D. Listen to the fetal heart and if normal, reassure and discharge her with the advice to contact the maternity unit if she has concerns
E. Perform a cardiotocography and if normal, discharge her with the advice to contact the
maternity unit if she has concerns

Answer 171

Listen to the fetal heart and if normal, reassure and discharge her with the advice to contact the maternity unit if she has concerns

Question 172

. A39-year-old woman is seen at 38weeks of gestation with reduced fetal movements.
Her BP is 150/95mmHg and urinalysis is negative for protein. Thefetal heartbeat
is heard with a sonicaid and you arrange a cardiotocography, which shows normal
baseline variability but no accelerations after 120min. What will be your plan for this
patient?
A. Admit for monitoring of the fetus with daily CTGs
B. Organize an ultrasound scan for biometry
C. Organize an ultrasound scan for growth and Doppler of the umbilical artery
D. Organize delivery
E. Refer for biophysical profile assessment

Answer 172

Organize delivery

Question 173

Awoman books for antenatal care at 8weeks of gestation in her first pregnancy. What is
the recommendation with regard to testing for blood group and antibodies?
A. Test blood group and antibody at booking and then at 28weeks of gestation
B. Test blood group and antibody at booking and then antibody at 28weeks
C. Test blood group and antibody at booking, 28 and 36weeks
D. Test blood group and antibody at booking and then blood group at 28weeks
E. Test blood group and antibody at booking, and 28weeks and then antibody at 36weeks

Answer 173

Test blood group and antibody at booking and then at 28weeks of gestation

Question 174

Apatient is seen in the antenatal clinic at 12weeks of gestation after having hadher
routine blood tests by the midwife in the community at 10weeks of gestation. Sheis blood
group O Rhesus D negative with red cell antibodies (titre of 2.4IU/L). What would be the
next logical step in the management of thispatient?
A. Assume that the baby is at risk of isoimmunization and monitor with serial antibody
measurement
B. Obtain a blood sample from the putative father to determine his genotype
C. Offer an amniocentesis to determine baby’s blood group
D. Offer non-invasive testing from maternal blood at around 16weeks of gestation
E. Perform a CVS at this gestation to determine blood group of the baby

Answer 174

Offer non-invasive testing from maternal blood at around 16weeks of gestation
( To do fetal genotyping)
* Avoid issues of non paternity
* If anti K at around 20w

Question 175

Atwhat minimum level of anti-K antibody would a referral to a fetal medicine unit be
necessary in a 27-year-old G3P2 who has had a previous caesarean section and a termination of pregnancy? Sheis currently at 16weeks of gestation

Answer 175

Any level of antibody

Question 176

What proportion of infants born with congenital CMV infection are born to women with
pre-existing CMV immunity?

Answer 176

Two thirds
* It avidity> 65% indicate past infection

Question 177

You reviewed a 27-year-old G2P1 on the delivery suite at 27weeks of gestation. Shewas
admitted complaining of regular uterine contractions. Following counselling, she was
started on a course of corticosteroids and magnesium sulphate (the latter for tocolysis).
What is the advantage of giving her MgSO4?
A. Reduces the risk of cerebral palsy in the baby
B. Reduces the risk of having a preterm delivery
C. Reduces the risk of her having eclampsia
D. Reduces the risk of intracranial haemorrhage
E. Reduces risk of ventricular haemorrhage

Answer 177

Reduces the risk of cerebral palsy in the baby

Question 178

A31-year-old G3P2 presents at 29weeks of gestation with preterm premature rupture
of fetal membranes. Sheis nothaving any contractions but complains of mild abdominal
discomfort. You have confirmed rupture of membranes and sent some of the amniotic
fluid for infection screen (culture). What proportion of women presenting with PPROM
have positive amniotic fluid cultures?
A. 15%–19%
B. 20%–24%
C. 25%–29%
D. 30%–34%
E. 35%–40%

Answer 178

30%–34%

Question 179

Aprimigravida was diagnosed with breast cancer at 12weeks of gestation. Following
surgery, she was commenced on chemotherapy. She went into spontaneous labour at
36weeks of gestation when on the last course of chemotherapy. Shewishes to breastfeed.
What advice will she be given?

