Specialties - O&G Flashcards
A few of these questions are taken from '450 SBAs in Clinical Specialities' which is an amazing resource. Those questions have an acknowledgement in the answer
Which of the following describes the first test typically used to screen pregnant women, that could indicate the risk of Down’s syndrome?
A. An USS performed at 20 weeks to assess for 11 major rare disorders
B. An USS performed between 11-14 weeks which assesses for associated cardiac and facial abnormalities
C. A sample of amniotic fluid taken from the 15th week which is analysed to detect fetal genetic or chromosomal abnormalities
D. Serum B-hCG and PAAP-A supplemented by an USS
E. A sample of placental villus taken from the 11th week which is analysed to detect fetal genetic or chromosomal abnormalities
D. Serum B-hCG and PAAP-A supplemented by an USS
As standard, the screening program for pregnant women is as follows:
11-14 weeks - dating scan and combined Down’s syndrome test. The dating scan itself can be done between 8-14 weeks, but this is restricted to 11-14 weeks if the mother wishes to screen for Down’s syndrome.
20 week - a USS to look for 11 rare but serious fetal abnormalities.
A 13 year old girl presents to a GUM clinic with concerns she may be pregnant. She reveals she has recently become sexually active with an older boy at her school. A pregnancy test is negative. She also says she has noticed some suspicious discharge.
What is the most important step for the doctor to take?
A. Counsel her on safe sexual practice in the future, and inform a colleague about your decision to maintain her privacy
B. Ask further questions about the nature of the relationship to ascertain whether there is any abuse
C. Advise her that she should use contraception, but it cannot be prescribed unless she returns accompanied by a parent or guardian
D. Inform the police, as is a legal imperative in a case of sexual activity in a child
E. Assess the girl’s capacity to consent, with a view to prescribing antibiotics if she is competent
B. Ask further questions about the nature of the relationship to ascertain whether there is any abuse
A doctor has no legal obligation to report underage sexual activity UNLESS there are signs of abusive or harmful activity. ‘A’ is a good answer in that she should be counselled, and the decision to maintain privacy of a young child in this case should be shared with a designated doctor, but the relationship should be assessed for harm or abuse before making the decision to preserve confidentiality.
‘C’ is untrue, as providing the child satisfies the requirements of the Fraser guidelines, they can be given contraception. ‘D’ is untrue because you are not necessarily legally compelled to break confidentiality here; you need to assess the nature of the relationship, and if it is abusive or harmful you would be compelled to break confidentiality.
‘E’ is true, as the child may be found to be Gillick competent, but not the biggest concern at the time.
NB: the difference between Gillick competence and Fraser guidelines
A 27 week pregnant woman presents to the maternal assessment unit with bright red vaginal spotting. She says this has happened twice over the past 3 weeks. She denies any pain but is extremely concerned for her baby.
What is the most appropriate next step in her management?
A. Admit to the antenatal ward, establish IV access, consider steroids, and employ a watch and wait approach
B. Perform an USS to determine the location of the placenta
C. Admit to the antenatal ward, attach a CTG probe, and take FBC and G&S
D. Take a focused history and basic obs, and perform a digital vaginal examination
E. Admit to the labour ward, inform a senior obstetrician, and take FBC, LFTs, U&Es, Coagulation screen, and X-match for 4 units
C. Admit to the antenatal ward, attach a CTG probe, and take FBC and G&S
This is a history of placenta praevia and, though an USS will confirm the diagnosis, it is more urgent to first establish the welfare of the fetus and take bloods to help predict and address haemorrhage. FBC, and G&S should always be taken, along with clotting studies and cross match depending on the severity of the bleeding and the clinical background.
A history of a painless bleed on a background of previous smaller bleeds is suggestive of placenta praevia - where the placenta lies in the lower segment of the uterus and may obstruct the internal cervical os. Placenta praevia complicates only 0.5% of pregnancies at term, but 10 times as many seem to feature a low-lying placenta at 20 weeks. This is because after 20 weeks the lower segment of the uterus expands, hence 90% of low-lying placentas then appear to move up.
The most obvious complication of placenta praevia is that it will obstruct the descent of the baby into the pelvis, and so will impair vaginal delivery.
Once the immediate health of mother and baby has been established, the source of the bleeding is identified, and the bleeding has stopped, the mother can potentially be sent home.
VAGINAL EXAMINATION SHOULD NEVER BE CARRIED OUT IN A PREGNANT WOMAN BLEEDING VAGINALLY WITHOUT EXCLUDING PLACENTA PRAEVIA - IT CAN PROVOKE MASSIVE BLEEDING.
Which of the following CTG traces would be considered pathological?
A. Decelerations with varying recovery periods in a woman who is 10cm dilated and has begun to push
B. Decelerations of 35bpm that occur only with contractions
C. Fetal heart rate of 105bpm in a 42+3 week baby with a transverse lie
D. Spikes in fetal heart rate from 150bpm to 170bpm occurring with uterine contractions
E. A stable fetal heart rate of 130bpm that has not varied by more than 5bpm for the last hour
E. A stable fetal heart rate of 130bpm that has not varied by more than 5bpm for the last hour
According to NICE guidelines, CTG traces can be classified as: normal, suspicious, pathological, or showing a need for urgent intervention. These categories are defined by the number of reassuring, non-reassuring, and abnormal CTG characteristics that appear:
Normal: all features are reassuring
Suspicious: 1 non-reassuring feature
Pathological: 1 abnormal feature OR 2 non-reassuring features
Needs urgent intervention: acute bradycardia, or a single deceleration lasting 3 minutes or more
A g3p0 pregnant woman is found to be Rh- at her 10 week booking appointment. The subsequent test for Rh D antibodies is positive, thought to be due to sensitisation in her 2 previous miscarried pregnancies. Her D-antibody levels are measured every 4 weeks, and she is referred to a fetal medicine specialist who monitors for fetal anaemia.
Which is the most appropriate method to monitor for fetal anaemia?
A. Regular USS to monitor the volume of amniotic fluid
B. Umbilical vein blood sampling
C. Fortnightly blood tests for fetal bilirubin
D. Continuous fetal heart monitoring past the 20th week of pregnancy
E. Doppler ultrasound scan of the middle cerebral artery
E. Doppler ultrasound scan of the middle cerebral artery
An MCA doppler is useful to monitor for fetal anaemia because of the physiological response to anaemia: the fetus will protect its most vital organs (particularly the brain) and so will increase its cardiac output, and especially the flow to the brain. This can be detected on a doppler scan of the middle cerebral artery (MCA). If fetal anaemia is suspected, umbilical vein sampling can be used to quantify the anaemia, though this carries a 1% chance of fetal loss.
Which of the following locations is endometriosis least likely to affect?
A. Fallopian tubes B. Vesico-uterine pouch C. Utero-sacral ligaments D. Rectum E. Recto-uterine pouch
D. Rectum
Endometriosis is defined as growth of endometrial tissue outside of the uterus. The most commonly affected sites are the recto-uterine pouch (Pouch of Douglas), the vesico-uterine pouch, the utero-sacral ligaments, the ovaries, and the fallopian tubes. Endometriosis can spread to affect any pelvic or abdominal organ, though this is less likely.
Endometriosis is an historically under-diagnosed and underestimated disease: it is diagnosed in 1-2% of women, but is estimated to affect 10%. Endometriomas are functionally similar to endometrium, meaning they become painful and bleed once a month. This cycle of inflammation and bleeding leads to painful irritation of the peritoneum and scarring. If this scarring occurs on the fallopian tubes or ovaries, it can impair fertility, and indeed the prevalence of endometriosis in subfertile women is 30-50%.
Even more importantly, endometriosis causes chronic pelvic pain. The pain usually begins ~4 days before the woman’s period, and is poorly localised in the pelvis or abdomen. The pain is not accompanied by excess vaginal bleeding as the affected locations do not communicate with the vagina, though PR bleeding may occur if the rectum or colon are involved. The impact of the chronic pain of endometriosis on quality of life is massive, so it is worth keeping this differential in mind for pain presentations.
Treatment is with hormonal options (Mirena coil, COCP, progesterone preparations, temporary menopause with GnRH agonist), analgesia, and laparoscopic removal of lesions if necessary.
Which of these diseases is likely to reduce in severity during pregnancy?
A. Rheumatoid arthritis B. Asthma C. Systemic lupus erythematosus D. Scleroderma E. Atopic dermatitis
A. Rheumatoid arthritis
During pregnancy there is a shift in the body’s immune system away from Th1-mediated responses, towards Th2 responses. This means that Th1-mediated diseases such as rheumatoid arthritis and multiple sclerosis will improve during pregnancy (though they will tend to rebound sharply afterwards).
A woman with a diagnosis of PCOS attends her local GP surgery asking for advice on getting pregnant, and how her condition will affect that.
Which of the following statements is false?
A. In PCOS women with insulin resistance, metformin improves live healthy birth rate
B. She is more likely to experience first trimester miscarriages than unaffected women
C. She is at no increased risk of pre-eclampsia
D. Letrozole is an alternative to clomiphene for ovulation induction with a lower chance of causing multiple pregnancy
E. Weight loss and diet control alone improve pregnancy outcomes
C. She is at no increased risk of pre-eclampsia
Which of the following CTG traces would be considered suspicious (by NICE guidelines)?
A. Early decelerations occurring with contractions, with a fetal heart rate of 150bpm
B. Rapid decelerations with varying recovery periods present for half an hour, with a heart rate of 130bpm and baseline variability of 15
C. Decelerations that start at the peak of uterine contraction and recover after the contraction ends, persisting for 40 minutes
D. A smooth, regular, wave-like pattern on the CTG cycling at a frequency of ~4Hz
E. Baseline heart rate of 105bpm with a baseline variability of 10bpm
E. Baseline heart rate of 105bpm with a baseline variability of 10bpm
A baseline heart rate of 100-110bpm is a non-reassuring trait, but the baseline variability is within the acceptable range of 5-25 bpm (all based on NICE guidelines). The presence of 1 non-reassuring trait makes this a suspicious CTG.
A and B are reassuring
C and D are pathological
A nulliparous 32 year old woman visits a fertility specialist regarding her trouble in conceiving. She has a PMHx of chronic pelvic pain, and has previously been investigated for possible pelvic inflammatory disease, IBS, and cystitis to no avail. She states that her pain is not constant, but begins four days before her period and lasts for the period’s duration. She also experiences deep dysparenunia, which ultimately led to her last break up and an inability to form any new relationships. On vaginal exam there are no abnormalities, though the patient reports deep tenderness. Her AMH is normal, and USS of the ovaries shows a good number of antral follicles, though hysterosalpingography shows impaired filling of the Fallopian tubes.
Given the likely diagnosis and the patient’s history, which of the following is the most appropriate management?
A. Hysterectomy with bilateral salpingo-oopherectomy
B. Laparoscopic destruction of endometrial lesions
C. NSAIDs and paracetamol, with potential for addition of opiates
D. Continuous COCP use
E. Implantation of the Mirena coil
B. Laparoscopic destruction of endometrial lesions
This case requires a management that alleviates the chronic pain but preserves fertility and allows this woman to continue trying to get pregnant, hence ‘A’, ‘D’ and ‘E’ are unsuitable. ‘C’ seems a fairly inadequate response for severe chronic pain, which this woman has probably tried using OTC analgesia for. Opiates are a bad idea for use in chronic pain.
Endometriosis is defined as growth of endometrial tissue outside of the uterus. The most commonly affected sites are the recto-uterine pouch (Pouch of Douglas), the vesico-uterine pouch, the utero-sacral ligaments, the ovaries, and the fallopian tubes. Endometriosis can spread to affect any pelvic or abdominal organ, though this is less likely.
Endometriosis is an historically under-diagnosed and underestimated disease: it is diagnosed in 1-2% of women, but is estimated to affect 10%. Endometriomas are functionally similar to endometrium, meaning they become painful and bleed once a month. This cycle of inflammation and bleeding leads to painful irritation of the peritoneum and scarring. If this scarring occurs on the fallopian tubes or ovaries, it can impair fertility, and indeed the prevalence of endometriosis in subfertile women is 30-50%.
