Day 11 Obstetrics

Question 1

A 24-year-old primagravida patient is being treated on the ward for antenatal haemorrhage.

In the course of her management, she receives a Kleihauer test.

What is the purpose of the Kleihauer test? (3)

Answer 1

• The Kleihauer test is performed in rhesus D -negative women to gauge the dose of anti-D immunoglobulin required
• The Kleihauer test is used to quantify the dose of Rh-D antigen in maternal circulation.

In significant sensitising events (events during which Rh-D antigen enters the maternal Rh-negative circulation), a Kleihauer test can guide the amount of anti-D IG needed to prevent maternal sensitisation

Question 2

A 30 year old woman has just given birth on the labour ward at 41 weeks gestation.

The birth was an uncomplicated vaginal delivery but the midwife had noticed the presence of some green coloured liquor during delivery.

At initial assessment, the newborn has noisy breathing, expiratory grunting and is using his accessory respiratory muscles.

The APGAR score at 5 minutes is 7.

Heart rate is 95 beats per minute, respiratory rate is 70 breaths per minute and the neonate appears pink.

Given the likely diagnosis, what is the most appropriate management plan?

Answer 2

Admission to NICU for oxygen and antibiotic therapy.

This is the most appropriate management. This neonate is showing signs of meconium aspiration syndrome (respiratory distress on a background of meconium-stained liquor and postdates delivery) and thus should be transferred to a specialist unit oxygen, antibiotics and close monitoring.

Question 3

A 30 year old woman who is pregnant with her second child presents to the antenatal clinic.

In her previous pregnancy she had an elective Caesarean section due to breech presentation.

This was carried out at 38 weeks and left her with a low transverse scar.

Otherwise, her pregnancy was uncomplicated.

She is currently 18 weeks pregnant and her scans and bloods so far have been normal.

This time round, she is keen to have a vaginal delivery at home and seeks advice.

What advice should be given to this mother?

Answer 3

She will be able to try for a vaginal delivery, but there is still a chance she will require an emergency Caesarean section

Classical Caesarean section and previous uterine rupture are both contraindications to VBAC. Other contraindications may include contraindications to any vaginal delivery such as major placenta praevia.

Question 4

A 31-year-old woman presents at 4 weeks of pregnancy with some minor vaginal bleeding.

She has no tenderness on abdominal examination.

Pelvic examination reveals some cervical motion tenderness.

She is referred for a pelvic ultrasound which does not identify any masses or active pregnancy.

A serial serum beta-human chorionic gonadotropin (B-hCG) measurement is taken at 0h and 48h:

0h: 24 IU/L
48h: 56 IU/L

What is the most appropriate next step in management of this patient? (2)

Answer 4

The pregnancy is likely intrauterine, order another ultrasound to confirm at a later date

• The high proportional increase in B-hCG (more than double over 48 hours) is suggestive that the embryo is successfully growing and is most likely to be located within the uterus.
• Another ultrasound at a later date when the fetus should be larger and easier to identify would confirm this result.
• An ectopic pregnancy would be likely if there was only a slight increase in B-hCG over 48 hours.

Question 5

A 36-year-old woman presents to her GP. She is distressed as she has recently had a miscarriage at 9 weeks.

This is her 3rd miscarriage; the previous two were at 7 and 8 weeks gestation.

Her past medical history includes two episodes of deep vein thrombosis.

On examination, there is a net-like, mottled, purplish discolouration of her left leg.

What is the most appropriate treatment to increase the chance of future pregnancies surviving to term?

Answer 5

Aspirin

• The description of her leg is suggestive of livedo reticularis.
• The change occurs when reduced blood flow leads to cyanotic areas of skin which are furthest from sites of ascending arterioles.
• The most likely diagnosis is antiphospholipid syndrome, an autoimmune condition which is associated with recurrent miscarriage and thromboses.
• The formation of thromboses is thought to lead to miscarriages, and thus by thinning the blood using aspirin there is an increased chance of prevention of clots, and hence a successful pregnancy.

Question 6

A 30 year old woman arrives in antenatal clinic to receive the results of her 18 week ultrasound scan.

This is her second pregnancy and her first baby was delivered three years ago via an emergency caesarean section for obstructed labour.

The ultrasound reports that there are no fetal or amniotic fluid abnormalities.

The placenta is in a fundal position and the villi have penetrated fully through the myometrium.

What is the most likely diagnosis?

Answer 6

Placenta percreta

Placenta percreta is the most severe form of abnormal placental villous adherence. Here the placental villi extend past the normal confines of the uterine myometrium and can even adhere to other abdominal structures such as the bladder. Common risk factors include placenta praevia, previous Caesarean section or uterine surgery and structural uterine abnormalities.

