450 SBAs In Clinical Specialties - Antenatal Care & Maternal Medicine Flashcards Preview

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Flashcards in 450 SBAs In Clinical Specialties - Antenatal Care & Maternal Medicine Deck (35)
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42 year old woman at antenatal clinic. 17 weeks pregnant and has missed the opportunity for combined Down's screening. You counsel her about the correct alternative - quadruple test. What assays make up the quadruple test?

A. AFP, PAPP-A, inhibin B, beta hCG

B. Unconjugated oestradiol, hCG, AFP and inhibin A

C. Beta hCG, PAPP-A, nuchal translucency and inhibin A

D. AFP, inhibin B, beta hCG, oestradiol

E. Unconjugated oestradiol, PAPP-A, beta hCG, inhibin A

B. Unconjugated oestradiol, hCG, AFP and inhibin A

1 B 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, APP 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 I 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.

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2. Breast lumps in pregnancy

A 33-year-old nulliparous woman is 29 weeks pregnant. She was referred to the rapid access breast clinic for investigation of a solitary breast lump. Sadly, a biopsy of this lump revealed a carcinoma. After much counselling from the oncologists and her obstetricians a decision is reached on her further treatment. What option below may be available to her?

A. Tamoxifen

B. Computed tomography (CT) of the abdomen-pelvis

C. Radiotherapy

D. Chemotherapy

E. Bone isoptope scan to look for metastases in order to stage the disease

D. Chemotherapy

2 D This is difficult to answer as it depends on how aggressive the cancer is. There may be a need for delivery but it would not be immediate as she is only 29 weeks pregnant. You would give a course of betamethasone in order to promote fetal lung maturity prior to delivery. Tamoxifen (A) is not safe in pregnancy and breastfeeding because of the high risk of teratogenicity. Radiotherapy (C) is contraindicated in pregnancy unless it is as a life-saving option. All chemotherapy is potentially teratogenic in the first trimester but may used in the mid- and third trimesters. Ideally birth should be 2-3 weeks after the most recent chemotherapy session to allow bone marrow regeneration. Bone isotope scans (E) and CT of the abdomen and pelvis (B) are likely to provide insufficient clinical value to warrant the high dose of radiation that the fetus would be exposed to.

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3. High risk antenatal care

A 38-year-old woman with type 2 diabetes attends the maternal medicine clinic. She has a body mass index (BMI) of 48 and is currently controlling her sugars with insulin. You have a long discussion about her weight. What should not be routinely offered to this woman?

A. Post-natal thromboprophylaxis

B. Vitamin C 10 mg once a day

C. Regular screening for pre-eclampsia

D. Referral to an obstetric anaesthetist

E. An active third stage of labour as increased risk of post-partum haemorrhage

B. Vitamin C 10 mg once a day

Obesity is an increasing problem for healthcare providers. The number of women falling pregnant who have a BMI >30 kg/esti (obese) is increasing year on year. The rate of increase of morbidly obese and super morbidly obese women falling pregnant Is dramatic. The Confidential Enquiries into maternal deaths informs us that a disproportionate number of mothers who die are obese. Ideally. pre-conception advice is key for these women; this should include weight loss and high-dose (5 mg) folic acid supplementation. This woman is already diabetic but those who are not need to be screened for diabetes. Venous thromboembolism risk is high

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4. Complications of pregnancy (1)

A nulliparous woman is seen at the antenatal clinic 27 weeks into her first pregnancy. Routine screening with a 75g oral glucose tolerance test for gestational diabetes mellitus (GDM) is performed. Which of the following would confirm a diagnosis of GDM?

A. Fasting plasma venous glucose of greater than 5.0 pmol/L

B. 2-hour plasma venous glucose of greater than 7.8 pmol/L

C. Random plasma venous glucose of greater than 4.8 pmol/L

D. 2-hour plasma venous glucose of less than 7.0 pmol/L

E. 2-hour plasma venous glucose of less than 7.8 pmol/L

B. 2-hour plasma venous glucose of greater than 7.8 pmol/L

4 B Between 2 and 5 per cent of pregnancies in the UK are complicated by diabetes, of which 85 per cent are gestational. Diabetes is associated with maternal and fetal risks. Risk factors include high BMI, previous macrosomic baby, previous history of GDM, family history of diabetes and ethnicity. Routine antenatal screening in Britain follows NICE and WHO guidance. Those women at risk of GDM should be tested using a 75 g oral glucose tolerance test (OGTT), where the fasted woman is given a 75 g oral load of glucose and has a venous plasma glucose level tested at 2 hours. The WHO definition of gestational diabetes encompasses both impaired glucose tolerance (2-hour glucose greater than or equal to 7.8 µmol/L (B)) and diabetes (random glucose greater than or equal to 7.0 µmol/L or 2-hour glucose greater than or equal to 7.8 µmol/L). The other answer options are therefore not correct.

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5. Routine antenatal care

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, rubella, hepatitis B and HIV

D. HIV, cytomegalovirus, rubella and hepatitis B

E. HIV, syphilis, rubella and group B Streptococcus

C. Syphilis, rubella, hepatitis B and HIV

5 CThe serum tests for infection that NICE recommend as an offer at booking are syphilis, HIV, hepatitis B and rubella (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).

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6. Disorders of placentation

A 34-year-old woman attends antenatal clinic for a routine ultrasound scan. Abnormalities of placentation are detected and a magnetic resonance imaging (MRI) scan is organized by the fetal medicine consultant. The MRI report shows: The placenta is in the lower anterior uterine wall with evidence of invasion to the posterior wall of the bladder'. What is the most likely diagnosis?