Even more importantly, endometriosis causes chronic pelvic pain. The pain usually begins ~4 days before the woman’s period, and is poorly localised in the pelvis or abdomen. The pain is not accompanied by excess vaginal bleeding as the affected locations do not communicate with the vagina, though PR bleeding may occur if the rectum or colon are involved. The impact of the chronic pain of endometriosis on quality of life is massive, so it is worth keeping this differential in mind for pain presentations.
Treatment is with hormonal options (Mirena coil, COCP, progesterone preparations, temporary menopause with GnRH agonist), analgesia, and laparoscopic removal of lesions if necessary.
Which of the following is the most important diagnostic tool for ectopic pregnancy?
A. Trans-vaginal USS B. Trans-abdominal USS C. One off serum beta-hCG D. Serial serum beta-hCGs E. MRI
A. Trans-vaginal USS
Serial beta-hCGs may be useful in guiding treatment, but TVUSS is the diagnostic investigation of choice. One-off beta-hCG should be used to confirm the diagnosis alongside TVUSS, and MRI may be useful in diagnosing Caesarean scar pregnancies.
Define placenta accreta, increta, and percreta
Accreta - the placenta invades past the basement membrane of the decidua (endometrium) and attaches to the myometrium
Increta - the placenta invades into the myometrium
Percreta - the placenta invades through the full thickness of the myometrium and may invade local organs
Cord prolapse occurs after rupture of membrane in 0.2% of births when the cord descends and becomes compressed. It is an emergency and can lead to fetal hypoxia if not dealt with.
Which of the following most increases the risk of cord prolapse?
A. Advanced maternal age B. Fully extended breech position C. Oligohydramnios D. Preeclampsia E. A transverse lie
E. A transverse lie
Cord prolapse is particularly associated with a transverse lie because that position creates the space through which the cord may exit the uterus. Though breech position increases the risk, at least in a fully extended breech the baby mostly obscures the internal cervical os.
Cord prolapse is an obstetric emergency as it may lead to rapid fetal hypoxia and death. The mother should be placed either with her knees to her chest, or in the Trendelenburg position (supine and with a feet elevated incline) and the presenting part of the baby should be elevated to avoid cord compression. Urgent delivery is necessary, generally via Caesarean section.
Which of the following statements comparing chorionic villus sampling (CVS) with amniocentesis is correct?
A. Amniocentesis is not necessarily accurate due to a risk of placental mosaicism of fetal cells
B. CVS carries ~3% risk of miscarriage, whereas amniocentesis has ~1% risk
C. Amniocentesis features as part of routine screening for pregnancies, but CVS does not
D. CVS can be carried out 4 weeks earlier than amniocentesis
E. Amniocentesis has the advantage of being performed earlier, giving the mother more time to make decisions
D. CVS can be carried out 4 weeks earlier than amniocentesis
CVS and amniocentesis are two tests used to look for genetic fetal abnormalities, and both carry a 1% risk of causing spontaneous miscarriage of a pregnancy. Neither one is considered superior in terms of accuracy of diagnosis, though there is a risk with CVS that mosaic cells (genetically different lineage) in the placenta will be sampled giving a false diagnosis.
CVS is usually performed between 11-14 weeks, and amniocentesis between 15-20 weeks; both can be performed later if needed, but not earlier. because of a higher risk of pregnancy loss. Neither one is part of a routine screening program, but is offered to pregnant women if there is considered to be a high risk of a genetic condition. CVS is arguably superior because it can be done earlier and so gives parents more time to make decisions about the pregnancy.
Which bloods and measurements should be taken as standard in someone with suspected preeclampsia
Blood pressure 24 hour urinary protein or dipstick or PCR Serum urea, creatinine, and uric acid FBC LFTs U&Es PTT
What is the underlying pathology of polyhydramnios?
Either increased fetal urine production (gestational diabetes, TTTS) or reduced fetal swallowing (duodenal atresia, bowel malformation, chromosomal abnormality, neurological issue)
Infection also associated
You examine the abdomen of a 32 week pregnant woman.
Which of the following findings would be abnormal?
A. A hyperpigmented line running down the midline of the abdomen
B. Being able to palpate five 5ths of the fetal head
C. A fundal height of 28cm
D. A fetal heart rate of 160bpm
E. A cephalic presentation
C. A fundal height of 28cm
The general rule for fundal-symphysial height is that from 24 weeks, it is equal to the gestation +2cm.
What is the underlying pathology of oligohydramnios?
Reduced amniotic fluid because of either loss (rupture of membranes) or decreased production (TTTS, urinary tract pathology, placental insufficiency)
Describe the pathophysiology of preeclampsia
Insufficient spiral artery remodelling leads to a lack of placental blood flow. This causes placental hypoxia, causing syncytiotrophoblast microparticles to be shed into the maternal circulation which causes systemic endothelial damage. This reduces NO and prostacyclin production leading to vasoconstriction, and also makes vessels leaky, leading to oedema and proteinuria.
A 17 year old girl presents to A&E with lower abdominal pain. She reports her periods have not been regularly coming, though she has had some irregular bleeding.
What is the most appropriate next step?
A. Take LFTs and U&Es B. USS of the pouch of Douglas C. TVUSS of the ovaries D. Take a clotting screen, G&S, and X-match E. Take a urinary b-HcG
E. Take a urinary b-HcG
Whilst there are a range of possible differentials for this presentation, a very important one is ectopic pregnancy, and this can be tested for very quickly and easily using a urinary pregnancy test.
A 29-year-old woman is seen at her booking visit and has blood taken for screening.
Which of these is the most appropriate set of booking tests?
A. Hepatitis C, human immunodeficiency virus (HIV), syphilis and toxoplasmosis
B. Rubella, hepatitis B, hepatitis C and syphilis
C. Syphilis, hepatitis B and HIV
D. HIV, cytomegalovirus, rubella and hepatitis B
E. HIV, syphilis, rubella and group B Streptococcus
C. Syphilis, hepatitis B and HIV
The serum tests for infection that NICE recommend as an offer at booking are syphilis, HIV, and hepatitis B (C). Cytomegalovirus (D) is a DNA virus that usually leads to asymptomatic infection. Transmission to the fetus leading to damage occurs in about 10 per cent of cases.
Forty to 50 per cent of all women of childbearing age have not had cytomegalovirus infection so it is not cost effective to screen everyone. Toxoplasmosis is contracted from such things as undercooked/cured meat and cat faeces. It is not routinely tested for in pregnancy as the low risk of toxoplasmosis (A) becoming a florid infection rather than an indolent disease in a non-immunocompromised infection makes it not worthwhile. It is not cost effective to test for hepatitis C (B).
Rubella used to be screened for as maternal infection in the first trimester causes 20% pregnancy loss and 90% congenital syndrome in the surviving babies. however Rubella is now rare enough that it is not cost effective to screen for it.
NB: This question is modified from ‘450 SBAs in Clinical Pathology’
Which of the following is not a physiological change in pregnancy?
A. 20-30% increase in red cell mass but up to 50% increase in plasma volume by term causing a dilutional anaemia
B. Increase tidal volume and minute ventilation due to the effects of progesterone
C. A drop in cardiac output immediately after delivery
D. A reduction in peripheral vascular resistance
E. 40% increase in cardiac output by 20 weeks
C. A drop in cardiac output immediately after delivery
Immediately after delivery CO increases to 60-80% more than pre-pregnancy because of the alleviation of pressure on the IVC by the gravid uterus. CO then rapidly returns to pre-pregnancy values within an hour or so post-partum.
Arterial pressure may decrease in mid-pregnancy, but will recover in the third trimester.
Which of the following options describes the start of labour?
A. From when the cervix reaches 10cm dilated
B. From the beginning of cervical dilatation accompanied by painful contractions
C. From when contractions reach a frequency of 3 in 10 minutes
D. From when the head is fully engaged in the pelvis (two fifths or less of the head palpable)
E. Rupture of the membranes
B. From the beginning of cervical dilatation accompanied by painful contractions
Labour is considered to start when painful contractions and cervical dilatation begin. This marks the start of the latent phase of the first stage of labour, which is generally slow. Once cervical dilatation reaches 4cm, the cervix dilates more rapidly, by about 1cm/hr in nulliparous women, and 2cm/hr in multiparous women. This second part is known as the active phase, and once a woman enters this phase they are said to be ‘in established labour’. The first stage of labour is complete when the cervix dilates to 10cm.
The second stage then covers the time from full dilation to delivery of the baby. The passive stage comes first, where the baby’s head descends into the pelvic floor. Once the mother feels the urge to push, the active stage begins. In practice the management of this stage will differ, but often women will be given ‘a passive hour’ from the time they are fully dilated to allow the baby to descend into the pelvis. Once the active stage begins, the baby is generally delivered relatively quickly (average 40 minuts in nullips, 20 minutes in multips) though it varies. If the active stage lasts over an hour, spontaneous vaginal delivery becomes unlikely and other options should be considered. However this stage may also resolve extremely quickly (the fastest I have seen is an active stage of 6 minutes).
The final stage is from delivery of the baby to delivery of the placenta. Up to 500mL of blood loss is considered acceptable in a vaginal birth. It is important to check that the whole placenta has been delivered, as it is surprisingly rigid and may hold open sections of the uterus. This is concerning because the uterus needs to clamp down after parturition in order to clamp off the spiral arteries, as they have been remodelled so that they cannot constrict. The uterus should be felt after parturition to feel whether it has contracted: if it has not, this is called uterine atony and they are at risk of post-partum haemorrhage.
A 32-year-old HIV positive woman who booked for antenatal care at 28 weeks gestation arrives on the delivery suite at 37 weeks with painful regular contractions and a cervix dilated to 4 cm. Ultrasonography confirms a breech singleton pregnancy with a reactive fetal heart rate.
What is the most appropriate management option?
A. Await onset of labour, avoid operative delivery, wash the baby at delivery
B. Induce labour with synthetic prostaglandins
C. Await onset of labour, but have a low threshold for expediting vaginal delivery using forceps
D. Await onset of labour, avoid operative delivery, administer steroids to the infant immediately after birth
E. Caesarean delivery, wash the baby at delivery
E. Caesarean delivery, wash the baby at delivery
Although knowledge of managing HIV positive pregnant women is beyond the scope of most undergraduate curricula, in this question the presence of HIV infection is largely a distractor. Delivery of HIV positive women aims to lower the risk of vertical transmission and reduce morbidity. Washing the baby shortly after delivery is a part of that strategy. Induction of labour (B) is not indicated unless there is a benefit to expediting delivery, which in the vignette above there is not.
Interventions which increase the risk of maternal/fetal blood transfusion (and therefore vertical transmission), such as amniocentesis, fetal blood sampling or forceps delivery, are avoided in HIV positive women so (C) is incorrect. Giving neonates steroids (D) is not warranted here for any reason. (A) and (E) could both be correct if the woman had a cephalic singleton delivery. However, this woman is at term, not in established labour and has a breech singleton pregnancy. Following publication of the planned vaginal versus caesarean delivery trial in 2000, which demonstrated improved fetal outcomes with caesarean delivery, most centres now exclusively offer elective caesarean section for these mothers. Hence, even if the woman was not HIV pregnancy, (E) would remain the single best answer.
NB: This question is reproduced from ‘450 SBAs in Clinical Pathology’
A 28 year old woman attends an appointment with her doctor to talk about getting pregnant. She is a known epileptic who has been well-controlled on sodium valproate for the last 5 years (i.e. since diagnosis). She wants to know how pregnancy will affect her condition, and what changes in her management may be needed.
What should the doctor tell her?