Question 7

A 34 year old G2P0 at 36 weeks gestation presents to the antenatal clinic complaining of a week long history of general malaise, vomiting, and anorexia. She has had a poor appetite. She also complains of abdominal pain on the right side and indigestion. She denies any visual changes, headaches, and swellings. She denies any abnormal discharge and reports presence of foetal movements. On examination, her blood pressure is 135/85 mmHg and she appears mildly jaundiced.

Her blood test results are shown below:

Hb: 129 g/l (115-160 g/l)
Platelets: 175 x 109/l (150-400 x 109/l)
WBC: 10 x 109/l (4.0 - 11.0 x 10 9/l)
PT: 16 secs (10-14 secs)

Bilirubin: 36 umol/l (3-7 umol/l)
ALP: 344 u/l (30-100u/l)
ALT: 200 u/l (3-40 u/l)
AST: 350 u/l (3-30 u/l)

What is the most likely diagnosis?

Answer 7

Acute fatty liver of pregnancy

Acute fatty liver of pregnancy is a rare complication of pregnancy but important to be aware of. It commonly occurs in the third trimester or immediately following delivery and is thought to be more common in nulliparous women as in the case of this patient. A typical patient will present with a few days history of general malaise, anorexia, vomiting, and jaundice. Pain in the right upper quadrant may sometimes be present. Blood results would show marked elevation of liver enzymes, prolonged PT, raised and bilirubin.

Question 8

A 34 year old woman is attending the maternity unit for an elective caesarean section at 39 weeks gestation.

She is administered spinal anaesthesia by the anaesthetist and draped and prepped for the operation.

Which of the following is the correct sequence of layers that will be dissected through to gain access to the foetus during caesarean section? (7)

Answer 8

1. Skin
2. subcutaneous fat
3. rectus sheath
4. rectus abdominus muscle
5. peritoneum
6. uterine myometrium
7. amniotic sac

During a caesarean section the skin is first incised using a scalpel, subcutaneous fat is divided to reveal the tough rectus sheath. This is incised again using a scalpel to reveal the rectus abdominus muscle below. This is generally dissected using blunt dissection with pulling apart of the fibres, rather than sharp cutting, to reveal the peritoneum covering the uterus. This is dissected away and the hysterotomy (uterine incision) is performed. An incision may also need to be performed in the amniotic sac if this has not already been perforated, to allow delivery of the foetus.

Question 9

A 29-year-old nulliparous woman is 34 weeks pregnant and presents to her GP with a two day history of flu-like illness and painful vesicular lesions around her vagina.

Given the most likely diagnosis, which of the following best represents the most appropriate course of action regarding further management of her pregnancy?

Answer 9

Offer the patient oral aciclovir and an elective Caesarian section

The most likely diagnosis here is herpes simplex virus. As such, aciclovir can be offered to treat the current presentation and a Caesarian section will greatly reduce the risk of vertical transmission to the foetus at delivery

Question 10

A 25 year old primiparous woman has just given birth on the labour ward at 41 weeks gestation.

The birth was a vaginal delivery and other than the presence of green - tinged liquor there were no other complications.

At initial assessment the newborn appears to have laboured breathing, expiratory grunting and nasal flaring.

Heart rate is 90 beats per minute and the neonate appears pink.

What is the likely diagnosis in this newborn?

Answer 10

​Meconium aspiration syndrome

• The green tinged liquor suggests that meconium is present and it is likely that this was inhaled by the infant before or during birth.
• Furthermore, the risk of meconium aspiration syndrome increases after 40 weeks gestation.

Question 11

A 17 year old lady presents to the emergency department with heavy vaginal bleeding and lower abdominal pain. Her last menstrual period was eight weeks ago. She describes bits of ‘skin-like’ substance within the blood. Vaginal bleeding is ongoing.

She looks well. Her observations are normal. On examination, her abdomen is mildly tender suprapubically. On speculum examination, her cervical os is open, no products of conception are seen, and ongoing bleeding is apparent.

What is the likely diagnosis? (3)

Answer 11

Incomplete miscarriage

Incomplete miscarriage occurs with abdominal pain and/or vaginal bleeding following a pregnancy loss where not all of the products of conception have been expelled from the uterus.

On speculum examination, the cervical os may be open or closed, or there may be products seen within the os. On ultrasound, products of conception are seen persisting within the uterus.

Patients with incomplete miscarriage may be managed with ‘watchful waiting’, medical management with Misoprostol, or surgical management with dilatation and curettage

Question 12

A 45 year old woman presents to the GP at 15 weeks gestation after finding out that she is pregnant.

This is her first pregnancy and she has read on the internet that Down’s syndrome is common in women over the age of 40.

She would like to find out what her risk is of having a child with Down’s syndrome.

Which test should she be offered?

(3)

Answer 12

The quadruple test

• The quadruple test is the screening test provided for pregnant women presenting after 13 weeks gestation.
• It involves blood tests to measure levels of the hormones B-hCG, AFP, uE3 and inhibin A. It does not involve an ultrasound scan.