Answer 179

To express the breast milk and discard for two weeks before breastfeeding

Question 180

You are performing a routine laparoscopic tubal occlusion on the Gynaecology Day List
of your unit. You have completed the procedure but during closure of the ports, your
trainee pricks you with a needle. Thepatient is from a high-risk country, although she has
notbeen tested for HIV. What would be the recommendation with respect to samples and
testing on you?
A. Abaseline sample for testing, another follow-up for testing at 3months and a third one at
6months for testing
B. Baseline sample for testing for HIV
C. Baseline blood sample for storage and a follow-up sample for testing at 12weeks
D. Baseline sample for testing and another follow-up for testing
E. Baseline sample for storage, a follow-up for testing and another at 6months fortesting

Answer 180

Baseline blood sample for storage and a follow-up sample for testing at 12weeks

Question 181

20-year-old woman is seen at 30weeks gestation with generalized pruritus especially
of the palms of the hands and soles of the feet. Adiagnosis of obstetric cholestasis is suspected. How common is this complication of pregnancy in theUK

Answer 181

7–8/1000pregnancies

Question 182

A33-year-old was induced at 37weeks of gestation on account of obstetric cholestasis.
What is the best time to perform a liver function test post-delivery to confirm that the
liver function test result has returned to normal?

Answer 182

Six weeks

Question 183

Awoman is seen at 24weeks gestation for follow-up. Thisis her second pregnancy– the
first was a stillbirth at 29weeks of gestation in a pregnancy complicated by obstetric
cholestasis. Sheis interested in knowing how this pregnancy can be monitored to reduce
the risk of a recurrence of the stillbirth. What is the best method of monitoring the baby
from 26–28weeks of gestation?
A. Amniocentesis to check for lecithin-sphingomyelin ratio
B. Cardiotocography
C. No reliable method is available
D. Transcervical amnioscopy for the identification of meconium-stained liquor
E. Umbilical artery Doppler

Answer 183

No reliable method is available

Question 184

What proportion of pregnant women is affected by nausea and vomiting in pregnancy?

Answer 184

Up to 80%

Question 185

A20-year-old woman is admitted with nausea and vomiting in pregnancy (NVP) at 7weeks
of gestation. What signs will make you diagnose hyperemesis gravidarum in this woman?

Answer 185

NVP with weight loss of more than 5% pre-pregnancy weight, dehydration and electrolyte
imbalance

Question 186

A25-year-old is seen at 7weeks of gestation in her first pregnancy with severe nausea
and vomiting in pregnancy (NVP). Initial management has failed to stem the vomiting.
Further investigations have been performed, including a thyroid function test. These
have been reported as increased free thyroxine and suppressed thyroid-stimulating hormone. What should be the recommended management of this biochemical abnormality?

Answer 186

Treat the hyperemesis and notthe abnormal thyroid function

Question 187

What is the most likely electrolyte derangement in a woman admitted with hyperemesis
gravidarum (HG)?
A. Hyperkalaemia, hypernatraemia, hyperchloraemia and ketosis
B. Hyperkalaemia, hypernatraemia, hypochloraemia and ketosis
C. Hyperkalaemia, hyponatraemia, hypochloraemia and ketosis
D. Hypokalaemia, hyponatraemia, hyperchloraemia and ketosis
E. Hypokalaemia, hyponatraemia, hypochloraemia and ketosis

Answer 187

Hypokalaemia, hyponatraemia, hypochloraemia and ketosis

Question 188

What is the most likely electrolyte derangement in a woman admitted with hyperemesis
gravidarum (HG)?
A. Hyperkalaemia, hypernatraemia, hyperchloraemia and ketosis
B. Hyperkalaemia, hypernatraemia, hypochloraemia and ketosis
C. Hyperkalaemia, hyponatraemia, hypochloraemia and ketosis
D. Hypokalaemia, hyponatraemia, hyperchloraemia and ketosis
E. Hypokalaemia, hyponatraemia, hypochloraemia and ketosis

Answer 188

Hypokalaemia, hyponatraemia, hypochloraemia and ketosis

Question 189

What is the estimated rate of mother-to-child transmission (MTCT) of HIV in women
who are on combination antiretroviral therapy (cART) with undetectable viral load at
the time of delivery in the UK?

Answer 189

0.1%–0.5%

Question 190

A30-year-old is offered HIV screening test at booking at 12weeks of gestation but declines.
What would be the next step in her management with respect to screening for HIV?
A. Document in her notes and re-offer testing at her next antenatal visit at 16weeks of
gestation
B. Document in her notes and re-offer testing at her 28weeks antenatal visit
C. Document in her notes and re-offer testing at her 36weeks antenatal visit
D. Document in her notes and offer rapid testing in labour
E. Document in her notes and treat her as potentially positive and offer prophylactic ART to
her newborn

Answer 190

Document in her notes and re-offer testing at her 28weeks antenatal visit

Question 191

When should a pregnant HIV-positive woman with a viral load of >30,000HIV RNA
copies/mL plasma who does notrequire treatment for herself commence cART?
A. Atthe start of the second trimester
B. Atthe start of the third trimester
C. By the 12th week of gestation
D. By the 16th week of gestation
E. By the 24th week of gestation