A. She will need to take the standard 400mcg dose of folic acid
B. Her medication dose will need to be increased, and then decreased shortly after birth
C. She will probably experience an increase in seizure activity during pregnancy, but this can be mitigated by drug dosage changes and monitoring
D. Sodium valproate given at the lowest therapeutic dose has no association with birth defects
E. She is at no more increased risk of psychiatric issues during pregnancy than a non-epileptic person
B. Her medication dose will need to be increased, and then decreased shortly after birth
‘A’ is wrong because women with epilepsy are recommended to take the higher 5mg dose of folic acid, as there is some evidence it reduces the incidence of congenital malformation in children of woman taking anti-epileptic drugs (AEDs).
‘B’ is correct because there is increased renal and hepatic clearance of drugs during pregnancy which, in addition to the haemodilution, necessitates a higher dose of AEDs. However these changes rapidly reverse post-partum, and so any epileptic woman whose AED dose was increased during pregnancy should be reviewed within 10 days post-partum to adjust the dose.
‘C’ is incorrect because most women will not experience seizure deterioration during pregnancy. Overall about 1/3 of epileptic women experience a deterioration during pregnancy, and the best predictor for this is their seizure activity immediately prior to pregnancy - if their epilepsy is well-controlled, they are unlikely to have seizures while pregnant. Epileptic women are particularly vulnerable to seizures during delivery and immediately post-partum, mostly due to the exhaustion and dehydration that accompanies that period.
‘D’ sodium valproate is associated with neural tube defects. There are conflicting opinions as to whether carbamazepine causes neural tube defects depending on who you ask. Lamotrigine is generally considered safe during pregnancy.
‘E’ is incorrect as both certain varieties of epilepsy and certain AEDs carry an increased risk of depression. This means that epileptic mothers are more at risk from depression during and immediately after pregnancy, and should be made aware so they can monitor any symptoms that arise and seek help.
NB: Babies born to mothers taking AEDs particularly need their vitamin K injection if the AED is enzyme inducing
A 37 week pregnant woman attends labour ward after her waters broke at home. She had been insistent on a home birth, but after several painful hours she has agreed to come to hospital. She is a known epileptic, and has been taking lamotrigine during her pregnancy. Several hours later the midwife checks her, and she is 8cm dilated, but tired and stressed. She begins to have a seizure shortly afterwards.
How should this seizure be managed?
A. Give I.V. Hartmann’s and supplementary oxygen if saturations dip, and take her immediately to theatre for C-section
B. Give tocolytics to reduce impact on the fetus, and wait for the seizure to self-terminate (give I.V. benzodiazepines if still seizing at 15 minutes)
C. Give I.V. lorazepam, consider I.V. phenytoin and tocolytics if seizures and uterine hypertony persist
D. Give rectal diazepam immediately, then repeat at 15 minutes if the seizure fails to terminate
E. Give buccal midazolam and begin an I.V. dextrose infusion
C. Give I.V. lorazepam, consider I.V. phenytoin and tocolytics if seizures and uterine hypertony persist
The acute management of a seizure in a pregnant woman is very similar to that of a non-pregnant person having an epileptic seizure.
First line management is to give I.V. lorazepam, which is usually achievable as women in labour should already have at least one cannula in situ. Diazepam can be given I.V. as an alternative. If there is no I.V. access, then rectal diazepam or buccal midazolam can be given, so ‘D’ and ‘E’ are good second line options. If seizures are not controlled by initial steps, I.V. phenytoin or fosphenytoin is given.
I.V. Hartmann’s and supplementary oxygen (A) may well be needed depending on oxygen saturations and hydration status/ blood pressure, but are not the best option here. Tocolytics may be used for a seizure during labour, but only if there is persistent uterine hypertonus due to the seizure and you become concerned for the fetal wellbeing. The CTG should be continuously monitored, and the decision to expedite delivery should be considered.
A nervous 42-year-old woman presents herself to your antenatal clinic very worried that she has missed the right time to have her combined test for Down’s syndrome screening. She is now 17 weeks pregnant and is very concerned about her age. You counsel her about the appropriate alternative, the quadruple test and arrange to have this done.
Which assays make up the quadruple test?
A. AFP, PAPP-A, inhibin B and beta hCG
B. Unconjugated oestriol, hCG, AFP and inhibin A
C. Beta hCG, PAPP-A, nuchal translucency and inhibin A
D. AFP, inhibin B, beta hCG and oestriol
E. Unconjugated oestriol, PAPP-A, beta hCG and inhibin A
B. Unconjugated oestradiol, hCG, AFP and inhibin A
Down’s syndrome screening is offered to all pregnant women in the UK. She is 42 which gives you an age related risk of one in 55 of having a child with Down’s syndrome. Early in the second trimester the combined test is offered. This includes an ultrasound scan of the fetal neck looking at the nuchal translucency (NT) and two blood tests – PAPP-A and beta hCG. This can be reliably performed from 10 to 13 weeks. Ideally, an integrated test using the combined test and the quadruple test can be used to create a Down’s risk.
As she has missed the chance to have an NT, she would only be offered the quadruple test, which is unconjugated oestradiol, total hCG, AFP and inhibin A – Answer (B). The downside of the quadruple test is that it has a 4.4 per cent false-positive rate compared with 2.2 per cent for the combined test and only 1 per cent for the integrated test. In the event of a high risk result, this woman would be offered an amniocentesis to exclude Down’s syndrome and other chromosome abnormalities.
NB: This question is reproduced from ‘450 SBAs in Clinical Pathology’
A 38 year old woman who is 11 weeks pregnant presents with spotting and lower abdominal cramping pain. Her observations are stable, and a speculum exam shows the cervical os is closed. During the history she states she has not passed any clots or solid products through her vagina. Her observations and history show she is otherwise well, and she has had no other issues or bleeding during this pregnancy. A TVUSS shows a normal CRL for 11 weeks.
What is the best next step?
A. Give a progesterone analogue
B. Prescribe a 10 day course of erythromycin and monitor fetal cardiac activity
C. Perform a serum b-hCG test and use the result to guide management
D. Counsel the woman that this history is indicative of a miscarriage, and discuss options for delivery/removal of products of conception
E. Counsel the woman that the fetus is alive, but there is a 1 in 4 risk of miscarriage
E. Counsel the woman that the fetus is alive, but there is a 1 in 4 risk of miscarriage
This is most likely a threatened miscarriage, in which there is bleeding but the os is closed and the fetus is still alive; it carries a 25% of actual miscarriage. Because the fetus is still alive, the USS should show a fetal pole and cardiac activity (detectable on USS from 5-6 weeks onwards).
‘A’ would imply a missed miscarriage - the fetus has died some time prior but the products of conception have not been passed so the mother is unaware. Later in pregnancy, this may be evident as the uterus will be smaller than expected. ‘B’ implies a septic miscarriage, as these are signs of infection, though there is nothing here to suggest this would be the case. ‘C’ is referring to the lower levels of beta-hCG seen in ectopic pregnancy. Ectopic pregnancy is a very important differential to exclude, but occurs in ~1% of pregnancies making miscarriage more likely
Molar pregnancy (D) is a possible differential, but occurs in 0.1% of pregnancies, whereas miscarriage occurs in ~20% of clinical pregnancies, especially in the first trimester, making ‘E’ a more likely finding.
A 7 week pregnant woman presents to antenatal clinic with nausea and vomiting of 2 weeks duration. She has been vomiting 6 times per day and has had trouble keeping food down at all.
What is the most appropriate next step?
A. Tell her to purchase OTC 1st generation antihistamines and come back in a week
B. Assess her hydration status, weigh her, and take bloods
C. Prescribe her dexamethasone and tell her to buy over the counter oral rehydration salts
D. Establish I.V. access, give Hartmann’s solution, then take a VBG to assess electrolytes
E. Prescribe vitamin supplements and assess the baby’s growth every 2 weeks after the dating scan
B. Assess her hydration status, weigh her, and take bloods
Hyperemesis gravidarum can be diagnosed when there is persistent nausea and vomiting in pregnancy (NVP) with the triad of >5% weight loss, electrolyte imbalance, and dehydration.
It usually follows the same pattern as regular morning sickness in that it begins around 4 weeks and usually disappears by 14-20 weeks. UTI, multiple pregnancy, and molar pregnancy can all cause hyperemesis gravidarum, and so should be routinely excluded.
A g2p1 woman attends the antenatal clinic to discuss options for the birth of her current pregnancy, and for her family planning thereafter. She delivered her previous baby by C-section, which was indicated by a failure to progress in labour, and is very keen for this baby to be delivered naturally.
How should you advise this woman?
A. There is a 1 in 5 chance she will need an emergency C-section anyway
B. A previous C-section using a lower uterine segment incision is a contra-indication to vaginal birth
C. 2 previous C-sections with no vaginal births is an absolute contra-indication to planning a vaginal birth
D. There is a ~2% risk of uterine rupture at the site of the previous C-section scar
E. Her failure to progress in a previous labour, combined with her never having given birth vaginally, make vaginal birth less likely
E. Her failure to progress in a previous labour, combined with her never having given birth vaginally, reduces the likelihood of vaginal birth
Vaginal birth after a previous C-section (VBAC) is complex, and each mother must be assessed individually on their suitability for vaginal birth. A successful VBAC carries the lowest risk of all options, but a failed VBAC with emergency C-section carries the highest, therefore the risks need to be appropriately weighed.
Advise her there is a 75% chance of success, but that attempting and failing vaginal birth to then perform an emergency C-section is the riskiest option. There is also an increased (~0.5%) risk of uterine rupture at the site of the C-section scar, which would necessitate a hysterectomy and would probably result in significant haemorrhage.
The best indicator of a successful VBAC is a previous vaginal birth, especially a previous VBAC which makes the odds of another successful VBAC 85-90%.
How should you monitor for toxicity in a patient receiving magnesium sulphate prophylaxis against eclampsia?
Monitor pulse, RR, and blood pressure, and test the patellar tendon reflex
This should be done at least once every 4 hours
A G1P0 32+0 week pregnant woman presents to A&E after she experienced a sudden gush of clear fluid from her vagina. There was no associated pain or bleeding. On speculum examination the cervix is closed with no bulging membranes and there is a pool of fluid in the posterior fornix. Her obs are recorded, bloods are taken, and a CTG is performed.
SO2: 98% RA HR: 71bpm BP: 115/83mmHg Temp: 36.7 Hb: 108g/L WCC: 8x10^9/L CRP: <3mg/L CTG: fetal heart rate 150bpm, variability 25bpm, some early decelerations
How should this patient be managed?
A. TVUSS to assess the liquor volume, discharge with safety netting if normal
B. Admit her and perform an IGFBP‐1 or PAMG‐1 test
C. Admit her, give erythromycin and steroids, and employ a watchful waiting approach
D. Give steroids and aim to induce labour within 24 hours
E. Continuous CTG monitoring for 24 hours, discharge with safety netting and follow-up if non-concerning
C. Admit the woman, give a 10 day course of erythromycin, offer steroids, and employ a watchful waiting approach
In a woman presenting with rupture of the membranes between 24+0 and 36+6 weeks, a speculum exam should be performed. If the speculum exam is not clear (does not show pooled liquor) then an IGFBP‐1 or PAMG‐1 test is a sensitive and specific marker to aid diagnosis. If PPROM is confirmed, the patient should be admitted for at least 48 hours as in >50% of cases preterm labour follows PPROM within 48 hours. Patients with no contraindications should be offered expectant management until 37 weeks with frequent clinical assessment.
Infection often co-exists with PPROM and may be either the result or the cause: the earlier the gestation, the more likely the infection is to have caused PPROM. Infection is an important complication and should be assessed using a combination of maternal history, maternal abdominal exam, CTG monitoring, bloods including a CRP and WCC, and potentially a high vaginal swab (though none of these should be used in isolation). Any woman presenting with PPROM should be given a course of antibiotics for 10 days or until she is in established labour – whichever comes first. Erythromycin is the first-line antibiotic. Co-amoxiclav is contraindicated as it raises the risk of necrotising enterocolitis in the newborn.
A. This patient requires admission and the measurement of amniotic fluid volume in the context of PPROM using ultrasound is not recommended or supported by evidence.