A. Placenta accreta

B. Placenta percreta

C. Placenta increta

D. Placenta praevia

E. Ectopic pregnancy

B. Placenta percreta

6 B Placenta praevia (D), where the placenta attaches to the uterine wall close to or overlying the cervical opening, afflicts one in 200 pregnancies. Placenta accreta (A) is firm adhesion of the placenta to the uterine wall without extending through the full myometrium, as occurs in placenta increta (C). If the placenta invades the full thickness of the myometrium and beyond it, it is called placenta percreta (B). Risk factors for placenta accreta (and increta and percreta) include the presence of uterine scar tissue, which may be seen in Asherman’s syndrome after uterine cavity surgery, for example dilatation and curettage. It is postulated that a thin decidua – the uterine cavity lining in pregnancy which is formed under the influence of progesterone – can encourage abnormal placentation. Although the case in this question may represent one example of placenta praevia owing to the placenta’s proximity to the cervical opening, it is more likely to be an example of placenta percreta here, given the invasion of the bladder. Ectopic pregnancy (E) may rarely carry to late pregnancy, leading to trophic invasion of the bladder, but in such cases an extrauterine pregnancy would be clearly demonstrated on ultrasound scanning.

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7. Painless antenatal bleeding

A 30-year-old nulliparous woman is 29 weeks pregnant. She presented to hospital with a history of a minor, unprovoked painless vaginal bleed of about a teaspoonful. Her anomaly scan at 20 weeks showed a low-lying placenta. Her fetus is moving well and continuous cardiotocography (CTG) is reassuring. What is the most appropriate management?

A. Allow home since the bleed is small

B. Admit and give steroids

C. Admit, intravenous access, observe bleed-free for 48 hours before discharge

D. Admit, intravenous access, Group and Save and administer steroids if bleeds more

E. Group and Save, full blood count and allow home; review in clinic in a week

D. Admit, intravenous access, Group and Save and administer steroids if bleeds more

7 DBleeding in pregnancy is a very common complaint. It can range from trivial to life threatening. The two main things to rule out are a placental abruption and placenta praevia. We know that this woman at 20 weeks had a placenta praevia. Abruptions tend to lead to painful bleeding. Small bleeds can precede very big bleeds so this woman should be admitted to hospital for observation and an ultrasound arranged the next day for placental localization. Therefore, (A) and (E) are incorrect. There is debate whether steroids should be given for small antepartum bleeds in a haemodynamically stable woman. In this case, it would be reasonable to wait to see if the bleeding returns before instigating a course of steroids, so (B) is not the most appropriate management. If the bleeding ceases and the woman otherwise remains well, there is no need to keep her in hospital for 48 hours (C) with the attendant risks (risk of hospital-acquired infections and venous thromboembolism associated with immobility).

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8. Rupture of membranes

A 28-year-old pregnant woman attends accident and emergency with a history of clear vaginal loss. She is 18 weeks pregnant and so far has had no problems. Her past medical history includes a large cone biopsy of the cervix and she is allergic to penicillin. She is worried because the fluid continues to come and there is now some blood. On examination it is apparent that her membranes have ruptured. What is the most appropriate initial management?

A. Discharge, ultrasound scan the next day

B. Offer her a termination as it is not possible for this pregnancy to continue

C. Admit, infection markers, ultrasound and steroids

D. Ultrasound, infection markers and observation

E. Discharge and explain that she will probably miscarry at home

D. Ultrasound, infection markers and observation

8 DThis is a very traumatic and frightening experience for any woman. Her large cervical cone biopsy is a risk factor for second trimester miscarriage. The outlook for this pregnancy is very poor if rupture of membranes is confirmed: most pregnancies at this gestation are lost if the membranes rupture. However, it would be inappropriate to offer termination (B) at this stage until there was definitive evidence of ruptured membranes, or if the mother requested it. This woman needs to be admitted to hospital for observation. She needs investigating to rule out infection – ensuring there is no leukocytosis, rising C-reactive protein or growth on a mid-stream urinary culture – along with regular observations. The main concern is that she is at risk of developing sepsis from the prolonged rupture of membranes. Owing to the risk to the mother of ascending infection, chorioamnionitis and thus generalized sepsis, this woman should not be discharged so options (A) and (E) are incorrect. It may well be that this woman will become septic and in order to save her life she will need to be induced, but while she remains well this is not the first step. She is

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9. Complications of pregnancy (2)

A 37-year-old woman in her fourth ongoing pregnancy presents to the labour ward at 34 weeks' gestation complaining of a sharp pain in her chest, worse on inspiration. An arterial blood gas shows: pH 7.51, PO2 8.0 kPa, PCO2 4.61 kPa, base excess 0.9. What is the most appropriate investigation?

A. Computed tomography pulmonary angiogram (CTPA)

B. MR1

C. D-dimer

D. Ventilation/perfusion scintigraphy

E. Ultrasound

D. Ventilation/perfusion scintigraphy

9 DThis patient has a respiratory alkalosis and is hypoxic. Coupled with her clinical presentation, it is imperative to immediately rule out a pulmonary embolism. Venous thromboembolism remains one of the largest causes of maternal mortality in the developed world, and preventing it remains a focus of modern obstetric practice. Imaging in pregnancy aims to deliver the highest diagnostic value for the lowest dose of ionizing radiation. Ultrasound (E) has little value in the investigation of pulmonary embolism and MRI scanning is unhelpful in showing the vascular abnormalities present in pulmonary embolism. D-Dimer (C) is normally raised after the first trimester of pregnancy, and in any case is only of predictive value and not diagnostic importance. This patient requires urgent definitive diagnosis, and only CTPA (A) or ventilation/perfusion (V/Q) (D) scanning will suffice. Of these, a V/Q scan exposes the patient to by far the lowest radiation dose, and is thus the preferred investigation in pregnant women.