Question 13

A 30 year old G2P0 at 38 weeks gestation presents to the antenatal clinic complaining of itchy palms and soles since two days. Her husband has commented on her skin looking yellow lately. She denies any fever, malaise, rash, visual disturbances, and headaches. Blood test reveals elevated bilirubin of 35 umol/l (3-17 umol/l) but all other liver function and clotting tests are normal.

What is the most likely diagnosis?

Answer 13

Intrahepatic cholestasis of pregnancy

• Intrahepatic cholestasis generally seen in third trimester.
• There is accumulation of bile salts in the serum.
• As a result it often involves pruritus in the palms and soles.
• Liver enzymes rarely rise above 250 u/l along with elevated bilirubin.

Question 14

A 28-year-old woman (para 1, gravida 3) presents to birth options clinic to create a delivery plan for her current dichorionic twin pregnancy.

She has no significant medical history other than a previous classical Caesarean section three years ago.

Which of the following is the best advice to offer?

Answer 14

Recommend a Caesarean section at 37 weeks gestation

A previous classical Caesarean section is an absolute contraindication to normal vaginal delivery. There is a risk of uterine rupture and the foetus may be expelled into the peritoneal cavity. Women with dichorionic twin pregnancies should be offered elective birth from 37 weeks 0 days.

Question 15

A 25 year primigravida at 14 weeks gestation presents to the Accident and Emergency complaining of severe nausea and vomiting.

She is unable to keep fluids down.

A diagnosis of hyperemesis gravidarum is suspected.

Which other symptoms might be found in this diagnosis? (3)

Answer 15

Evidence of hypokalaemia on the ECG

Vomiting causes potassium loss leading to hypokalaemia, which would show signs on an ECG such as the U waves, small or absent T waves, prolonged QT and PR intervals along with ST depression. They are usually a later finding in the course of the disease.

Ketonuria

Early signs include ketonuria and/or weight loss of up to 5% of overall pre-pregnancy weight. Ketonuria is caused by the lack of nutrition and starvation mode brought on to the body by persistent vomiting. Treatment is usually with electrolyte rehydration therapy and anti-emetics. Admission may be necessary for IV hydration.

Weight loss of more than 5% of overall body weight despite treatment with oral antiemetics

Question 16

A baby is born at term to a 28 year old primigravida, who has had no prenatal screening.

The baby has a very large head and after 2 days has a tense fontanelle.

He undergoes a CT scan which shows enlargement of the lateral and third ventricles.

What is the most likely cause?

Answer 16

Maternal rubella infection.

Rubella can cause aqueductal stenosis leading to congenital hydrocephalus.

Question 17

A 23 year old primigravida woman attends her local maternity unit at 40+2 weeks gestation for induction of labour.

Her midwife examines her and finds her cervix difficult to reach as it is very posterior.

It is long, closed and firm to the touch.

What medication is appropriate to prescribe at this time?

Answer 17

Vaginal prostaglandin E2 pessary

• Prostaglandins are administered into the vagina and act to ‘prime’ the cervix, allowing it to become softer and shorter in preparation for labour.
• The pessary is inserted by a suitably experienced person, and left in situ for 24 hours before reassessment of the cervix.

Question 18

A 30 year old primiparous woman presents to the labour ward at 33 weeks gestation with regular painful uterine contractions occurring every 15 minutes.

A vaginal examination reveals that she is 3cm dilated.

Her observations are normal and fetal cardiotocogram is reassuring.

There have been no known complications with the pregnancy so far.

The obstetric consultant decides to offer tocolytic intervention to delay the delivery to allow time for maternal corticosteroids to take effect.

Which of the following is the most appropriate tocolytic agent?

Answer 18

Oral Nifedipine

Current guidelines recommend oral nifedipine as the first line tocolytic agent to use in pre-term labour.

Question 19

A 28 year old G1P0 at 42 weeks gestation is undergoing vaginal delivery.

She had developed gestational diabetes at 24 weeks gestation and recent ultrasound confirmed foetal macrosomia.

During delivery, baby’s shoulders get stuck following delivery of the head.

Keeping the most likely diagnosis in mind, what is the appropriate first-line management?

Answer 19

Oral antibiotics are recommended in asymptomatic bacteriuria in pregnancy

Correct. Oral antibiotics are recommended in cases of asymptomatic bacteriuria to prevent progression to pyelonephritis and increased risk of preterm labour.

Women should have a routine urinalysis at booking to screen for asymptomatic bacteriuria. If this is positive for nitrites or leukocytes, it should be sent for culture.

Question 20

A 30 year old primiparous woman at 37 weeks gestation is having regular uterine contractions which are 15 minutes apart.