B. This would be a good answer if the speculum examination were less conclusive, but is unnecessary here.
D. There is no reason to induce labour here
E. There is no indication for continuous CTG monitoring and this woman should not be discharged home given the risk she will deliver soon.
NB: “established labour” refers to the second part of the first stage of labour: when the cervix dilates from 4cm to 10cm.
A 20 week pregnant woman attends antenatal clinic for the 18-21 week abnormality scan. No fetal abnormalities are detected, and baby looks to be growing well, however the placenta is observed to be low-lying, close to the internal cervical os.
What is the most appropriate next step?
A. Counsel the woman that 60% of low-lying placentas do not progress to placenta praevia, and that you will reassess its position later
B. Do nothing for the moment but offer the woman a follow-up scan at 32 weeks
C. Measure the distance from the nearest placental edge to the cervical os; if it is within 20mm, book the woman for Caesarean section at 37 weeks
D. Counsel the mother that vaginal birth will not be safe, and that an elective C-section is the best option
E. Counsel the mother that if the placenta is >10mm from the cervical os at 32 weeks, it is safe to proceed with a vaginal birth
B. Do nothing for the moment but offer the woman a follow-up scan at 32 weeks
5% of pregnancies feature a low-lying placenta at 20 weeks, but only 10% of these are still low-lying at term. This is because the lower segment of the uterus expands later than the upper segment, so low-lying placenta usually ‘move up’ after 20 weeks. It is important to determine whether this position will persist, so the mother should be invited for a TVUSS at 32 weeks, and then again at 36 weeks if it is still low-lying. If the placenta is lying directly over the internal cervical os, then it is praevia. If the placenta does not cover the os but is within 20mm, then it is low-lying (this distinction is used because of the difference in risks during delivery). Cervical length should also be assessed at 32 weeks, as this indicates risk of preterm labour and massive haemorrhage during C-section.
She should be counselled that if the placenta is low-lying or praevia, that vaginal birth may be inadvisable or impossible depending on the placenta’s position. She should also be told to attend hospital urgently if she experiences abdominal pain, contractions, or vaginal bleeding. She should be counselled on the risk of massive haemorrhage with delivery, and should be consented to receive blood products and potentially a hysterectomy in the worst case scenario.
A 33 week pregnant woman presents to A&E with increasingly frequent contractions, and is worried she may be going in to labour. The SHO takes a history, basic obs, and a urinary sample for analysis. They then examine her abdomen, attach a CTG probe (the trace is reassuring), and perform a speculum exam. The cervix is closed, and there is no fluid suggestive of ruptured membranes.
What is the most appropriate next step?
A. Perform a TVUSS to measure cervical length
B. Contact PICU to secure a bed, and arrange a C-section delivery
C. Perform a fetal fibronectin test to assess whether she is in preterm labour
D. Give nifedipine or atosiban along with corticosteroids for fetal tissue maturation
E. Give a bolus of I.V. magnesium sulphate and start an infusion lasting for 24 hours or until birth
A. Perform a TVUSS to measure cervical length
In a woman presenting with potential preterm labour, the stage of pregnancy has a small effect on how you diagnose her: if she is less than 30 weeks pregnant and the history and exam suggest preterm labour, then proceed to treatment. If she is 30 weeks pregnant or more, then a TVUSS can be used to assess cervical length: a length of 15mm or less is diagnostic of preterm labour. If TVUSS is contraindicated or unacceptable, then fetal fibronectin can be used instead, but guidelines specifically state not to use the two together. If the cervix were dilated and it was clear she was in labour, this step would be unneccessary.
Once preterm labour is diagnosed, tocolysis can be attempted to stop the labour. First line is nifedipine (CCB) but oxytocin receptor antagonists (e.g. atosiban) can be used if nifedipine is contraindicated. Magnesium sulphate is given I.V. to the mother for neuroprotection of the preterm baby, and corticosteroids should be given to help mature the preterm baby’s lungs.
‘D’ and ‘E’ are therefore both correct treatment options once preterm labour is diagnosed, but are not the best next step. ‘B’ is wrong as there are no indications for C-section, and ‘C’ is unnecessary as there are no contraindications to TVUSS, and there is no need to use the two diagnostic methods together.
Assuming no prior results were available for comparison, which of the following blood results would be most useful in diagnosing HELLP syndrome?
A. A low haemoglobin B. Elevated CRP C. Elevated AST and ALT D. Low platelets E. Elevated ALP
C. Elevated AST and ALT
Though thrombocytopenia and anaemia are components of HELLP syndrome, they are also both physiological features of pregnancy. In this scenario - assuming no prior results are available for comparison - AST and ALT are more useful because they are a component of HELLP syndrome not physiologically raised in pregnancy. ALP is physiologically raised in pregnancy, and CRP is a very general measure of inflammation.
Which of the following physiological changes occur in pregnancy?
A. Decreased red cell mass B. Increased factor XI C. Decreased MCV D. Thrombocytopenia E. Decreased factor VII
D. Thrombocytopenia
Thrombocytopenia of the mother (gestational thrombocytopenia) is normal and is thought to occur due to increased consumption rather than a dilutional effect. This is because it manifests late in the pregnancy, unlike the dilutional anaemia.
Match the following to either oligohydramnios or polyhydramnios depending on which they are associated with.
A. COX inhibitors B. Fetal renal disease (e.g. Bartter syndrome) C. Tracheoesophageal fistula D. Gestational diabetes E. Anencephaly F. IUGR G. Posterior urethral valves H. Down syndrome
Oligohydramnios:
A. COX inhibitors
F. IUGR
G. Posterior urethral valves
Polyhydramnios: B. Fetal renal disease (e.g. Bartter syndrome) C. Tracheoesophageal fistula D. Gestational diabetes E. Anencephaly H. Down syndrome
How does excretion of glucose by the kidneys differ in pregnant women?
Glycosuria generally occurs around a serum concentration of 11mmol/L in non-pregnant patients, but will often occur at a lower threshold in pregnancy
A type I diabetic woman attends her local GP surgery seeking counselling about getting pregnant.
Which of the following statements is false?
A. There is an increased risk of preterm labour and fetal lung immaturity
B. There is a 3-4 times increased risk of neural tube and cardiac abnormality, dependent on peri-conceptual glucose control
C. Diabetics are monitored regularly for preeclampsia, but not routinely given prophylaxis
D. Birth trauma and delivery complications are more likely
E. She may have to take as much as triple her usual medication
C. Diabetics are monitored regularly for preeclampsia, but not routinely given prophylaxis
Pre-existing diabetics are at high risk of developing preeclampsia during pregnancy, and so should be given 75-150mg aspirin ODS from 12 weeks till the end of their pregnancy.
Management of diabetics during pregnancy is complex, with myraid potential complications. Established diabetics face more complications than gestational diabetics, with type I and II faring similarly. Maternal complications include: increased birth trauma and delivery complications (due to macrosomia); increased insulin requirement; hypoglycaemia (from attempts to control tightly); UTIs, wound infection, and endometritis; preeclampsia; worsening of pre-existing ischaemic heart disease; and worsening of diabetic retinopathy.
Management of these patients begins pre-conceptually, where the patient is advised to closely monitor their blood glucose levels. Diabetic prospective mothers are advised to take the higher dose of folic acid (5mg instead of 400mcg) for 3 months before conception up until week 12 of pregnancy; this is because of the increased risk of neural tube defects (there is also increased risk of cardiac defects).
Retinal function, renal function, signs of preeclampsia, and fetal growth must all be monitored during pregnancy. Labour is more likely to be complicated, so problems like increased birth trauma and shoulder dystocia should be planned for. Post-partum the baby is particularly vulnerable to hypoglycaemia which must be monitored for. Finally, it is important to note that the mother’s insulin requirement will rapidly return towards pre-pregnancy after delivery, and failure to attenuate insulin doses may lead to hypoglycaemia.
Gestational diabetes in diabetes presenting during pregnancy in susceptible women, due to changes in metabolism. It account for ~90% of diabetes in pregnancy, increase the risk of developing type II diabetes later, and is associated with conditions impairing glucose tolerance e.g. PCOS. An OGTT is performed between 24-28 weeks to assess for gestational diabetes, or earlier (shortly after the booking appointment) if the woman has developed it before.
NB: glycosuria in pregnancy is a less significant finding than normal because a pregnant woman’s kidneys have a lower threshold for excreting glucose (normal being serum concentration of 11mmol/L)
A 35 year old woman who is 20 weeks pregnant notices a hard painless breast lump and visits her GP. She is referred to specialist breast services, and a carcinoma of the breast is diagnosed. The mother is obviously extremely upset and wants to know more about the disease and how it can be managed.
Which of the following statements regarding breast cancer in pregnancy is true?
A. Systemic chemotherapy is safe from the second trimester onwards
B. The mother needs to make a decision on whether to continue the pregnancy before 24 weeks gestation
C. Pregnancy inherently worsens the prognosis of breast cancer
D. Depending on receptor expression within the tumour, Tamoxifen and Herceptin may be used
E. Radiotherapy is a good and widely used option alongside chemotherapy in breast cancer during pregnancy
A. Systemic chemotherapy is safe from the second trimester onwards
‘B’ is not true, for though 24 weeks is the general limit for TOP, it may be carried out at any time if there are risks to the mother’s health.
‘C’ is untrue, though the prognosis of breast cancer is worse in the cohort of pregnant women overall. However this is because pregnant women obviously make up the younger demographic of women with breast cancer, and it is this demographic who are more likely to develop aggressive cancers that do not respond to hormonal treatments.
‘D’ is incorrect as both tamoxifen and Herceptin are contraindicated during pregnancy and breastfeeding.
‘E’ is wrong because radiotherapy is only used if absolutely necessary e.g. to preserve the spinal cord if it is being compressed.
A 34-year-old woman attends for her booking in her third pregnancy. She had a caesarean section in her first pregnancy 4 years ago and has had a successful vaginal birth after caesarean section (VBAC) 2 years ago. She has a BMI OF 26.
What is the best predictor for a successful VBAC?
A. BMI of less than 30 B. Less than 35 years old C. Previous vaginal birth D. Short inter-pregnancy interval E. Spontaneous onset of labour
C. Previous vaginal birth
NB: this is reproduced from a set of practice SBAs for the MRCOG exam
Which of the following statements about obstetric anal sphincter injury (OASI) during labour is false?
A. Dysuria is a possible complication
B. The woman should wait 3 weeks before attempting any significant activity
C. They occur in 6% of primips, and 2% of multips
D. 60-80% of women with an OASI will experience long-term complications
E. There is an increased risk of recurrence
B. The woman should wait 3 weeks before attempting any significant activity
It is recommended to wait 4-6 weeks before attempting significant physical activity after an OASI.
A 28-year-old woman attends the mental health antenatal clinic at 12 weeks for a booking assessment. This is her first baby.
Which condition gives her the highest risk of puerperal psychosis?
A. Anorexia nervosa B. Bipolar affective disorder C. Moderate depression D. Obsessive compulsive disorder E. Recurrent anxiety
B. Bipolar affective disorder
NB: this is reproduced from a set of practice SBAs for the MRCOG exam
A 22 year-old-woman presents to the early pregnancy unit with mild left iliac fossa pain. Examination is normal. She has a positive urine pregnancy test. Her serum human chorionic gonadotrophin (hCG) is 700 IU/L. A transvaginal ultrasound scan reports:
‘Bulky anteverted uterus with a 2 mm cystic area centrally located within the endometrial cavity. Both ovaries have normal ultrasonic appearances. There are no adnexal masses or free fluid in the pelvis.’
What is the most appropriate management?
A. Diagnostic laparoscopy +/- proceed B. Methotrexate therapy C. Serum hCG (human chorionic gonadotrophin) measurement in 48 hours D. Serum progesterone E. Ultrasound scan in seven days
C. Serum hCG (human chorionic gonadotrophin) measurement in 48 hours
This is a pregnancy of unknown location (PUL). Ultrasound findings suggest a pseudosac, as a true gestational sac would be eccentrically located and have a double decidual sac sign (two concentric rings surrounding an anechoic sac). The visualisation of the yolk sac is the critical landmark of the gestational sac. Performing serial serum hCG measurements is the next most appropriate step to guide further management.