Answer 191

Atthe start of the third trimester
* If > 100,000 👉 now
30.000-100.000 👉 second trimester
< 30.000👉 24w

Question 192

A40-year-old from Zimbabwe attends for her first antenatal visit at 16weeks of gestation. Sheis counselled about the increased risk of aneuploidy and wishes to have an
amniocentesis. What would be the most appropriate approach to this procedure?
A. Defer the procedure until her HIV status is known
B. Perform an HIV test and the amniocentesis but commence her on ART until the HIV
results are back
C. Perform an HIV test if she has no objection and then perform the amniocentesis
D. Perform the procedure and manage depending on the outcome
E. Offer rapid HIV test and proceed to perform amniocentesis if negative, and if positive,
counsel against the procedure and perform an NIPT test

Answer 192

Defer the procedure until her HIV status is known

Question 193

What should the recommendation be for a 37-year-old HIV-positive woman (diagnosed
when she booked at 10weeks of gestation) who has a high-risk combined trisomy 21test
at 12weeks of gestation and wishes to have CVS? Shehas notbeen commenced on cART
yet as she is only 12+4weeks and her CD4 count is >500cells/µL.
A. Defer invasive testing until the viral load is <50HIV RNAcopies/mL plasma
B. Measure HIV viral load and consider invasive testing if <50HIV RNA copies/mLplasma
C. Offer NIPT and only consider invasive testing if it is abnormal
D. Perform the CVS but commence on cART
E. Perform the procedure as the CD4 count is normal

Answer 193

Defer invasive testing until the viral load is <50HIV RNAcopies/mL plasma

Question 194

Awoman on cART has had a spontaneous vaginal delivery following induction of labour
at 41+4weeks’ gestation. What measures should be taken to reduce vertical transmission
to the baby?
A. Avoid breastfeeding
B. Avoid breastfeeding and administer triple ART therapy for 4weeks
C. Avoid breastfeeding and administer triple ART for 6weeks
D. Avoid breastfeeding and commence the baby on zidovudine monotherapy
E. Avoid breastfeeding and give the baby a 4-week course of zidovudine monotherapy

Answer 194

Avoid breastfeeding and give the baby a 4-week course of zidovudine monotherapy
( During 4 hours of delivery)

Question 195

A32-year-old G2P1 presents with lower abdominal pains, which are intermittent. Shehas
not had any vaginal discharge or leakage of water per vaginam. Shedoes nothave any
symptoms of urinary tract infection and is apyrexial. Sheis 28+2weeks pregnant. What
will be the next stage in her management?
A. CTG for 30min to determine the frequency of uterine contractions if any and the state of
the fetus
B. Nifedipine
C. Oncofetal fibronectin
D. Speculum examination followed by digital examination if indicated
E. Ultrasound scan for cervical length

Answer 195

Speculum examination followed by digital examination if indicated

Question 196

A30-year-old primigravida attends for her anomaly ultrasound scan at 18weeks of gestation, and the cervix is suspected to be short. Atransvaginal ultrasound scan was performed, and the cervix measured 20mm with a closed os. What would be the next logical
step in the management of this patient?
A. Commence on nifedipine
B. Commence on vaginal progesterone
C. Monitor the cervix weekly and consider a cerclage if its length is less than 15mm
D. Offer an interval cervical cerclage
E. Reassure and offer routine antenatal care

Answer 196

Commence on vaginal progesterone
* to women with no history of spontaneous preterm birth or mid-trimester loss in whom a transvaginal ultrasound scan has been carried out between 16+0
and 24+0weeks of gestation that reveals a cervical length of less than 25mm

Question 197

Who should be offered screening for sickle cell disease and thalassaemia in theUK?
A. All Afrocarribeans as early as possible
B. All Afrocarribeans, Asians, middle-Europeans and Mediterranean as soon as possible
C. All Asians, Afrocarribeans and Mediterranean as soon as possible
D. All Asians as soon as possible
E. All women as early as possible

Answer 197

All women as early as possible
( ideally by 10w)

Question 198

An ultrasound has been performed on a primigravida at her booking visit. What is the
crown-rump length (CRL) for measuring nuchal translucency (NT)?
A. 40–80mm
B. 45–84mm
C. 45–90mm
D. 54–84mm
E. 60–85mm

Answer 198

54–84mm

Question 199

Aprimigravida books for antenatal care at 10weeks of gestation. What is the recommended number of antenatal visits she should have assuming that the pregnancy remains
low risk?

Answer 199

10visits

Question 200

What is the best approach to assess gestational age for a woman booking with a CRL of
93mm?

Answer 200

Head circumference

Question 201

You have booked a 23-year-old rhesus (D) positive primigravida for antenatal care.
When will you request for screening for atypical antibodies during her pregnancy?