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10. Antenatal haemorrhage

A 32-year-old woman in her second pregnancy presents at 36 weeks gestation with a history of a passing gush of blood stained fluid from the vagina an hour ago, followed by a constant trickle since. The admitting obstetrician reviews her history and weekly antenatal ultrasound scans have shown a placenta praevia. What is the most appropriate management? She has a firm, posterior cervix and has not been experiencing any contractions.

A. Induction of labour with a synthetic oxytocin drip

B. Cervical ripening with prostaglandins followed by a synthetic oxytocin drip

C. Digital examination to assess the position of the fetus

D. Monitor for 24 hours and manage as for preterm pre-labour rupture of membranes (PPROM)

E. Caesarean delivery

E. Caesarean delivery

10 E The gush of fluid followed by a steady trickle suggests ruptured membranes. At 36 weeks gestation she is technically preterm, and this combined with an absence of contractions indicates PPROM. This woman also has a placenta praevia, which indicates that the placenta is low-lying. As soon as the candidate realises this, it is clear that a vaginal delivery is not possible. Therefore, options (A) and (B) are immediately incorrect as these management options aim for an end-result of vaginal delivery. Digital assessment of a patient with antepartum haemorrhage is contraindicated (C) unless a diagnosis of preterm labour has been made; this is to reduce the risk of infection. We are therefore left with either caesarean delivery or managing conservatively as PPROM (D). Management of PPROM involves the use of a 10-day course of antibiotic prophylaxis against chorioamnionitis, steroids to aid fetal lung maturation before the 34th week, and expectant management until 34 weeks gestation. The RCOG recommends that a patient with PPROM should be delivered between 34 and 36 weeks gestation. This woman’s pregnancy is in its 36th week and so delivery should be expedited. With a placenta praevia, the only feasible mode of delivery is caesarean section (E).

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11. Physiology of pregnancy Maternal physiology changes throughout pregnancy to cope with the additional demands of carrying a fetus. Which of the following changes best represents a normal pregnancy?

A. Stroke volume increases by 10 per cent by the start of the third trimester

B. Plasma volume increases disproportionately to the change in red cell mass creating a relative anaemia

C. Plasma levels of fibrinogen fall, reaching a trough in the mid-trimester

D. Systemic arterial pressure rises to 10mmHg above the baseline by term

E. Aortocaval compression reduces venous return to the heart, in turn increasing pulmonary arterial pressure

B. Plasma volume increases disproportionately to the change in red cell mass creating a relative anaemia

11 B Understanding the physiological changes of pregnancy is vital to the recognition of pathology. There is a marked increase in fibrinogen, as well as factors VII, X and XII throughout pregnancy (C). Stroke volume increases from the first trimester and is over 30 per cent higher than in the non-pregnant state by the third trimester (A). Although there are often changes in the maternal blood pressure in pregnancy, largely due to changes in peripheral vascular resistance, neither the systemic (D) nor the pulmonary arterial pressures (E) alter. The gravid uterus does cause aortocaval compression, but this does not affect the pulmonary circulation. Haemodilution, caused by a relative increase in the plasma volume compared to the red cell mass, causes a reduction in haemoglobin concentration (B).

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12. Contraception after pregnancy

A 30-year-old woman attends the antenatal clinic asking to be sterilized at the time of her elective caesarean. She is 34 weeks into her second pregnancy having had her first child 2 years ago via an emergency caesarean section. She is not sure that she wants any more children. Further more, she does not wish to try for a vaginal birth. She has tried the contraceptive pill in the past but does not like the side effects. You talk to her about other options, including the sterilization she is requesting. What is the best management option for this woman?

A. Mirena coil

B. Sterilization at the time of her caesarean section

C. T380 coil

D. lmplanon

E. Vasectomy

C. T380 coil

12 C This woman has come to you asking for a permanent solution to not falling pregnant. It is important to find out why she wants a sterilization at 30 years old. It is imperative to explain that it is permanent, irreversible, has a failure rate of one in 200 and, if it fails, an increased risk of ectopic pregnancy. You must explore all long-acting reversible contraceptive methods with her, these being the Mirena coil, copper coil (T380) implanon and depoprovera IM injections. If she is sure that hormones (A, D) have a bad effect on her then the copper coil would be appropriate for her. This would leave her with the chance to have further children if she changes her mind or there is an unforeseen change in her circumstances. A vasectomy (E) is a very successful contraceptive method but it is a decision her partner would need to be here to discuss and to make, so in these circumstances it is not the most appropriate option. If she understands all the options and still wants a sterilization (B) it would be worth her having a second opinion before agreeing to it as it should be viewed as an irreversible procedure and one not without risk.

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13. Complications of pregnancy (3)

A 41-year-old multipara attends the antenatal clinic at 36 weeks gestation complaining of lower abdominal cramps and fatigue when mobilizing. Clinical examination is unremarkable save for a grade I pansystolic murmur, loudest over the fourth intercostal space in the midaxillary line. What is the most appropriate management?