NB: this is reproduced from a set of practice SBAs for the MRCOG exam
A 30 week pregnant woman presents to antenatal clinic with intractable itching. It is worst on her palms and soles, and has been badly disturbing her sleep. She has tried taking antihistamines and changing laundry detergent to no avail.
What would be the most appropriate management for this patient?
A. Measure LFTs weekly until delivery, and then again post-partum
B. Prescribe emollients and tell her to take 1st generation antihistamines about 30 minutes before going to bed
C. Advise her this is a reaction in susceptible people to increased levels of oestrogen, but is ultimately harmless
D. Conduct weekly CTG monitoring and USS of the fetus to monitor for complications and chance of stillbirth
E. Monitor bile acids serum concentration at least fortnightly up till delivery, and use the information to guide mode of delivery
A. Measure LFTs weekly until delivery, and then again post-partum
‘C’ is correct in that cholestasis of pregnancy is caused by a reaction in susceptible women to increased levels of circulating oestrogen. However it is by no means ultimately harmless, and carries an increased risk of premature birth and meconium passage.
‘B’ would be appropriate for atopic dermatitis, and may provide some relief here, but is not the best option.
‘D’ and ‘E’ are incorrect because CTG, USS, and bile acids serum concentration are not useful in predicting fetal morbidity and mortality, so there is no use in performing them any more regularly than you would for an uncomplicated pregnancy.
NB: there is a common perception that cholestasis of pregnancy increases the risk of stillbirth, but this is not well supported by evidence, and if it exists is thought to be a very slight increased risk
Which of the following can a standard CTG accurately measure?
A. The intensity of uterine contractions
B. The frequency and duration of uterine contractions
C. The intensity and frequency of uterine contractions
D. The frequency and resting tone of uterine contractions
E. The frequency of uterine contractions
E. The frequency of uterine contractions
External transducer CTG traces are considered to only be accurate in assessing the frequency of uterine contractions. The duration and intensity should be assessed by palpating the uterus.
You are urgently called to assist with a g5p5 woman who has just given birth to twins and is in the middle of post-partum haemorrhage. The midwife estimates blood loss of 1100ml and informs you there is a valid G&S sample and two wide bore cannulas in situ. The patient is semi-conscious with a BP of 85/50 and a HR of 115bpm. The midwife in charge, anaesthetic reg, and obstetric reg have all arrived, and an MOH call has been put out so the transfusion lab and haematologist have been notified.
What is the best next step?
A. Urgently move the woman to theatre and assess surgical options from intrauterine balloon, to artery embolisation, to hysterectomy
B. Immediately give I.V. O- packed RBCs and cryoprecipitate, then begin a syntometrine infusion
C. Rub up the uterine fundus, give I.M. ergometrine, and begin an oxytocin infusion
D. Put her in the head down position, give 15L oxygen, give warmed I.V. Hartmann’s, and take blood for clotting, FBC, U&Es, and cross-match for 6 units
E. Take her to theatre for an examination under anaesthesia to assess tone of the uterus, and plan measures to stem blood loss from there
D. Give 15L oxygen, give warmed I.V. Hartmann’s, then take blood for clotting, fbc, U&Es, and cross-match for 6 units
Green Top Guideline on PPH:
https://obgyn.onlinelibrary.wiley.com/doi/full/10.1111/1471-0528.14178
A 5 week pregnant woman presents with vaginal bleeding. A speculum exam reveals some blood and a closed cervical os. A USS reveals a normally situated placenta and a visible fetal pole. However there is no detectable heartbeat, and the fetal pole is measured at 6mm.
What is the most appropriate next step?
A. Ask her to come back for another scan in a week’s time
B. Advise the woman that based on her LMP dates, a heartbeat should be detectable and this is likely to be a miscarriage
C. Counsel the mother that she has miscarried and discuss medical vs. surgical management
D. Measure the diameter of the gestational sec
E. Reassure the mother that this is absolutely normal at this stage of pregnancy and send her home
A. Ask her to come back for another scan in a week’s time
The guidelines for determining whether there is a viable intrauterine pregnancy using TVUSS are as follows:
If there is a fetal heartbeat, there is a viable pregnancy
If there is no heartbeat but there is a fetal pole, measure it
Whether the pole is above or below 7mm, you will likely re-scan in a minimum of 7 days
If there is no pole, measure the gestational sac diameter
Whether the sac diameter is above or below 25mm, you will likely re-scan in a minimum of 7 days
A 26 week pregnant woman presents with abdominal pain. It is intense, and she came straight to A&E as soon as it started. Abdominal palpation reveals a tense woody feel, and a speculum exam reveals a closed os and no bleeding. Her obs are as follows:
HR - 105bpm
BP - 95/60mmHg
RR - 26rpm
O2 Sats - 99%
You attach a CTG transducer and the trace shows a baseline rate of 120bpm, variability of 4bpm, with no accelerations but late decelerations occurring in the majority of contractions.
What is the most likely cause of this clinical picture?
A. Bleeding from vasa praevia, causing rapid exsanguination and hypoxia of the fetus
B. Bleeding from a disturbed placenta praevia, causing hypoxia of the fetus
C. Separation of the placenta from the endometrium, and bleeding into the space between them
D. Inflammation and rupture of the appendix
E. Inflammation of the gallbladder secondary to cholestasis of pregnancy
C. Separation of the placenta from the endometrium, and bleeding into the space between them
This is a history of a concealed placental abruption: the placenta detaches from the endometrium and begins to bleed into the space between them. The blood does not exit the uterus until the bleeding becomes very severe, so a concealed abruption does not present with bleeding. This occurs in around 20% of abruptions, so the absence of bleeding in abdominal pain in pregnancy is not considered reassuring.
The clues in the history are the tense woody abdomen, the haemodynamic instability, and the pain, along with the CTG suggestive of fetal distress/hypoxia (reduced variability, late declerations). Given the severity of the abruption, this woman would need a C-section, despite the age of the fetus.
A 22 year old woman is referred to gynaecology with increasingly heavy and painful periods over the last 6 months. Biochemical tests reveal a microcytic anaemia, but normal TFTs, B12, and folate. After thorough investigation these symptoms are attributed to dysfunctional uterine bleeding. She has no PMHx, but has a significant FMHx of VTE. The patient is extremely distressed by the bleeding, and desperately wants to not have to worry about bleeding more than anything.
Which of the following treatments would be best for this patient?
A. Implant a Mirena coil
B. Prescribe tranexamic acid and mefenamic acid
C. Supplementation of iron, B12, and folate to correct the anaemia
D. Ask her to trial aspirin +/- paracetamol for a week then return
E. Prescribe the COCP and advise continuous use
B. Prescribe tranexamic acid and mefenamic acid
Tranexamic acid antagonises lysine binding sites on plasminogen, reducing conversion to plasmin and so preventing fibrinolysis. Mefenamic acid is a COX inhibitor that is particularly useful in reducing menstrual pain. When used together they provide synergistic relief from both heavy bleeding and pain, and so are a good option in this patient.
‘A’ is the NICE-recommended first line treatment and is effective at reducing heavy bleeding. However, for the first 6 months a Mirena coil causes constant light bleeding. If the patient can weather this period, then they will get occasional light periods (~1/3 have no periods at all) but in this patient the initial 6 month period is likely to prompt them to either refuse or remove the coil after a few months. The Mirena coil lasts 5 years before it has to be replaced (the copper IUD lasts 10).
‘C’ would be a good step, but the patient is not reporting the symptoms of anaemia, so it isn’t the most pressing concern and the pain and bleeding is affecting her life more.
‘D’ is not a particularly strong option because it seems likely she has tried over the counter medication before, and it will not address the bleeding issue, which she is most concerned about.
‘E’ would be a reasonable option were it not for the significant FMHx of VTE.
Which of the following statements on complications of the LLETZ is false?
A. There is a 15% chance of recurrence after a LLETZ
B. It may damage the cervix and lead to increased risk of preterm birth
C. It may cause scarring that stenoses the cervix
D. It may make it difficult to monitor the patient with further smears
E. There is a risk of endometritis
A. There is a 15% chance of recurrence after a LLETZ
The LLETZ is an effective procedure, and is successful in over 95% of cases:
https://obgyn.onlinelibrary.wiley.com/doi/full/10.1111/j.1471-0528.2000.tb11623.x
A 27 year old woman presents to her GP with vaginal bleeding unrelated to her periods which sometimes occurs spontaneously, but may also occur after sex. A speculum exam reveals an abnormal looking, bleeding area of the cervix which is then swabbed. Analysis of the swab reveals a squamous cell carcinoma of the cervix. The lesion is biopsied and staged as CIN 3.
Which of the following statements about CIN 3 (cervical intraepithelial neoplasia) is false?
A. It may spontaneously remit
B. It may recur after treatment
C. It is heavily associated with HPV infection
D. It progresses to invasive carcinoma extremely slowly
E. It usually presents in women >50
E. It usually presents in women >50
CIN is most common in women in their late 20s/ early 30s, and is associated with HPV infection in 99.7% of cases - infection with HPV is generally considered to be a prerequisite. The transformation zone of the cervix (where squamous epithelium gives way to columnar) is particularly vulnerable to HPV infection, hence it is also more vulnerable to cervical cancer.
CIN is a major cause of death worldwide, but less so in the Western world because of vaccination against HPV. The two main vaccines are Cervarix (bivalent protection against serotypes 16 and 18) and Gardasil (quadravalent protection against 6, 11, 16, 18).
CIN 3 refers to malignancy that occupies >2/3 of the epithelial thickness of the cervix, but has not breached the basement membrane. Progression to full carcinoma (invasion of the basement membrane) is a very slow process and may take decades (one study found the medium progression time to be over 20 years - see below). CIN may recur after treatment, but equally there is a trend in young women to develop dysplastic lesions which then spontaneously remit as the immune system brings them under control.
Link to CIN 3 - cancer progression study:
https://academic.oup.com/aje/article/178/7/1161/211254
NB: This question is taken from a Capsule case
A 35 year old woman attends her GP after her sister is diagnosed with ovarian cancer. She is concerned for herself and her daughters and wants to learn as much as she can about the disease.
Which of the following statements are true?
A. She should avoid taking the oral contraceptive pill to minimise her risk of developing ovarian cancer
B. The fact she has had children increases her risk of developing ovarian cancer
C. Her sister’s diagnosis significantly increases her risk of developing cancer at some stage
D. Most cases of ovarian carcinoma are caught early whilst they are still confined to the ovary, and prognosis is better in younger women
E. Ovarian cancer typically metastasises to the peritoneum and para-aortic nodes
E. Ovarian cancer typically metastasises to the peritoneum and para-aortic nodes
‘C’ is unlikely to be true without a stronger family history, as the majority of women with ovarian cancer have no known risk factors, and genetics are thought to play a part in only 1% of cases. Where there is a genetic basis, it is the strongest risk factor, but the presence of such a risk factor is uncommon.
‘A’ is untrue - taking oral contraceptives has actually been shown to reduce the risk of ovarian cancer, and an important analysis of 45 studies in the Lancet suggested the pill has actually prevented hundreds of thousands of cases (https://www.thelancet.com/article/S0140-6736(08)60167-1/fulltext).
‘B’ is false: having children reduces the risk of multiple cancers, including breast and ovarian. ‘D’ is also false: ovarian cancer is typically caught late due to its subtle and non-specific presentation. This leads to a higher mortality rate than comparable cancers e.g. endometrial or cervical.