Speculum examination shows clear fluid pooled in the vagina and a digital examination shows that the cervix is fully effaced and 5cm dilated.

The cervix has been dilating around 1cm every 2 hours.

Fetal presentation is cephalic and fetal station is -2.

Which stage of labour is this woman experiencing?

Answer 20

First stage – active phase

The active phase of the first stage of labour is described as cervical dilation from 3cm to 10cm.

Question 21

A 30-year-old G1P1 presents to the booking visit at the antenatal clinic.

She is briefed about the antenatal care timetable.

She is wondering when the anomaly scan would be performed as she is concerned about any abnormalities in her baby.

When is the anomaly scan usually performed?

Answer 21

18-20 + 6 weeks

This is the timeframe for the anomaly scan to be performed.

Anomaly scan evaluates anatomical structures of the foetus, placenta, and maternal pelvic organs.

This allows for careful planning of the pregnancy as well delivery.

Question 22

A 35 year old woman was seen at 28 weeks gestation in the antenatal clinic as she was worried about some abnormal discharge.

Her previous baby stayed in hospital for 2 weeks after birth for neonatal sepsis.

Endocervical and high vaginal swabs were taken which were negative for chlamydia and gonorrhoea.

However, a positive culture Group B Streptococcus was found incidentally.
In light of this finding how should this woman be managed?

Answer 22

She should be given antibiotics intravenously during labour and delivery to prevent newborn GBS infection

​This is the most appropriate management. Intra-partum antibiotics reduce the baby’s risk of early onset GBS infection and thus perinatal mortality.

Question 23

You are bleeped to a patient on labour ward who has just delivered a healthy baby.

The midwife reports that while he was performing controlled cord traction, the patient began to bleed and the uterine fundus is no longer palpable in the abdomen.

What is the most likely diagnosis?

What is the most appropriate next step in management?

Answer 23

Inversion of the uterus

This question is describing a case of uterine inversion.

Immediate replacement of the uterus is the best first step as the greater the delay in attempting this, the greater the likelihood the manoeuvre will fail.

General resuscitation measures should also be taken and tocolytic drugs can be used to aid replacement of the uterus if a first attempt fails.

Question 24

A 27 year old patient comes in with a feeling very anxious, low in mood, and is unable to sleep at night. She delivered her first baby 6 weeks ago.

She reports feeling sad all the time and a reduced appetite.

She feels guilty about not being able to connect well with her baby either and says she feels like crying all the time.

What is the most likely diagnosis?

Answer 24

Postpartum depression

This is a classic presentation of post-partum depression. It affects about 10-15% of women Symptoms typically start within a month and peak at 3 months. Symptoms are similar to symptoms of depression under other circumstances such as low mood, anhedonia, anergia, difficulty sleeping and anxiety. This patient has presented with these symptoms after 6 weeks of giving birth.

Question 25

A 30 year old woman is brought in by her husband to accident and emergency due to a two week history of persistent nausea and vomiting. Her husband also reports she has been more confused over the last three days. She is 10 weeks pregnant and this is her first pregnancy. For several days now she has not been tolerating food but has been able to drink water. On general examination she appears fatigued there is also some noticeable weakness of her ocular muscles bilaterally. Which complication of hyperemesis gravidarum is this woman likely suffering from?

Answer 25

**Wernicke’s encephalopathy secondary to hyperemesis gravidarum** Wernicke’s encephalopathy is the most likely cause of this woman’s confusion and ophthalmoplegia. It is caused by thiamine deficiency which can be precipitated in severe vomiting and reduced food intake. * Treatment is with Vitamin B1 (thiamine) supplementation.

Question 26

A 33 year old primigravida presents to the antenatal clinic at 11 weeks gestation complaining of a week long history of persistent intractable nausea and vomiting. She is experiencing difficulty keeping liquids down and has been unable to go to work. Her urine shows ketones ++. She asks whether there's a medication she can try. **What is the most appropriate pharmacological therapies?** **(4)**

Answer 26

**promethazine/cyclazine** then **Ondansetron** then **Metoclapromide**

Question 27

Straight facts about ECV | (3)

Answer 27

**_ECV_** * only 50% are successful * For nulliparous and multiparous women, the recommended time for ECV is 36 and 37 weeks respectively * Tocolytics can increase the success rate of ECV

Question 28

**What regarding the mode and timing of delivery in patients with gestational diabetes is correct?**

Answer 28

**Women with gestational diabetes should give birth no later than 40+6 weeks of gestation.** Gestational diabetes is when women develop high levels of blood sugar levels during pregnancy. It is usually diagnosed at 24-28 weeks of gestation on the basis of elevated blood glucose levels on glucose tolerance tests. Women with gestational diabetes have a significantly increased risk of stillbirth, because of which women are advised to deliver no later than 4o+6 weeks of gestation. Caesarean section or elective induction is performed if spontaneous delivery has not occurred by then.