Answer 201

Atbooking and 28weeks

Question 202

An anomaly ultrasound scan performed at 20weeks of gestation on a primigravida shows
a low-lying placenta. What action will you take on this patient?
A. Admit her into the hospital from 32weeks
B. Admit her into the hospital from 34weeks
C. Perform a transvaginal ultrasound scan at 32weeks to confirm praevia
D. Repeat the transabdominal ultrasound scan at 32weeks
E. Request for a transvaginal ultrasound scan to confirm the diagnosis before making a management plan

Answer 202

Repeat the transabdominal ultrasound scan at 32weeks
Repeat not perform because: Only women whose placentas extend over the internal os should be offered another transabdominal scan at 32weeks not only low lying

Question 203

Atwhat gestational age should an external cephalic version be attempted on a primigravida who is diagnosed with a breech presentation at 35weeks of gestation?

Answer 203

37w
* Where it is notpossible to schedule an appointment for the version at 37weeks, it should be
scheduled at 36weeks.

Question 204

A26-year-old haemophilia Acarrier is about to have a CVS at 11weeks of gestation on
account of an abnormal nuchal translucency. What precaution if any should be undertaken prior to this procedure?

Answer 204

Check factor VIII levels ( should be more than 0.5)
* More accurate: Check factor VIII and von Willebrand factor (vWF).

Question 205

A30-year-old haemophilia B carrier is now36weeks pregnant. What is the greatest risk
to this woman in view of her carrier status?
A. Increased risk of antepartum haemorrhage
B. Increased risk of placental abruption
C. Increased risk of neonatal intracranial and extracranial haemorrhage
D. Increased risk of primary postpartum haemorrhage
E. Increased risk of stillbirth

Answer 205

Increased risk of primary postpartum haemorrhage
* coagulation factors may normalize during pregnancy in carriers, with an early fall in
levels postnatally

Question 206

A22-year-old woman attends for her routine anomaly ultrasound scan at 20weeks and
informs the team that her partner has severe haemophilia B. Thedetail scan is normal
and she is informed that the fetus is male. What advice should be offered to this woman?
A. Planned elective CS at 39weeks of gestation
B. Prenatal diagnosis by means of amniocentesis as soon as possible
C. Prenatal diagnosis by means of amniocentesis in the third trimester
D. Prenatal diagnosis by means of cordocentesis (fetal blood sampling)
E. Reassurance and support during the pregnancy

Answer 206

Reassurance and support during the pregnancy
But if she is a carrier 👉 Prenatal diagnosis by means of amniocentesis in the third trimester ( after 34w)

Question 207

When would you abandon an attempted ventouse delivery in a 20-year-old primigravida
who had a delay in the second stage of labour?
A. After a failed second application of the cup
B. Delivery is notimminent following two contractions of a correctly applied instrument by
an experience operator
C. If the cup comes off after one failed pull
D. If the cup comes off after the second application
E. When there has been no evidence of progressive descent with moderate traction during
each contraction

Answer 207

When there has been no evidence of progressive descent with moderate traction during
each contraction

Question 208

A26-year-old primigravida is undergoing a trial of vaginal breech delivery. Thebreech
is frank with an estimated birth weight of 3100g. Sheprogressed at a normal rate, but
the cervix has remained at 7cm for the past 3h. Thefetal heart rate is normal. What
would be the next plan for her?
A. Augment with oxytocinon and manage as for a cephalic presentation
B. Augment with oxytocinon for 2 h and then re-assess
C. Proceed to a caesarean section
D. Re-examine in 2h and if no progress, perform a CS
E. Re-examine in 3–4h and if no progress, perform a CS

Answer 208

Proceed to a caesarean section

Question 209

What is the main risk of giving a high dose of oxytocin to a 30-year-old primigravida in
the management of postpartum haemorrhage?

Answer 209

Hypotension

Question 210

What is the estimated overall failure rate of the haemostatic suture in the management of
primary postpartum haemorrhage?

Answer 210

25%

Question 211

A26-year-old G2P1 was induced at 37weeks following prolonged rupture of fetal membranes. Labour was augmented with syntocinon following slow progress at 4 cm dilatation.
Sheprogressed to full dilatation and delivered 6h after augmentation with syntocinon.
Syntocinon (10units) was given IM with the delivery of the anterior shoulder. Themidwife has called you because since the delivery of the placenta, the patients has been bleeding and has lost a total of 600mL blood. What will be the first step you will take in her
management?
A. Examine the placenta to see if it is complete
B. Empty the bladder by inserting a Foley catheter
C. Rub uterine contractions
D. Secure an intravenous access with a 14gauge cannula
E. Send blood for cross-matching

Answer 211

Rub uterine contractions