Match the following infections with the appropriate description:
A. Trichomonas vaginalis
B. Bacterial vaginosis
C. Pelvic inflammatory disease
D. Thrush
- Frothy yellow/ green discharge, vulvovaginitis, strawberry cervix
- Vaginal discharge, cervical excitation, abdominal pain, deep dyspareunia
- Vulval pruritis, superficial dyspareunia, cottage cheese discharge
- Thin grey/ white discharge with a strong fishy smell, clue cells are seen on microscopy, alkaline vaginal environment
- Frothy yellow/ green discharge, vulvovaginitis, strawberry cervix - A. Trichomonas vaginalis
- Vaginal discharge, cervical excitation, abdominal pain, deep dyspareunia - C. Pelvic inflammatory disease
- Vulval pruritis, superficial dyspareunia, cottage cheese discharge - D. Thrush
- Thin grey/ white discharge with a strong fishy smell, clue cells are seen on microscopy, alkaline vaginal environment - B. Bacterial vaginosis
A 34 week pregnant woman presents to the maternal assessment unit with reduced fetal movements. She has noticed for the past two days that the baby has not been moving as much as before, and is very worried.
What is the most appropriate next step?
A. Examine the pregnant abdomen, then perform an USS of the fetus to assess wellbeing and growth
B. Attach a CTG trace to assess fetal wellbeing
C. Attach a CTG trace to assess fetal wellbeing, then ask the mother to record the number of kicks she feels for the next 7 days and come back for a follow-up
D. Assess risk factors for stillbirth and IUGR, then use a handheld doppler to look for a fetal heartbeat
E. Reassure the mother that in 70% of cases of one-off RFM there is no underlying pathology, and tell her to return if the problem persists
D. Assess risk factors for stillbirth and IUGR, then use a handheld doppler to look for a fetal heartbeat
The first step when assessing a woman with reduced fetal movements (RFM) is to exclude fetal death. This is done by finding the fetal heartbeat with a handheld doppler.
Once this is done, there should be a general assessment including palpation of the abdomen (to assess size as IUGR is associated with RFM) and a CTG trace to assess fetal wellbeing.
If no abnormalities are detected, the mother should be reassured that 70% of pregnancies featuring one episode of RFM feature no complications. She should be asked to return if it happens again or if she experiences any other symptoms. She should not be asked to keep a formal record of the number of kicks, as this is not a useful indicator of fetal health, and increases maternal anxiety by making the mother fixate on the number of kicks.
A 37 week pregnant g3p2 woman presents to antenatal clinic: her baby was noted to be in breech position at a previous appointment so she was asked to return at 37 weeks. Examination reveals the baby is still in breech.
How should you counsel the woman on breech birth and external cephalic version?
A. ECV is generally a safe procedure, but you must inform her there is a 5% risk of needing an emergency C-section as a result of complications
B. ECV is a very simple procedure for which she doesn’t need to be given any medications
C. ECV is most often successful, with few babies reverting to breech afterwards
D. ECV is generally painless, though there may be some mild discomfort
E. ECV has a better chance of success in multips, but increases the risk of instrumental delivery or C-section compared to natural cephalic presentation
E. ECV has a better chance of success in multips, but increases the risk of instrumental delivery or C-section compared to natural cephalic presentation
‘A’ is incorrect, as there is only a 0.5% risk of complications necessitating an emergency C-section. ‘B’ is incorrect, as she should be given tocolytics (e.g. ritodrine?) to increase the chance of success, and may be offered analgesia if they cannot tolerate the procedure without it.
‘C’ is only slightly wrong - there is a 50-50 chance of success, but it is true that few babies revert to breech after a successful attempt. The chance of success is around 60% in multips and 40% in primips, so overall is considered to be 50% though individual factors affect this considerably. ‘D’ is wrong - it is uncomfortable and may well be painful, so ‘D’ is misleading.
There is no absolute consensus on ECV contraindications, but the following are usually considered: multiple pregnancy, Rh isoimmunisation, APH within the last week, abnormal fetal monitoring, and rupture of membranes
An emergency call goes out from a room where a 37+3 week pregnant woman is in labour. The registrar arrives and is informed by the midwife that the patient has been in the latent first stage of labour for two hours, and a few minutes ago her membranes ruptured. Shortly after ROM the patient became rapidly SOB, then became drowsy and lost consciousness. A quick A-E approach shows saturations of 91% and crackles in both lungs on auscultation, a HR of 140, and a of BP 80/40.
What is the most likely diagnosis?
A. Myocardial infarction B. Pulmonary embolism C. Amniotic fluid embolism D. Cerebrovascular accident E. Haemorrhage
C. Amniotic fluid embolism
Amniotic fluid embolism is a rare complication of pregnancy, usually occurring during labour, where amniotic fluid enters the maternal circulation causing an anaphylactoid reaction and rapid circulatory collapse. This classically occurs when the membranes rupture, and though it is rare (~1 in 50,000 pregnancies) it is so lethal that it is still a significant cause of maternal mortality and morbidity.
The first sign of amniotic fluid embolism is usually symptoms of hypotension and circulatory collapse with rapid acute heart failure, quickly followed by pulmonary oedema, ARDS, and DIC.
The speed of deterioration along with the bilateral crackles on auscultation make this most likely to be an amniotic fluid embolism, though ‘A’, ‘B’, ‘D’, and ‘E’ are important differentials.
A 21 year old woman attends an emergency appointment with her GP. She overslept and was unable to take her ‘Micronor’ traditional POP at 7 a.m. as she usually does, and it is now 2 p.m.
How should the GP advise her?
A. Take her pill now then take the next one at the usual time, and use condoms till she has been taking the POP for 48 hours
B. To take her pill now, and not to worry as 1 missed pill does not affect the efficacy
C. To take her pill now, and to take levonorgesterel emergency contraception
D. To take her pill now, and not to worry because she is still within the 12 hour window
E. To take her pill now, and not take the regular 1 week break
A. Take her pill now then take the next one at the usual time, and use condoms till she has been taking the POP for 48 hours
Micronor is a brand of progesterone-only pill (POP) that must be taken in the same 3 hour window every day. POPs are taken continuously and do not have a week off (so ‘E’ is wrong).
‘B’ would be true for the COCP when missing one pill does not matter, but for the POP barrier contraception should be used until there is 48 hours worth of coverage. ‘C’ is incorrect because there is nothing to suggest emergency contraception is necessary here. ‘D’ would be correct if she were taking Cerazette which has a 12 hour window in which to take it, but Micronor only has a 3 hour window so she has missed the pill. ‘E’ is incorrect because there is no such break with the POP.
A 36 year old woman presents to her GP with fears she may be pregnant. She had unprotected sex 4 days (96 hours) ago and is extremely worried that it is too late to do anything to prevent pregnancy.
What is the most appropriate management for this patient?
A. Perform a serum hCG, and offer a medical TOP depending on the result
B. Offer insertion of the copper IUD
C. Perform a urinary pregnancy test, and offer levonorgesterel depending on the result
D. Prescribe levonorgesterel and tell her to take a urinary pregnancy test in 1 week
E. Prescribe the COCP and tell her to take a urinary pregnancy test in 1 week
B. Offer insertion of the copper IUD
The copper IUD is effective up to 5 days after either sexual intercourse, or the day of ovulation (whichever is latest). The copper IUD is the most effective form of emergency contraception and prevents implantation of the embryo (making it ethically dicey for some people). Though an excellent form of emergency contraception, the copper coil is not ideal as a LARC because it makes womens’ periods heavier and more painful.
NB: If the woman is having regular menstrual cycles, the day of ovulation will reliably be 14 days from the first day of menstruation.
A 17 year old girl presents to her GP with concerns she may be pregnant. She has been taking the COCP but has lost track of the days and thinks she has missed the first two pills of her first week. She had unprotected sex with her boyfriend on the last day of her week off (3 days ago - 72 hours).
Which of the following is the best option?
A. Tell her to take the COCP as normal and abstain from sexual intercourse for at least 7 days
B. Tell her to take the COCP as normal and practice barrier contraception for at least 7 days
C. Tell her to take the last missed pill plus the pill for that day, reassure her that missing two days is not significant
D. Tell her to take the last missed pill plus the pill for that day and practice barrier contraception for at least 7 days
E. Tell her to take the COCP as normal, offer emergency contraception, and advise her to use barrier contraception for 7 days
E. Tell her to take the COCP as normal, offer emergency contraception, and advise her to use barrier contraception for 7 days
Missing one COCP dose is not concerning, the patient should be advised to take the missed pill immediately and then take the pill as they would normally, even if that means taking two pills in one day. If two pills have been missed (at least 48 hours since the last pill) then the next step depends on which pill was missed.
If the missed pill was in the first week, then the woman will need to use barrier contraception for a week and take emergency contraception if she has had unprotected sex in the preceding 7 days.
If the missed pills were in the 2nd or 3rd week there is less concern: barrier contraception may be used if the woman is worried, but emergency contraception won’t be necessary as long as the rest of the cycle has been taken correctly.
Match each form of contraception with the correct statement:
A. Is the most effective form of contraception listed (according to Pearl index)
B. Prevents implantation of the embryo as emergency contraception
C. Carries a risk of osteoporosis
D. Carries the highest risk of VTE
E. Lasts for 5 years before it must be replaced
F. A progesterone receptor modulator that may be given as a tablet up to 5 days after unprotected sex as emergency contraception
G. Is taken continuously with no breaks
H. The active ingredient of the Mirena coil which may also be used for emergency contraception
- Mini-pill
- COCP
- Mirena coil
- Copper coil
- Levonorgesterel
- Ulipristal
- Depo-provera (progesterone depot injection)
- Progestogen implant
A. Is the most effective form of contraception listed (according to Pearl index) - 8. Progestogen implant
B. Prevents implantation of the embryo as emergency contraception - 4. Copper coil
C. Carries a risk of osteoporosis - 7. Depo-provera (progesterone depot injection)
D. Carries the highest risk of VTE - 2. COCP
E. Lasts for 5 years before it must be replaced - 3. Mirena coil
F. A progesterone receptor modulator that may be given as a tablet up to 5 days after unprotected sex as emergency contraception - 6. Ulipristal
G. Is taken continuously with no breaks - 1. Mini-pill
H. The active ingredient of the Mirena coil which may also be used for emergency contraception - 5. Levonorgesterel
An 18 year old woman visits her GP to discuss methods of contraception, specifically the COCP.
Which of the following statements regarding the COCP is true?
A. The COCP is a better option than the mini-pill in patients with a history of migraine
B. The annual risk of VTE in COCP use is ~0.05-0.1%
C. The COCP will make periods lighter and less painful, but it is important to have them regularly by taking every 4th week off
D. The COCP is relatively contra-indicated in women over 35 if they are smoking >30 per day
E. The COCP can be used post-partum after 21 days in breastfeeding women
B. The annual risk of VTE in COCP use is ~0.05-0.1%
The annual risk of VTE in COCP use according to the European Medicines Agency is 5-12 per 10,000. In the non-COCP population this risk is 2 per 10,000. The COCP is generally accepted to increase VTE risk 3-3.5 fold, but the absolute increase in risk is only 0.08%.
‘A’ is incorrect because the COCP is relatively contraindicated in migraine without aura, and is absolutely contraindicated in patients who have had migraines with aura due to an increased risk of stroke. ‘C’ is false, though the standard advice has always been to have a week off, there is not benefit to this unless the woman wants to keep track of her periods to reassure her she is not pregnant.
‘D’ is nearly correct, but the COCP is absolutely contraindicated in women over 35 who are smoking more than 15 per day. ‘E’ is wrong because the COCP is absolutely contraindicated for the first 6 weeks post-partum in breastfeeding mothers as it interferes with breastfeeding.
A 63 year old woman presents to her GP with a 1 month history of unexplained bloating. She has tried two diet changes to resolve the bloating (cutting out gluten, reducing carbohydrates) but it has not improved. She also describes early satiety at mealtimes and constipation.
What is the most appropriate initial management of this patient?