A. Urgent outpatient echocardiogram and referral to a maternal-fetal medicine consultant

B. Reassurance and a 38-week antenatal clinic follow-up

C. Admission and work-up for cardiomyopathy

D. Post-natal referral to a cardiologist

E Admission to the labour ward for induction of labour

B. Reassurance and a 38-week antenatal clinic follow-up

13 B This question tests the candidate’s ability to distinguish physiological sequelae of normal pregnancy from more worrying features. In pregnancy, a soft systolic flow murmur is frequently audible on auscultation of the praecordium due to dilatation across the tricuspid valve causing mild regurgitant flow. Such a flow murmur is physiological and will disappear after delivery. Furthermore, the increasing size of the gravid uterus displaces the heart upwards and to the left. Mild abdominal pains and fatigue are common, particularly in the later stages of pregnancy. The woman in this case is experiencing normal pregnancy, and no specific treatment is necessary (B). Induction is not indicated in normal pregnancy at this gestation (E). Preterm induction of labour is offered to women for whom the maternal and fetal risks of continuing pregnancy outweigh the benefits associated with delivery at a later gestation (e.g. fetal maturation). Investigating physiological murmurs which pose no maternal or fetal risk may cause the mother unnecessary alarm (A, C, D). Maternal echocardiography (A) may be relevant if there was suspicion of structural heart disease (e.g. cardiomyopathy) or valvular disease (e.g. aortic steonsis in order to assess the patient’s capacity to cope with the stress on the heart during labour, and in particular the second stage of labour.

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14. Infection in pregnancy

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 4cm. 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

14 E 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.

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15. Complications of pregnancy (4)

A 41-year-old multiparous woman attends accident and emergency at 32 weeks gestation complaining of sudden onset shortness of breath. A CTPA demonstrates a large saddle embolus. What is the most appropriate treatment regimen?

A. Load with warfarin to achieve a target international normalized ratio (INR) of 3.0

B. Load with warfarin to achieve a target international normalized ratio (INR) of 2.5

C. Load with warfarin to achieve a target international normalized ratio (INR) of 20

D. 80 mg enoxaparin twice daily

E. 7.5 mg fondaparinux once daily

D. 80 mg enoxaparin twice daily

15 D This woman requires treatment for pulmonary embolism. She is in the third trimester of pregnancy, which is when wafarin is contraindicated (A, B, C). Warfarin is a teratogen, although its use has different effects depending on the gestation of the fetus. Use in the first trimester confers the most risk of teratogenicity, and is associated with fetal warfarin syndrome, a constellation of symptoms comprising nasal hypoplasia, vertebral calcinosis and brachydactyly. The risk of teratogenicity with warfarin use in the mid- and third trimesters is reduced but evidence exists to show a chance of cerebral malformations and ophthalmic disorders. Although both enoxaparin (Clexane) (D) and fondaparinux (Arixtra) (E) are both indicated in the treatment of pulmonary embolism, evidence of efficacy and safety in pregnancy only exists for enoxaparin: this is the agent used in the UK for the treatment of pulmonary embolism in pregnancy. Recognizing and treating pulmonary embolism in pregnancy is particularly important since it is one of the largest killers of mothers, as reported in the Confidential Enquiry into Maternal and Child Health.

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6. Antepartum haemorrhage

A 21-year-old woman attends the labour ward with per vaginal bleeding of 100 mL. She is 32 weeks pregnant and has had one normal delivery in the past. An important history to note is that of an antepartum haemorrhage in her last pregnancy and she smokes 10 cigarettes a day. Her 20-week anomaly ultrasound revealed a posterior fundal placenta. She admits she and her partner had intercourse last night and is concerned by terrible abdominal pains. What is the most likely diagnosis?

A. Vasa praevia

B. Placenta praevia

C. Placenta accreta

D. Placental abruption

E. Cervical ectropion

D. Placental abruption

16 D This woman gives a worrying history of painful vaginal bleeding.

Vasa praevia (A) is rare and occurs at the time of rupture of membranes, presenting as a painless bleed associated with sudden fetal compromise and not infrequently intrauterine demise. Placenta praevia (B) characteristically presents as a painless bleed. In this case we know the placenta is not low so this is not the answer. Placenta accreta (C) is a diagnosis of an adherent placenta which may be made on attempting to deliver the placenta post-partum. Placenta accreta is commonly associated with a previous caesarean section scar but can be present in an unscarred uterus. Intercourse can lead to vaginal bleeding as a result of contact with the cervix. A cervical ectropion (E), which is common in pregnancy, is a cause of vaginal bleeding but would not lead to abdominal pains. This woman is most likely having a placental abruption (D) – a separation of the placenta from the wall of the uterus. Risk factors include a previous abruption, smoking, a growth restricted baby and hypertension. Classically, the presentation is of a painful vaginal bleed. Abruptions can be life threatening to both mother and child.

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17. Rhesus isoimmunization

At a booking visit a first time mother is told that she is rhesus negative. Which of these answers is the most appropriate advice for the mother?