Question 29

A 30 year old primiparous woman is admitted onto the labour ward for an induction of labour at 41 weeks gestation. She is placed on a synthetic oxytocin infusion with continuous cardiotocography monitoring. 60 minutes after the start of the infusion the midwife calls the obstetrician as she is worried about her CTG reading. The fetal heart rate is 95 bpm and she is contracting six times in 10 minutes, with each contraction lasting 30 seconds. There is no vaginal bleeding present and maternal observations are stable. Only the fetal head can be palpated at the cervical opening. **Which complication of augmented labour is this woman likely to be suffering from?**

Answer 29

**Uterine hyper**-**stimulation** is defined as greater than 5 contractions occurring within 10 minutes and is due to administration of prostaglandins or oxytocin for induction of labour. The fetal bradycardia is likely a consequence of the increased frequency of contractions and thus increased compression on the fetal head. Uterine hyper-stimulation can usually be reversed with tocolytic agents.

Question 30

A 25 year old woman presents to the GP complaining of a two day history of thin, grey, offensive vaginal discharge. On speculum examination there is no bleeding and the cervical os is closed. A vaginal swab is taken which demonstrates the presence of Gardnerella Vaginalis and pH test gives an abnormally alkaline result. She is worried about this as she is currently 30 weeks pregnant with her first baby. **The is the most likely diagnosis?** **What is a potential complication?**

Answer 30

**Increased risk of pre-term delivery** This woman has **bacterial vaginosis** demonstrated by the vaginal swab and pH test. Although the pathogenesis is unknown, bacterial vaginosis has been shown to increase the risk of preterm delivery and late miscarriage.

Question 31

A 32-year-old primagravida discovers from her booking blood tests that she has contracted hepatitis B. She is both HbsAg and HbeAg positive at the time of delivery. **Which of the following options represents the best management for the foetus? (3)**

Answer 31

HBV IgG and HBV vaccination within 24 hours of delivery This patient is positive for both Hbs and Hbe antigens, increasing the risk of vertical transmission at delivery. Using both HBV IgG and a vaccine reduces the risk of the foetus contracting HBV at birth to ~5%

Question 32

A 35 year old woman has delivered her first baby on the labour ward at 39 weeks gestation. There were no problems during pregnancy and the baby was delivered via an uncomplicated vaginal delivery. Following birth, the midwife noticed a perineal tear which appeared to extend through the muscle fibres of the external anal sphincter. On examination, the internal anal sphincter appears intact. There is some minimal bleeding coming from the tear. **How should this woman be managed?**

Answer 32

**Repair in theatre and discharge with laxatives** This is the most appropriate management option. This woman has a grade three tear involving the external anal sphincter. Perineal tears which are grade three or four require surgical repair in theatre by an experienced clinician and under regional or general anaesthetic. Laxatives are given post-operatively to prevent constipation and reduce risk of compromising the repair.

Question 33

Facts about Chorionic Villus Sampling | (5)

Answer 33

There is a risk of foetal limb abnormalities if CVS is performed before 11 weeks gestation CVS has a higher rate of failed culture compared with amniocentesis CVS results in miscarriage in ~1% of cases CVS is typically offered between 11-13 weeks gestation *Amniocentesis can be performed from around 15 weeks gestation*

Question 34

A 32 year old G1P1 presents for a follow-up appointment 6 weeks post-delivery. She is wondering if she can stop breastfeeding due to breast pain and engorgement and move her baby to specialised formula feeds. She is informed and counselled about a medication which would help her stop breastfeeding. **Which of the medication is used to suppress lactation?**

Answer 34

**C**abergoline This is the correct answer. Cabergoline is a dopamine receptor agonist, which inhibits prolactin production leading to suppression of lactation. This is the correct answer.

Question 35

A 26 year old woman at 30 weeks gestation presents Accident and Emergency with bleeding that she noticed this morning. She describes the blood as fresh red following by some spotting since. She denies any pain and the baby is moving well. Urinalysis is unremarkable and observations are stable. Diagnosis of antepartum haemorrhage is made. **Which of the following is the most likely cause of the haemorrhage?**

Answer 35

**Placenta praevia** Placenta praevia is a condition where the placenta lies over the cervical os. It can be complete or partial depending on how much of the os it covers. It results in shearing of the placenta when stretched. It classically presents with painless bleeding after 20 weeks gestation as in the case of this woman.

Question 36

A 38-year-old woman presents for her detailed ultrasound scan at 21 weeks gestation. She has her blood pressure recorded and found to be 160/100 mmHg, compared with 125/90 mmHg at booking. Aside from asthma, she has no other medical history. **Which of the following is the most appropriate management?**

Answer 36

**Nifedipine** Labetalol is normally considered first in gestational hypertension. Given that it is contra-indicated in this patient due to her asthma, NICE guidelines recommend nifedipine. If Nifedipine is not suitable, then methyldopa should be considered.