A. Refer them to a specialist GI unit for further investigation +/- OGD
B. Give specialist dietary advice on high fibre food and water intake, and consider trialling laxatives
C. Arrange an USS
D. Measure her serum Ca125 level
E. Take baseline bloods including FBC, U&Es, LFTs, and INR, and take a stool sample
D. Measure her serum Ca125 level
This history could well be describing IBS, however new onset IBS in a woman of this age is rare, and all presentations of IBS-like symptoms in this demographic should be investigated for ovarian cancer. Ideally the GP would take a history focusing on the risk factors for ovarian cancer (nulliparity, family history, BMI, PMHx e.g. endometriosis etc.). However that is not an option here, and the next thing that should be done is a serum Ca-125 measurement. If the level is 35 IU/mL, the woman should be referred for an USS of her abdomen and pelvis. If a mass is found she is then referred to a specialist, if not she may require other investigations or be asked to monitor her symptoms and return if they worsen.
If the Ca-125 and USS suggest ovarian cancer, the disease should be staged in secondary care with a CTAP (CT abdo pelvis) with added chest CT if clinically indicated. Histology or cytology should then be used for tissue diagnosis.
A 75 year old woman visits her GP regarding a lump she has noticed in her vagina. She also describes a sensation of heaviness and dragging that is particularly noticeable in the evening and when she stands up after sitting for a while. She also describes urinary symptoms including hesitancy, increased frequency. On examination there is a bulging of the upper anterior wall of the vagina.
What is the most likely cause of the mass?
A. Apical prolapse B. Gynaecological malignancy, exploration and excision C. Enterocoele D. Cystourethrocoele E. Rectocoele
D. Cystourethrocoele
A 38-year-old woman presents to her GP with difficulty conceiving. She and her partner have been having regular unprotected sex (once every 2-3 days) for a year and a half. Her periods have been coming irregularly, her cycle is 27-33 days long, and she usually bleeds for ~5 days. The husband’s sperm has already undergone analysis and his count and morphology are normal.
How should this couple be managed?
A. Order a hysterosalpingogram along with day 2 LH and FSH
B. They should be told to continue trying and that if they have not conceived after 2 years of unprotected regular sex they can be seen by a sub-fertility specialist
C. Measure day 21 progesterone and day 2 LH and FSH
D. Educate the couple in the use of temperature-based ovulation predictors to be trialled for 3 months
E. Measure day 2 LH, FSH, and oestradiol, plus AMH
C. Measure day 21 progesterone and day 2 LH and FSH
Mid luteal progesterone should be measured to confirm ovulation, though this will be challenging in this patient due to the irregular cycle. In this case the irregular cycle is the indication for measuring gondadotropins.
Other tests would also probably be carried out (e.g. hysterosalpingiogram, AMH, antral follicle count), but the ones described here are those specifically indicated by the menstrual irregularity.
A 39 year old woman visits her GP regarding contraception. She is 36 weeks pregnant and wants to know how she should manage contraception once she has given birth. She has previously used the COCP and was very happy with it. She is booked in for an elective C-section and plans to breastfeed her baby.
What should the GP tell her?
A. She does not have to worry about falling pregnant within the 6 weeks following birth, but should begin taking the COCP in the 5th week to cover herself
B. She will need to use barrier contraception as soon as she begins to have sex again, and should take a pregnancy test if she has unprotected intercourse at any time post-partum
C. She will not fall pregnant within the first 21 days, then afterwards should use contraception, but not the COCP
D. If she wants an IUD inserted, she will have to wait till 4 weeks post-partum
E. She will not fall pregnant whilst breast-feeding due to the high levels of prolactin in her blood
C. She will not fall pregnant within the first 21 days, then afterwards should use contraception, but not the COCP
Women will not fall pregnant within the first 21 days post-partum, but afterwards will need to use contraception. This should be planned for before birth, and can be initiated soon after birth; an IUD can be inserted within 48 hours post-partum, though outside of this window the woman will have to wait 4 weeks (hence ‘D’ is almost right but not quite).
‘A’ is wrong because not only can a woman fall pregnant within the 6 weeks post-partum, she should not take the COCP as it interferes with milk production and so may cause problems with breastfeeding. ‘B’ is wrong because there is a 21 day ‘safe period’. ‘E’ is wrong.
A 35 year old woman currently in labour at 38 weeks (having declined C-section) begins to experience difficulties. She is obese and a known type II diabetic prior to pregnancy. The midwife calls for help as the head has been delivered but the shoulders are stuck. The labour ward team rush in and first fold the woman’s legs up towards her and apply suprapubic pressure to try and deliver the shoulders, but this fails.
What should be the next step in this patient’s management?
A. Give uterotonics and attempt to deliver the baby’s posterior arm
B. Switch the mother’s position so that she is on all fours, then repeat the previous manoeuvres
C. Perform a Zavanelli manoeuvre to allow the woman to be rushed to theatre for C-section
D. Perform an episiotomy and attempt internal rotational manoeuvres (Wood’s screw)
E. Perform an episiotomy and repeat the suprapubic pressure, then perform a symphysiotomy if it fails
D. Perform an episiotomy and attempt internal rotational manoeuvres (Wood’s)
Shoulder dystocia is when the baby’s shoulders become stuck after delivery of the head. It is an obstetric emergency and in these cases there is only minutes in which to act to deliver the baby before brain damage occurs. There is no agreed-upon time limit before brain damage in dystocia, though limiting the time to 5 minutes or less carries a very low risk of hypoxic encephalopathy. There are known risk factors for dystocia including macrosomia, maternal diabetes and obesity, previous dystocia in labour, and induction/ augmentation of labour but there is no good way to predict dystocia and most cases are considered unpredictable.
If the baby is delivered in a way that puts excess traction on the neck, they are at risk of brachial plexus injury, specifically Erb’s palsy (C5, C6 nerve root injury). If the baby is not delivered rapidly they are at risk of brain damage.
Upon suspicion of shoulder dystocia the midwife or doctor should immediately call for help and position the mother lying flat near the edge of the bed. They then implement McRobert’s manoeuvre and apply suprapubic pressure which resolves the dystocia in 90% of cases. If this fails the patient will need an episiotomy to allow a hand into the vagina to attempt an internal rotation manoeuvre (Wood’s screw manoeuvre) and to deliver the posterior arm. If all these fail they may be repeated with the woman on all fours, or the consultant obstetrician may decide on a symphysiotomy (division of the maternal pubic symphysis), cleidotomy (division of the baby’s clavicle), or Zavanelli manoeuvre (pushing the baby back up through the birth canal, then immediately performing a Caesarean section)
See appendix 2:
https://www.rcog.org.uk/globalassets/documents/guidelines/gtg_42.pdf
A woman in established labour develops a pathological CTG trace, with late decelerations present in the majority of contractions for the past 35 minutes. The obstetric registrar views the trace and concludes there is evidence of fetal distress. She is 40 weeks pregnant and is being induced with an oxytocin infusion. She is contracting at a rate of 5 in 10.
What is the most appropriate next step in this woman’s management?
A. Examine the abdomen, vagina, and check her observations, then move her into the left lateral position and wait 5 minutes to see if that resolves the fetal distress
B. Examine the abdomen and vagina, and if feasible attempt to expedite delivery using forceps
C. Move her into the left lateral position and stop the oxytocin infusion
D. Move her into the left lateral position and stop the oxytocin infusion, examine the abdomen, vagina, and check her observations
E. Attempt to expedite delivery with instruments, and if that fails proceed to C-section
D. Move her into the left lateral position and stop the oxytocin infusion, examine the abdomen, vagina, and check her observations
Fetal distress usually refers to signs of fetal hypoxia +/- acidosis, of which late declarations is one. In this case it seems likely that the induction of labour with oxytocin has lead to over-stimulation of the uterus which has caused the fetal hypoxia. Over-stimulation is defined as having a series of contractions each lasting 2 minutes or more, or having 5 or more contractions in 10 minutes.
The most obvious step is to stop the oxytocin infusion, and turning the mother into the left lateral position to relieve pressure on the maternal inferior vena cava and aorta. After that the abdomen and vagina should be examined to look for cord prolapse, presence of liquor, and to examine the tonicity of the uterus. Maternal observations are also important as maternal hypotension an compromise fetal blood supply.
Fetal blood sampling may be used to assess the well-being of the child, and a pH of less than 7.2 is often used as the cutoff for expediting delivery urgently (though Impey suggests this is unnecessarily conservative).
A 42 year old woman attends her first booking appointment for pregnancy having had her last menstrual period 9 weeks ago. The appointment reveals several risk factors: she has chronic renal impairment and smokes 12 cigarettes per day despite past efforts to quit. She agrees to engage with services to help her quit smoking, and is determined to continue with this pregnancy.
Which is the best next step in the management of this woman’s pregnancy?
A. Book her in for a uterine artery Doppler scan at 20-24 weeks
B. Assess her every 1-2 weeks using abdominal palpation and CTG monitoring
C. Refer her for serial uterine artery Doppler scans and USS for fetal size from 26-28 weeks onwards
D. Book her in for reassessment at the start of the third trimester with a uterine artery Doppler scan and an USS to assess fetal well-being and size
E. Prescribe low does (75mg) aspirin from 16 weeks and reassess her pregnancy at 20 weeks with USS to assess fetal well-being and size
C. Refer her for serial uterine artery Doppler scans and USS for fetal size from 26-28 weeks onwards
The chronic renal impairment and smoking of 11 or more cigarettes per day gives this woman a high risk of having a small for gestational age (SGA) baby. There is no way to boost the growth of an SGA baby other than by minimising risk factors, and the only initial management is to monitor the pregnancy.
If there are one or more major risk factors, the mother should be sent for serial assessment of fetal size on USS and uterine artery Doppler scans beginning at 26-28 weeks. If there are 3 or more minor risk factors, the mother should be sent for a uterine artery Doppler at 20-24 weeks. If the 20-24 week Doppler is abnormal, the woman should be referred for serial assessment of fetal size on USS and uterine artery Doppler scans beginning at 26-28 weeks.
Depending on the results of the Doppler scans and the growth of the baby, the obstetrician may recommend delivering the baby early especially if there is static growth. In this case the mother would require steroids to mature the baby’s lungs, and there should be adequate planning for complications depending on the gestational age of the baby when it is delivered.
The RCOG guidelines are very helpful for this area, and there is an investigation flowchart and table of risk factor sin the appendix:
https://www.rcog.org.uk/globalassets/documents/guidelines/gtg_31.pdf
A 50 year old woman attends her GP to discuss the long-term implications of the menopause. She has not had a period in 14 months and has been experiencing mood swings, hot flushes, insomnia, and a loss of libido combined with vaginal dryness. The insomnia has been affecting her ability to function during the day, and the sexual symptoms are impacting her relationship with her partner. She asks her GP about the benefits and risks of starting HRT.
How should the GP counsel her?
A. Taking a progestogen alongside oestrogen reduces the risk of breast cancer
B. Though her testosterone levels will also drop, it is an unimportant and scarce hormone in women and supplementing it would not benefit her
C. Her risk of osteoporosis will increase post-menopause, but can be offset with vitamin D supplementation if she wants to avoid hormone use
D. Vaginal oestrogen is a promising option for her, as it will improve her libido and vaginal dryness, as well as her hot flushes
E. An oestrogen-only patch would not increase her risk of VTE
E. An oestrogen-only patch would not increase her risk of VTE
Menopause has two main functions: control of menopausal symptoms, and improving long-term health. The former reason is the most common indication, as the symptoms of insomnia, hot flushes, irritability/ mood swings, reduced libido, and vaginal dryness can be very distressing.
HRT can be taken in many different preparations, and may consist of oestrogen alone, or there may be progesterone added. The decision to add a progestogen rests on whether the woman still has a womb, as unopposed oestrogen therapy increases the risk of endometrial cancer. However if the woman does not have a womb, lone oestrogen is the preferred choice, because progestogens increase the risk of breast cancer, whereas lone oestrogen therapy has little or no effect on breast cancer risk, hence ‘A’ is wrong.
‘B’ is incorrect because not only are testosterone levels over 100 times higher in pre-menopausal women than oestrogen levels, but testosterone supplementation can be helpful in restoring libido.
‘C’ is correct in that her risk of osteoporosis will increase, but vitamin D supplementation will do nothing to prevent this; don’t confuse osteoporosis with osteomalacia.