A. It is important to have anti-D as it will make sure your baby does not develop antibodies

B. If you have any bleeding before 12 weeks be sure to get an injection of anti-D

C. Anti-D will stop your body creating antibodies to your baby's blood that may help protect the health of your next child

D. If your partner is rhesus negative you do not need to have anti-D

E. You need one injection that will cover your pregnancy even if you have episodes of vaginal bleeding

C. Anti-D will stop your body creating antibodies to your baby's blood that may help protect the health of your next child

17 C The basis of this question is rhesus isoimmunization. If a rhesus negative mother is carrying a rhesus positive baby and then has a feto-maternal transfer of blood, the mother’s immune system will respond to the fetal cells (sensitization). The mother will create anti-D antibodies. The problem arises in any subsequent pregnancy if she has a rhesus positive fetus. The anti-D antibodies will cross the placenta and attack the fetal red blood cells causing a haemolytic anaemia. (A) is wrong as it has no effect on this pregnancy. There is no need to have anti-D before 12 weeks gestation (B). Theoretically, if the woman’s partner is rhesus negative their child will be rhesus negative (D). However, with possibly one in 10 partners not being the real father it would be prudent to advise all women to have the anti-D (avoiding accusing them of infidelity). National guidance now is to have one injection of 1500 IU at 28 weeks gestation but if there are sensitizing events such as vaginal bleeding, abdominal trauma or an external cephalic version the mother will need further doses (E). By elimination, (C) is therefore the best option.

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18. Antepartum haemorrhage

A 42-year-old pant 4 with a dichorionic-diamniotic (DCDA) twin pregnancy at 31 weeks gestation presents to hospital with a painful per vaginam bleed of 400 mL. The bleeding seems to be slowing. She is cardiovascularly stable, although having abdominal pains every 10 minutes. There is still a small active bleed on speculum and the cervix appears closed. Both fetuses have reactive CTGs. She has had no problems antenatally and her 28-week ultrasound revealed both placentas to be well away from the cervix. What is your preferred management plan?

A. Admit to antenatal ward, ABC, IV access, Group and Save, CTG, steroids, consider expediting delivery

B. Reassure and ask to come back to clinic next week if there are any problems

C. Admit for observation. IV access

D. Admit to labour ward. ABC, IV access. full blood count, cross-match 4 units of blood. CTG, steroids, consider expediting delivery

E. As bleeding settled and placenta not low, offer admission but arrange follow-up if refused

D. Admit to labour ward. ABC, IV access. full blood count, cross-match 4 units of blood. CTG, steroids, consider expediting delivery

18 D There are serious concerns about this woman. She continues to have a significant per vaginam bleed in keeping with a placental abruption. She is not in labour and both twins have normal CTGs. It would be wrong to let this woman go home. She may well need to be delivered urgently by caesarean section. Answers (A) and (D) provide the most logical course of management, the only difference being that, in (D), that you are anticipating the very real prospect of this woman needing a blood transfusion and delivery. She should be admitted to your high risk area (i.e. labour ward). Initial assessment should involve a cardiovascular review, IV access, full blood count and cross-match for 4 units of blood. Continuous CTG should be in place and antenatal steroids should be commenced as while the patient bleeds the fetuses are at risk. If delivery is imminent, the steroids will not have enough time to affect fetal lung maturity. It is imperative that you involve the consultant obstetrician, anaesthetist, paediatricians and senior midwife as early as possible. Answers (B) and (C) confirm that the doctor has not grasped the seriousness of the situation. Twin pregnancies are at an increased risk of abruption. This woman should not be allowed to go home (E) as her life is in danger. (D) would be the most appropriate answer from the above.

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19. Seizures in pregnancy

You are the FYI covering the antenatal ward. A 27-year-old nulliparous woman who is 36 weeks and 5 days pregnant has been admitted to your ward with suspected pre-eclampsia. The emergency buzzer goes off in her room. You are the first to attend and find your patient flat on the bed having a generalized seizure -what do you do?

A. Call for help. ABC, nasopharyngeal airway, IV access and wait for fit to stop

B. Call for help. ABC. protect her airway, prepare for grade 1 caesarean section

C. Call for help. ABC. left lateral tilt, wait for seizure to end, listen in to fetus

D. Call for help. ABC. left lateral tilt, protect airway, prepare magnesium

E. Call for help. ABC, protect airway, prepare magnesium, check blood pressure

D. Call for help. ABC. left lateral tilt, protect airway, prepare magnesium

19 D Your first suspicion should be that this woman is having an eclamptic fit. This is a potentially life-threatening situation. You will need help as soon as possible. Calling for help, lying the woman flat and tilting her onto her left are the first steps; therefore (C) and (D) are the best answers in an obstetric emergency. You need to protect her airway but insertion of an additional airway (A) in an actively fitting woman would be difficult and potentially dangerous. Also, obtaining IV access while someone is fitting is not safe. Option (B) may well be what happens but in the first instance you need to stabilize the mother and not be preparing to operate yourself. The airway, breathing, circulation approach is a sensible reliable method of leading through this emergency. Tilting onto the left will relieve any aortocaval compression and stop the woman choking if she vomits. The mother must be your primary concern so until the seizure has stopped and the cause of her seizure – likely a raised blood pressure – is controlled, it is prudent not to try and monitor the fetus. This is why answer (C) is not the best course of action as the mother should have her BP checked before checking the fetal heart. This is because even if there is evidence of fetal distress it is not possible to deliver the fetus until the mother is stable. Magnesium sulphate is used as a cerebral membrane stabilizer and should be given as soon as possible. Once the seizure has finished you will need to re-check her airway, breathing and circulation and then monitor the fetus. Option (E) is in fact a good answer but it is important not to forget to put a pregnant woman into a tilt with a wedge or a pillow, even when fitting. Answer (D) is the most appropriate answer.