Question 37

True statements regarding (TTTS) | (5)

Answer 37

The recipient twin is at risk of developing foetal hydrops The donor twin is more likely to survive to birth Specialist centres are able to offer treatment. Problem vessels are transected with lasers in-utero Usually both foetuses have abnormal development The donor twin can develop high output cardiac failure as a consequence of severe anaemia

Question 38

What is a Frank breech?

Answer 38

Frank breech presentation is where the legs are fully extended up to the shoulders and the presenting part is the buttocks.

Question 39

A 24 year old woman attends the hospital six weeks postpartum for a debrief. She had a normal vaginal delivery of a healthy baby boy, however 30 minutes later the placenta was 'stuck' and could not be delivered by controlled cord traction. There was a significant post-partum haemorrhage and the woman remembers being rushed to theatre where she underwent an emergency hysterectomy to control the haemorrhage. Her first baby was born via caesarean section and she remembers being told there were higher risks opting for a vaginal delivery after caesarean section. **What is the most likely underlying cause for her post-partum haemorrhage and subsequent hysterectomy?**

Answer 39

Placenta accreta Placenta accreta occurs when the placenta invades into the myometrium. It is more common in women with a previous history of caesarean section. This is usually detected at routine ultrasound scans, however may not become apparent until delivery. The placenta fails to be delivered and results in significant post-partum haemorrhage and requirement for hysterectomy.

Question 40

A 38 year old woman is on the postnatal ward after vaginal delivery of twins at 37 weeks gestation. The pregnancy was uncomplicated and her booking bloods were unremarkable. The lochia has been heavy since the delivery 6 hours ago, but now she is beginning to pass large clots of blood and has soaked the bed sheets with blood. There were no complications during labour and the placenta was delivered using controlled cord traction. The midwife reports that the placental membranes were complete on examination. Her temperature is 36.5ºC, blood pressure is 110/70 mmHg and heart rate is 108 bpm. She is currently alert but looks paler than earlier. There is abdominal pain and the uterus is soft and palpable at the level of the umbilicus. On speculum examination there are several large blood clots in the vaginal canal but no visible perineal or vaginal tears. **What is the most likely cause of her postpartum haemorrhage?**

Answer 40

**Uterine atony** The failure for the uterus to contract after delivery, otherwise known as uterine atony, is the most common cause of postpartum haemorrhage. A major risk factor for uterine atony is uterine over-distension, as seen in multiple pregnancy. The soft and high position of the uterus is also an indication that there is atony. It is important to recognise that this woman is at risk of haemorrhagic shock and thus requires immediate intervention.

Question 41

**Absolute contraindications to External Cephalic Version** **(7)**

Answer 41

**Absolute contraindications to External Cephalic Version** 1. Caesarean section is already indicated for other reason 2. Ante-partum haemorrhage has occurred in the last 7 days 3. Non-reassuring cardiotocograph 4. Major uterine abnormality 5. Placental abruption or placenta praevia 6. Membranes have ruptured 7. Multiple pregnancy (but may be considered for delivery of the second twin)

Question 42

You are called to see a patient on labour ward who had planned for a physiological third stage of labour. However, it has been an hour with no delivery of the placenta and the patient asks to switch to active management. **How should the stage of labour be actively managed?** **Which two drugs can be used? (2)** **Name two side effects (2)**

Answer 42

Intramuscular oxytocin (10 IU) is given first line in active management Oxytocin is preferred over Syntometrine, which is associated with greater side-effects Active management reduces blood loss in the third stage of labour and reduces the risk of anaemia Oxytocin increases the risk of nausea and vomiting

Question 43

A 35-year-old woman attends fertility clinic with a **history of recurrent early miscarriages.** Physical examination revealed a **reddish**-**cyanotic**, **reticular** pattern of **rash on the skin**. After a few investigations, she is **diagnosed with anti-phospholipid syndrome (APS).** **Which of the treatments offer her the best chance of preventing further miscarriage? (2)** **How do they work? (2)**

Answer 43

**Start Aspirin** and **Low-Molecular-Weight Heparin (LMWH)** Aspirin and LMWH started after missing a period help prevent miscarriage in pregnant women. Aspirin reduces the risk of thrombosis by **inhibiting platelet aggregation** and subsequent pregnancy loss in APS. LMWH augments the activity of **antithrombin III and prevents the conversion of factor Xa to its activated form** thus resulting in prevention of prothrombin to thrombin which helps stabilise fibrin clot as part of the final common pathway of coagulation. Both anti-platelets and anticoagulants are required to prevent thrombosis leading to recurrent miscarriages.