‘D’ is true in that it would help her vaginal dryness, but a vaginal preparation will not improve her libido or her hot flushes. Vaginal oestrogen’s major advantage is its lack of systemic side-effects, and it does not increase the risk of cancer or VTE. However this lack of systemic effect also means it will not improve symptoms of the menopause outside of the vagina. HRT patches (E) are a way of taking HRT without any increased risk of VTE, whilst still addressing the symptoms of menopause.
More information on HRT:
https://www.nice.org.uk/guidance/ng23/ifp/chapter/Benefits-and-risks-of-HRT
Which of the following is considered a minor, not a major risk factor for an SGA baby?
A. Renal impairment
B. BMI <20
C. Unexplained ante-partum haemorrhage during the pregnancy
D. Daily vigorous exercise while pregnant
E. Cocaine use while pregnant
B. BMI <20
All pregnant women should be screened for risk factors for a small for gestational age (SGA) baby at their booking appointment (8-10 weeks). There are many risk factors which have been divided into major and minor by RCOG depending on the odds ratio with respect to having an SGA baby based on a meta analysis study.
The obstetric consultant is called to see a 37 week pregnant primip mother in the second stage of labour who has not progressed for the last 3 hours. She has an epidural anaesthesia tube in situ that has been working well, she is 10cm dilated but has seemingly not progressed in the second stage of labour and is very fatigued. The fetal head is 1/5 palpable and the vertex is at station +1cm. Operative delivery is decided to be the best course of action and the woman is consented.
How would this operative delivery be classified?
A. Outlet B. Low C. Mid D. High E. This would require Caesarean section
C. Mid
Operative delivery is indicated to shorten the second stage of labour in a mother at risk of complications, to resolve fetal distress, or to deliver a baby where progress of labour has halted.
Operative delivery should only be used if the fetal head is 1/5 or less palpable, and the leading part of the head has at least reached the ischial spines. This of course means that operative delivery is only possible once the cervix is fully dilated and the baby has descended into the pelvis.
Operative vaginal deliveries are classified as below:
Outlet:
Fetal scalp visible without separating the labia
Fetal skull has reached the pelvic floor
Fetal head is at or on the perineum
Low:
Leading point of the skull (not caput) is at station plus 2 cm or more and not on the pelvic floor
Mid:
Fetal head is no more than 1/5th palpable per abdomen
Leading point of the skull is above station plus 2 cm but not above the ischial spines
High:
Not included in the classification as operative vaginal delivery is not recommended in this situation where the head is 2/5th or more palpable abdominally and the presenting part is above the level of the ischial spines
GTG 26 on operative delivery:
https://www.rcog.org.uk/globalassets/documents/guidelines/gtg_26.pdf
A 15 week pregnant woman visits hospital for amniocentesis to determine her baby’s risk of Down syndrome, as her combined test indicated an increased risk of Down syndrome.
Which of the following should this woman be offered after her amniocentesis?
A. No anti-D prophylaxis is required
B. 500 IU anti-D prophylaxis
C. Standard routine anti-D prophylaxis either as a single dose at 29 weeks, or as two doses at 28 and 34 weeks
D. 500 IU anti-D prophylaxis and an FMH test
E. 250 IU anti-D prophylaxis
E. 250 IU anti-D prophylaxis
Sensitising event under 12 weeks = no action needed
Special sensitising event* under 12 weeks = min. 250 IU
Sensitising events 12-20 weeks = min. 250 IU
Sensitising events 20+ weeks = min. 500 IU + FMH test** (includes labour***)
Routinely give 1 dose (1500 IU) at 28 weeks or 2 doses (min. 500 IU each) at 28 and 34 weeks
- Special sensitising events are molar pregnancy, ectopic pregnancy, termination of pregnancy, or uterine bleeding that is heavy, repeated, or painful
- *Feto-maternal haemorrhage test is also known as a Kleihauer–Betke test and is used to quantify the amount of fetal haemoglobin that enters the mother’s bloodstream
- **Anti-D prophylaxis after birth is based on typing of baby’s cord blood
NB: This is obviously only necessary in a Rh- non-sensitised woman, and a woman’s blood type will be tested for at her booking appointment (before 10 weeks)
Guidelines:
https://onlinelibrary.wiley.com/doi/full/10.1111/tme.12091
A 25 week pregnant woman presents to her GP with suprapubic pain and dysuria. The symptoms began a day ago and have been accompanied by small amounts of blood. She is otherwise well with normal observations.
How should this patient be managed?
A. Take an MSU for culture and sensitivities, then prescribe antibiotics based on the results when available
B. Tell her to go to A&E urgently
C. Take an MSU for culture and sensitivities, perform a urine dipstick, and prescribe Nitrofurantoin 100mg BDS for 7 days
D. Encourage her to remain hydrated, perform a urine dipstick test, and prescribe Trimethoprim 200mg BDS for 14 days
E. Encourage her to rest and stay hydrated, recommend or prescribe analgesia, but counsel her that avoiding antibiotics is preferable and that she should return if the symptoms persist in 3 days
C. Take an MSU, perform a urine dipstick, and prescribe Nitrofurantoin 100mg BDS for 7 days
Management of a UTI in pregnancy is similar to management in a non-pregnant woman. Nitrofurantoin is first line and safe to give in pregnancy, though NICE recommends it is avoided near term. Second line is Amoxicillin (depending on culture sensitivities) or Cefalexin.
If the patient shows signs of systemic illness or more severe pain in their side, they may need to attend secondary care and be treated for pyelonephritis.
A 24 year old woman presents to her GP with a 9 week history of amenorrhea and a 2 week history of nausea and vomiting. A urinary pregnancy test done in the clinic is positive, but when she attends her dating scan a few weeks later the pregnancy cannot be visualised in the uterus. An adenexal mass is visualised within the left fallopian tube which moves separately to the ovary; this is diagnosed as a clear ectopic pregnancy. A serum bhCG is taken and the level is 1800 IU/L. Her observations are stable and she is reporting no other symptoms. She is asked to visit hospital two days later when the bhCG is repeated and is 1870 IU/L.
How should this patient be managed?
A. Employ a watchful waiting approach as the ectopic pregnancy may self-resolve, take serial beta-hCG measurements on day 2, 4, and 7
B. Refer her for an urgent laparoscopy +/- salpingotomy
C. Refer her for emergency laparoscopy and saplingectomy
D. Offer a choice of expectant management or a single I.M. dose of 5mg/square metre methotrexate
E. Offer a choice of laparoscopy or a single I.M. dose of 5mg/square metre methotrexate
E. Offer a choice of laparoscopy or a single I.M. dose of 5mg/m^2 methotrexate
Though this woman has been diagnosed with an ectopic pregnancy - a very serious and potentially dangerous condition - she is currently asymptomatic and haemodynamically stable. A more acute picture would necessitate emergency surgical management, but this picture means that treatment does not need to be rushed and does not necessarily need to be surgical.
In these cases beta hCG is used to guide treatment:
<1000 IU/L: expectant management
<1500 IU/L: patient’s choice between methotrextate and expectant management
1500-5000 IU/L: patient’s choice between methotrexate and surgery
>5000 IU/L: surgery
NB: The ectopic pregnancy must not be larger than 35mm, there must be no visible heartbeat, and no pain or haemodynamic instability, otherwise surgery is indicated
‘A’ would only be appropriate for a beta-hCG of less than 1500 IU/L, though it is correct in that beta-hCG must be re-measured on day 2, 4, and 7. If the value drops by 15% by day 7, then monitoring is continued until it is less than 20IU/L. If the value does not drop by 15% by day 7, then senior advice is sought.
The obstetric consultant is called to see a 37 week pregnant g3p2 mother in the second stage of labour who has not progressed for the last 2 hours. She has an epidural anaesthesia tube in situ that has been working well, she is 10cm dilated but has seemingly not progressed in the second stage of labour and is very fatigued. The fetal head is 3/5 palpable and the vertex is at station -1cm.
How should this patient be managed?
A. Carry out fetal blood sampling and use the pH in conjunction with CTG tracing to guide management
B. Expedite delivery using forceps
C. Begin an oxytocin infusion and reassess in 1 hour, monitoring obs every 15 minutes
D. Expedite delivery using ventouse
E. Caesarean section
E. Caesarean section
Seeing as the fetal head is more than 1/5 palpable, this baby is not suitable for operative delivery. At 3/5 palpable this baby’s head is not even engaged in the pelvis, which in combination with failure to progress means this woman will need a C-section.
A 56 year old woman presents to her GP with a 2 week history of vaginal bleeding. Her last menstrual period was when she was 50, and she has been taking HRT since symptoms of the menopause began. She denies any pain, other discharge, or fever, and states the bleeding happens most days and does not appear to have a pattern or be a consequence of sex.
How should this woman be managed?
A. Refer to secondary care for a CTAP
B. Perform a speculum and bimanual exam, and let the findings guide further investigations and management
C. Perform an USS in primary care and act based on the results
D. Urgent 2 week suspected cancer referral
E. Make a routine referral to a specialist gynaecologist
D. Urgent 2 week suspected cancer referral
Post-menopausal bleeding should essentially always trigger an urgent referral because of the risk of endometrial cancer.
A 36 week pregnant woman attends an antenatal care appointment, and the doctor palpates her abdomen and determines her baby is currently in the breech position. She is offered ECV but is not keen and wants to know more about what will happen if her baby is delivered breech. She hopes to avoid any major surgery.
Which of the following is not true regarding breech birth?
A. If she opts for a planned C-section, that will not increase the risk of complications of vaginal birth in a subsequent pregnancy
B. The risk of perinatal mortality for planned breech delivery is 4 times higher than in C-section, but still low
C. There is a 40% chance the mother will need an emergency Caesarean - the most high risk method of delivery
D. Breech presentation at term occurs in 3-4% of pregnancies
E. C section is recommended in the presence of certain risk factors e.g. high or low fetal weight, Footling presentation, evidence of fetal distress
A. If she opts for a planned C-section, that will not increase the risk of complications of vaginal birth in a subsequent pregnancy
https://obgyn.onlinelibrary.wiley.com/doi/epdf/10.1111/1471-0528.14465
At what point is the fetal head considered to be ‘engaged’?
A. When the widest point of the presenting part is in line with the ischial spines
B. When 3/5 or less of the head is palpable abdominally
C. When the widest diameter of the presenting part passes through the pelvic inlet
D. When the presenting part reaches a positive station
E. When the presenting part reaches station +5cm
C. When the widest diameter of the presenting part passes through the pelvic inlet
Engagement usually happens at 34-35 weeks and refers to when the widest point of the presenting part passes the pelvic inlet. At this point the head will be a maximum of 2/5 palpable by definition, and generally the vertex will be level with the ischial spines, though obviously this depends on the size of the baby and the mother’s pelvis.
An obstetric consultant visits a new mother who gave birth 5 days ago on the postnatal ward, and while speaking with her notices her mood seems low. The mother confirms that she feels somewhat depressed and tired, and guilty as she does not feel how she thought she would as a new mother.
How should this mother be managed?
A. Trial fluoxetine
B. Take a history to assess for psychiatric issues, but reassure her this is very likely ‘baby blues’ which happens in half of all women after childbirth and will soon pass
C. Take a history to assess for psychiatric issues, and try to assess the mother’s symptoms more formally e.g. with the Edinburgh Postnatal Depression Scale
D. Take a brief focused history, then contact Liason Psychiatry and ask them to come and assess the patient
E. Take a history to assess for psychiatric issues, then offer a trial of outpatient therapy to see whether it alleviates her symptoms
B. Take a history to assess for psychiatric issues, but reassure her this is very likely ‘baby blues’ which happens in half of all women after childbirth and will soon pass
The ‘baby blues’ affect 50% of all women during the first week after childbirth and only persist a few days. It causes low mood, irritability, anxiety, and labile mood. Whilst guilt is not a classic feature, it is understandable why this mother feels guilty that she feels this way when societal expectations tell her she should be ecstatic.
Postnatal depression in 10%, 70% risk of depression in later life.