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20. Thrombocytopenia

A 38-year-old woman in her first pregnancy is 36 weeks pregnant. She presents to the labour ward feeling dizzy with a mild headache and flashing lights. Her past medical history Includes systemic lupus erythematosus (SLE), renal stones and malaria. Her blood pressure is 158/99 mmHg with 2+ protein in her urine. Her platelets are 55 x 10911., Hb 10.1 g/dL, bilirubin 62 pmol/L, ALT 359 IU/L. urea 23 mmol/L and creatinine 64 pmol/L. What is the most likely diagnosis?

A. Thrombotic thrombocytopenic purpura (IT?)

B. HELLP syndrome

C. Idiopathic thrombocytopenic purpura (fIP)

D. Systemic lupus erythematosus (SLE)

E. HIV

B. HELLP syndrome

20 B TTP can occur at any time in pregnancy and is characterized with a pentad of microangiopathic haemolytic anaemia, thrombocytopenia, fever, neurological involvement and renal impairment (A). There is evidence of haemolysis here but her renal function is normal. ITP is caused by autoantibodies against platelet surface antigens and is a diagnosis of exclusion (C). SLE (D) is a multisystem connective tissue disorder that can show haemolytic anaemia and thrombocytopenia. HIV (E) can cause a thrombocytopenia. It is likely that this woman has been tested for HIV as it forms part of the routine tests offered to mothers at booking. This woman appears to have developed HELLP syndrome (B) – a variant of pre-eclampsia. It is characterized by haemolysis, elevated liver enzymes and low platelets. She has symptomatic pre-eclampsia so answer (B) is the most likely cause.

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21. Vertical infections

A 19-year-old woman in her first pregnancy presents to the GUM clinic with an outbreak of primary herpes simplex infection on her labia. She is 33 weeks pregnant. What is the best advice regarding her herpes?

A. Aciclovir from 36 weeks until delivery

B. Caesarean section should be performed if she labours within the next 8 weeks

C. Reassure as the infection will pass and pose no further concern

D. If she labours within 6 weeks, a caesarean should be recommended

E. Aciclovir for 10 days and an elective caesarean at 39 weeks

D. If she labours within 6 weeks, a caesarean should be recommended

21 D If primary herpes develops in pregnancy it is imperative to consider risk of vertical transmission. If the herpes presents at the time of delivery or within 6 weeks of the due date a caesarean is the safest mode of delivery (D). If she labours within 6 weeks (not 8 weeks) of developing primary herpes she should consider a caesarean (B). If she refuses to have a caesarean then IV aciclovir during labour and close liaison with the neonatologist is recommended. Neonatal herpes is rare at one in 60 000 but can lead to encephalitis, hepatitis and disseminated skin lesions. There is no evidence that aciclovir in the antenatal period decreases the chance of fetal infection – (A) and (E). You can reassure the woman (C) but only if she delivers after 6 weeks when the herpes should have cleared. It would be wrong to tell her that all will be well regardless of the timing of delivery.

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22. Antenatal care (1)

A 33-year-old woman presents to hospital with a 2-day history of itching on the soles of her feet and the palms of her hands. Her pregnancy has been straightforward and she has good fetal movements. Liver function tests reveal an alanine transaminase (ALT) of 64 IU/L and bile acids of 30 pmo11L You suspect that she might have developed obstetric cholestasis. Which of the following bits of advice is true?

A. She could have intermittent monitoring in labour

B. Ultrasound and CTG surveillance help prevent stillbirth

C. Poor outcomes can be predicted by bile acid levels

D. Ursodeoxycholic acid (UDCA) helps prevent stillbirth

E. Meconium stained liquor is more common in labour

E. Meconium stained liquor is more common in labour

22 E Obstetric cholestasis is characterized by itching and deranged liver function, especially an elevated bile acid level (above 20 μmol/L). Once diagnosed, liver function should be checked weekly. The main concern is that of stillbirth so most clinicians recommend inducing patients between 37 and 38 weeks gestation. There is no way of predicting stillbirth (B). Preterm labour is more likely as well as meconium stained liquor in labour (E). UDCA is unlicensed but has been used for a long time and has no apparent side effects. It helps to treat the pruritis and reduce the bile acid level but there is no data to suggest it helps reduce stillbirths (D). There is no direct link between the level of bile acids and the outcome of the pregnancy (C). Obstetric cholestasis may increase fetal risk CTCG, so continuous CTG, not intermittent (A), is advised.

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23. Headaches in pregnancy

A 24-year-old woman who is 32 weeks pregnant presents to the labour ward with a terrible headache that has not improved despite analgesia. It started 2 days ago and came on suddenly. She has stayed in bed as it hurts to be in sunlight and she vomited twice this morning. Her past medical history includes a macroprolactinoma (which has been removed) and occasional migraines. She is haemodynamically stable with no focal neurology or papilloedema. You arrange for her to have a CT of her head as an emergency, which adds no further information to aid your diagnosis. There are red cells on lumbar puncture but no organisms are isolated. What is the most likely diagnosis?