Question 44

A 21-year-old (parity 2, gravida 3) woman is 16 weeks pregnant and presents to clinic with intractable vomiting. She describes constant nausea, weakness and reduced urine output. On examination you find that she has dry mucous membranes and prolonged capillary refill time. **Which of the management option is most appropriate initially for this patient? (2)** **Which would be the worst fluid to recussitate the patient? (1)**

Answer 44

* Thiamine supplements * Intractable vomiting can result in thiamine deficiency, which in turn can cause Wernicke's encephalopathy and result in foetal death ## Footnote **Dextrose is massively contraindicated in hyperemesis, therefore, thiamine would be the best answer.** **Dextrose precipitates the body's need for thiamine which can precipitate wernicke's.**

Question 45

A 38 year old para 1 German woman is referred for an oral glucose tolerance test. She is well, had a booking BMI of 31.5, and has a medical history of polycystic ovarian syndrome and chronic fatigue syndrome. Her previous pregnancy was three years prior and resulted in vaginal delivery of a healthy baby boy at 39+4 weeks, weighing 3.7kg. Her maternal grandfather and cousin both had diabetes. She admits to having a 'sweet tooth'. **Which attributes merit referral for an oral glucose tolerance test (OGTT)? (5)**

Answer 45

**Her BMI** **Selective screening for gestational diabetes is based on risk factors. Patients with any of the following risk factors can be offered an OGTT at 26-28 weeks gestation:** * BMI above 30kg/m2. * Previous macrosomic baby (weighing 4.5kg or above). * Previous gestational diabetes. * First degree relative with diabetes. * Ethnic origin with a high prevalence of diabetes (South Asian, black Carribbean, Middle Eastern)

Question 46

You are taking an obstetric history for a newly pregnant patient attending her pre-booking appointment. She tells you she has had the following pregnancies: * 2014: Miscarriage at 14 weeks gestation. * 2015: Stillbirth male at 28 weeks gestation. * 2017: Elective caesarean section of two twin males at 36+0 weeks gestation. * 2019: Elective caesarean section live female at 39+2 weeks gestation. * 2019: Medical termination at approximately 7 weeks gestation. **How would you describe this patients gravidity and parity?**

Answer 46

**G6 P3+2** Gravidity is the number of 'gravid events' i.e. pregnancies a person has had in total (including this one). (SIX in this case). Multiple pregnancies are always counted as one. Parity is the number of 'parous events' i.e. number of times a person has given birth (either vaginally or via caesarean section), to a pregnancy with a gestational age of at least 24+0 weeks, regardless of whether the foetus was live or stillborn. (Three in this case). Giving birth to a multiple pregnancy is always counted as one. Parity is suffixed by the number of miscarriages or terminations earlier than 24+0 weeks (+2 in this case)

Question 47

A 25 year old woman delivers her first baby vaginally in the birth centre at 37 weeks gestation. On examination, the newborn has chorioretinitis, hearing impairment and hydrocephalus. She is also suffering from frequent seizures. On questioning, the mother remembers having a flu-like episode early in the pregnancy but this resolved quickly so she did not seek medical advice. ## Footnote **What is the most likely causative organism for this newborn’s features?**

Answer 47

**Toxoplasma Gondii** Toxoplasma Gondii is the most likely organism. It is a parasite commonly found in cat faeces or contaminated food products. Infected mothers may be asymptomatic or have mild flu-like symptoms. Early infection with toxoplasma can lead to congenital toxoplasmosis, a severe condition typically presenting with hydrocephalus, seizures, visual and hearing impairment.

Question 48

A 35 year old G1P0 at 37 weeks gestation presents to the antenatal clinic complaining of a week long history of general malaise, vomiting, and anorexia. She also complains of abdominal pain on the right side and indigestion. She denies any visual changes, headaches, and swellings. She denies any abnormal discharge and reports presence of foetal movements. On examination, her blood pressure is 135/85 mmHg and she appears mildly jaundiced. **Her blood test results are shown below:** * Hb: 100 g/l (115-160 g/l) * Platelets: 93\* 10^9/l (150-400 x 109/l) * WBC: 11 \* 10^9/l (4.0 - 11.0 x 109/l) * PT: 15 secs (10-14 secs) * Bilirubin: 38 umol/l (3-7 umol/l) * ALP: 410 u/l (30-100u/l) * ALT: 300 u/l (3-40 u/l) * AST: 350 u/l (3-30 u/l) **What is the definitive treatment?**

Answer 48

**Immediate delivery** **Acute fatty liver of pregnancy** is a rare complication of pregnancy but important to be aware of. It commonly occurs in the third trimester or immediately following delivery and is thought to be more common in nulliparous women as in the case of this patient. A typical patient will present with a few days history of general malaise, anorexia, vomiting, and jaundice. Pain in the right upper quadrant may sometimes be present. Blood results would show marked elevation of liver enzymes, prolonged PT, raised and bilirubin. Low platelets will be seen due to consumptive coagulopathy. Once stabilized, delivery should be performed. Delay in treatment can result in coma and death secondary to hepatic failure. It resolves spontaneously after delivery, which is the definitive treatment.