A. Migraine

B. Viral meningitis

C. Cerebral vein thrombosis (CVT)

D. Subarachnoid haemorrhage (SAH)

E. Idiopathic intracranial hypertension (IIH)

A. Migraine

23 A This in fact is very difficult as all five could be the cause for this headache. Migraines (A) are common, especially in pregnancy, even without a history of previous migraines. The concern here is that, although the symptoms could fit with a migraine, you need to consider other diagnoses. Subarachnoid haemorrhage (D) has a very sudden onset. In addition to the presenting symptoms there is often papilloedema and focal neurology. The negative CT result does not completely exclude SAH. A lumbar puncture would help diagnosis, looking for blood, bilirubin or xanthochromia in the cerebrospinal fluid. A CVT (C) classically presents post-partum. It has similar symptoms but up to two-thirds will have neurological deficit. MRI is generally a better imaging modality but is often not available out of hours. IIH (E) characteristically occurs in young obese women. It is a headache associated with papilloedema and raised intracranial pressure without CT or MRI evidence of hydrocephalus or a space occupying lesion. Viral meningitis (B) would classically give a fever as well as headache, vomiting, photophobia and neck stiffness. It is likely that a migraine is the most likely cause of her symptoms but it is important to remember that people with an acute onset of headache could have much more serious pathology.

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24. Antenatal care (2)

A 19-year-old woman in her first pregnancy is admitted to the labour ward with a 4-hour history of lower abdominal pain - she is 22 weeks pregnant. She has not had any vaginal bleeding but describes a possible history of rupture of her membranes. Her past medical history includes an appendectomy and a large cone biopsy of her cervix. On examination she has palpable lower abdominal tenderness, her cervix is 2cm dilated, she has an offensive vaginal discharge and her temperature is 38.9°C. Her white cell count is 19.0 x 10911.. and her C-reactive protein is 188 mg/L. There are no signs of cardiovascular compromise. How would you manage this woman?


A. Insert a cervical suture

B. 12 mg betamethasone, atosiban for tocolysis and antibiotics

C. Head down, bed rest, antibiotics and await events

D. Antibiotics and induce labour

E. Caesarean section

D. Antibiotics and induce labour

24 D This woman is unwell with sepsis. The history of possible ruptured membranes, offensive vaginal discharge, abdominal pain and a temperature point towards a diagnosis of chorioamnionitis. Inserting a rescue cerclage (A) is contraindicated in the presence of infection. She is 22 weeks pregnant and thus the fetus is not viable, which means she should not receive antenatal steroids (B). Tocolysis is contraindicated as she has septic chorioamnionitis. This woman needs to have antibiotics (D) to treat her infection and more importantly needs to have labour induced in order to remove the nidus of infection – the pregnancy. This is a very difficult scenario to deal with as obviously this is the last thing that the mother wants to do. In light of the gestation and how unwell the mother is, induction is the most appropriate course of action. Watchful waiting under antibiotic cover would not be appropriate (C). A caesarean section (E) or hysterotomy at this gestation should be avoided.

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25. Antenatal care (3)

A 24-year-old multiparous woman is 23 weeks pregnant. She has not had chicken pox before. She goes to a collect her 3-year-old son from a birthday party and comes into contact with a child with an infective chicken pox infection. She is naturally very anxious. What is the best course of management?

A. Wait and see if she develops a rash. If she does treat with aciclovir

B. Test for varicella antibodies and give varicella zoster immunoglobulin (VZIG) within the first 24 hours

C. Test for varicella antibodies and give aciclovir within the first 24 hours

D. Test for varicella antibodies and give VZIG within 10 days

E. Reassure that there is no significant risk at present as contact was so brief

D. Test for varicella antibodies and give VZIG within 10 days

25 D Mothers who have not had chicken pox are at risk of developing the disease in pregnancy. Pregnant women tend to be affected much worse if they contract chicken pox. Also, if chicken pox is contracted before 28 weeks gestation there is the risk of fetal varicella syndrome (eye defects, hypoplasia of limbs and neurological defects). This woman has had a significant contact with chicken pox and the fact that her child has been with the infected child means that he may well now be about to develop chicken pox. Waiting is simply not a sensible option (A) as she is at risk of developing chicken pox herself and potentially developing fetal varicella syndrome. Although the mother thinks that she has never had chicken pox she may have had a previous subclinical or unknown childhood infection, so if she has antibodies no further action is necessary. Aciclovir can be used to treat chicken pox within 24 hours of the rash appearing so does not need to be started straight away (C). The appropriate management here is for VZIG to be administered (on consultation with the blood products laboratory as it may be in short supply) (D) if her antibody screen is negative. This situation will make mothers very anxious and they will want VZIG straight away, which is not appropriate as her antibodies will not be back yet (B). The Health Protection Agency advises that VZIG may be given within 10 days of exposure. Answer (E) is not appropriate as you are not taking any steps to find out whether this mother is at risk.

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26. Breech presentation

A 32-year-old woman in her third pregnancy is 37 weeks pregnant and has an extended breech baby on ultrasound. After discussion in the antenatal clinic. which of the following is not an absolute contraindication to an external cephalic version (ECV)?

A. Multiple pregnancy

B. Major uterine abnormality

C. Antepanum haemorrhage within 7 days

D. Rupture of membranes

E. Small for gestational age with abnormal Doppler scan

E. Small for gestational age with abnormal Doppler scan

26 E ECV is offered from 36 weeks in first time mothers and from 37 weeks in multiparous women. Answer (E) is only a relative contraindication along with pre-eclampsia, a scarred uterus and oligohydramnios. At term, 3–4 per cent of all babies are breech. The success of ECV is dependent on case selection and operator experience. The success ranges from 30 to 80 per cent. If the baby turns cephalic there is a 95 per cent chance that it will stay there. In multiple pregnancy (A) ECV is contraindicated due to the risk of abruption and the fact that there is little or no room to turn the fetus. A major uterine abnormality (B) such as bicornuate uterus is a cause of breech presentation. The pregnancy has usually implanted in one of the horns of the uterus and there is no space to turn. You will not be able to turn the baby and may use excessive force. If there has been an antepartum haemorrhage (C) you should not be putting pressure on the uterus as this may increase the chance of an abruption. When the membranes have ruptured (D) the fetus is unlikely to turn as there is less space as the liquor has been drained.

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27. Diabetes mellitus in pregnancy (1)

A 24-year-old type 1 diabetic woman has just had her first baby delivered by caesarean section at 35 weeks due to fetal macrosomia and poor blood sugar control. The operation is straightforward with no complications. She has an insulin sliding scale running when you review her on the ward 12 hours postoperatively. She has begun to eat and drink. How would you manage her insulin requirements?

A. Continue the sliding scale for 24 hours

B. Change her back to her pre-pregnancy insulin and stop the sliding scale

C. Halve the dose of insulin with each meal for the next 48 hours

D. Stop the insulin now that baby is delivered

E. Sliding scale for 48 hours to prevent hyperglycaemia

B. Change her back to her pre-pregnancy insulin and stop the sliding scale

27 B Once she is eating and drinking, which will usually be about 6 hours after the operation, she can have the sliding scale taken down. She can now be put back on her pre-pregnancy doses of insulin. Naturally you will need to monitor her blood sugars to ensure that this is adequate insulin replacement. Stopping the insulin (D) all together is not correct as she is a type 1 diabetic who needs exogenous insulin. Continuing the sliding scale for 24 (A) or even 48 (E) hours is unnecessary if the patient is eating. It subjects them to frequent finger prick testing, including at night when they are trying to sleep. Halving her pre-pregnancy dose of insulin (C) is likely to give her less than she requires and provoke hyperglycaemia.

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28. Maternal medicine

A 19-year-old woman is referred to your pre-conception clinic. She has SLE and wants to fall pregnant. She is currently not on any treatment and has no symptoms. As part of your general counselling you should talk about the risks associated with pregnancy. Which of the following is not a particular risk to a woman with SLE?

A. Fetal growth restriction

B. Diabetes mellitus

C. Pre-eclampsia

D. Stillbirth

E. Preterm delivery

B. Diabetes mellitus

28 B SLE is a systemic connective tissue disorder that is more common in black African and black Caribbean women with an overall incidence of one in 1000. It may manifest as arthritis, renal impairment, neurological involvement, haematological complications, serositis–pericarditis or as various permutations of the above. Pregnancy increases the likelihood of a flare by 40–60 per cent. There is an increased risk of spontaneous miscarriage, fetal death (D), pre-eclampsia (C), preterm delivery (E) and fetal growth restriction (A). There is no specific link to diabetes.

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29. Antenatal care (4)

A 44-year-old women who is is weeks pregnant presents to your clinic with a 2-day history of a viral illness. She is extremely anxious and is in floods of tears. She recently had some soft cheese in a restaurant and after an intemet search she is convinced she has a particular infection. What infection is she concerned about?

A. Toxoplasmosis

B. Cytomegalovirus (CMV)

C. Listeria monocytogenes

D. Hepatitis E

E. Parvovirus B 19

C. Listeria monocytogcncs

29 C Listeria monocytogenes (C) can cause listeriosis and pregnant women are at particular risk as they are immunocompromised. It is a food-borne infection and can be present in unpasteurized cheese and pâté. In pregnancy it can cause mid-trimester loss, early meconium and preterm labour. It typically presents as a flu-like illness. Toxoplasmosis (A) is caused by the parasite Toxoplasma gondii and characteristically is contracted via contact with cats and their faeces. CMV (B) is usually subclinical and 50–60 per cent of women in the UK are already immune having had exposure prior to pregnancy. It is not associated with food. Hepatitis E (D) is a non-chronic hepatitis transmitted by the faeco-oral route but it can have a fulminant course in pregnancy. Parvovirus B 19 (E) causes a facial rash called fifth disease/slapped cheek syndrome or erythema infectiosum. It has a respiratory droplet route of transmission.

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30. Rashes in pregnancy

A 26-year-old woman is 37 weeks pregnant and consults you about a rash that started on her abdomen and has now spread all over her body. Interestingly her umbilicus is spared. The rash is very itchy and nothing is helping. The rash is her first problem in this pregnancy. of interest. her mother has pemphigoid and her sister has psoriasis. What is the most likely cause of her rash?

A. Pemphigoid gestationis

B. Pruritic unicarial papules and plaques of pregnancy (PUPP)

C. Impetigo herpetiformis

D. Prurigo gestationis

E. Contact dermatitis

B. Pruritic unicarial papules and plaques of pregnancy (PUPP)

30 B Rashes in pregnancy are relatively common but there are very few that need medical attention. PUPP (B) classically starts on the abdomen in stretch marks and has peri-umbilical sparing. It can then move all over the body. It normally occurs after 34 weeks of pregnancy and disappears after birth. Pemphigoid gestationis (A) is a blistering condition that starts in the umbilicus and spreads. Prurigo gestationis (D) is usually a rash of the trunk and upper limbs with abdominal sparing. Impetigo herpetiformis (C) is a blistering condition that always presents with a febrile illness and if not treated early can lead to maternal and fetal death. (E) is a possibility as she may have had a reaction to a topical lotion, i.e. stretch mark cream. However, you would not find peri-umbilical sparing.