Question 49

A 28 year old G2P1 at 22 weeks gestation presents to the Emergency Department with light vaginal bleeding. She is worried about a miscarriage. She denies any pain or any previous history of bleeding. On examination, there is light bleeding per vaginally and the cervical os is closed. Ultrasound confirms the presence of a foetus in the uterus, but no foetal heartbeat is seen. **What type of miscarriage is this likely to be?**

Answer 49

**Missed miscarriage** **Miscarriage is defined as expulsion of an embryo of up to 24 weeks.** Missed miscarriage is where the gestational sac contains a dead foetus without expulsion. It may present with light vaginal bleeding and cervical os will be closed. There is usually no pain. Symptoms of pregnancy also disappear as the foetus has died. **Inevitable miscarriage presents with bleeding per vagina with clots and pain. Cervical os is open as passage of products of conception is still underway.**

Question 50

You are asked to see a 29-year-old woman in clinic who has recently found out she is pregnant. She has a history of type 1 bipolar affective disorder, for which she takes lithium. Despite treatment she suffered an episode of mania 9 months previously. How should this patient's psychiatric medication be managed during the antenatal period?

Answer 50

**Switch gradually to an antipsychotic** NICE recommend that in the event a patient with unstable bipolar affective disorder, taking lithium becomes pregnant, one should recommend switching their medication gradually to an atypical antipsychotic

Question 51

A 28 year old G2P1 is **7 weeks into her pregnancy**. She has a history of hypothyroidism for which she is taking 50 micrograms of levothyroxine daily. She reports feeling well in herself and no symptoms. Thyroid function tests are performed and the results indicate the following: ## Footnote **Free thyroxine (fT4) 18 pmol/l (11-22 pmol/l)** **Thyroid-stimulating hormone (TSH) 2.1 μu/l (0.17-3.2 μu/l)** **Which of the following is the next best step in the management of this patient?**

Answer 51

**Increase levoythyroxine by 25 mcg and repeat the thyroid function tests in 4 weeks.** NICE recommends increasing levothyroxine by 25 mcg as soon as pregnancy is confirmed despite a euthyroid state. This patient is currently euthyroid but because of her pregnancy, needs an increased dose of levothyroxine. The explanation for this is that in pregnancy there is a physiological increase in serum free thyroxine until the 12th week of pregnancy as the foetus is dependent on mother's circulating thyroxine until the 12th week of development when the foetal thyroid develops. Untreated hypothyroidism can lead to neurodevelopmental delay of the foetus. This surge is not seen in hypothyroid patients. Therefore, levothyroxine should be increased to mimic this surge.

Question 52

A 22 year old woman attends at week 29 of her second pregnancy due to some mild post-coital vaginal bleeding. The bleeding occurred immediately following intercourse and has now entirely settled. She is otherwise well and her pregnancy is progressing normally. You perform a speculum examination to exclude preterm labour or ongoing antepartum haemorrhage. **Which finding would represent an abnormality on speculum examination and require further investigation?**

Answer 52

**The presence of an odourless clear-white watery fluid in the posterior vaginal vault** The presence of a watery fluid pooling in the posterior vaginal vault may indicate premature prelabour rupture of membranes (**PPROM**). It is important to elicit any history of vaginal fluid loss and consider performing a fibronectin test to assess for **PPROM**.

Question 53

You see a 24 year old primigravida woman who has attended the maternity ward at 39+2 weeks gestation in early labour. The woman is well and this is an uncomplicated pregnancy. The midwife performs a routine cardiotocography (CTG) over 30 minutes. Which is a normal CTG in the first stage of labour?

Answer 53

* Baseline rate: 110-160 * Variability: 5-25bpm * Accelerations: present. * Decelerations: absent.

Question 54

A 27 year old G1P1 with a previous history of gestational diabetes and a macrosomic baby presents to the antenatal clinic for the booking visit appointment. ## Footnote **When is the booking appointment?** **What is the most appropriate investigation for diagnosing gestational diabetes for this patient?**

Answer 54

**8 to 12 weeks: booking appointment** **A 2-hour oral glucose tolerance test as soon as possible following the booking visit** Gestational diabetes is when women develop high levels of blood sugar levels during pregnancy. It is usually diagnosed at 24-28 weeks of gestation on the basis of elevated blood glucose levels on glucose tolerance tests. In the case of previous history of gestational diabetes, they are offered an oral glucose tolerance test as soon as possible after the booking visit followed by an additional test at 24-28 weeks if the first one is normal. NICE recommends that with women a risk factor other than previous gestational diabetes should be offered an oral glucose tolerance test at 24-28 weeks. Risk factors include family history of diabetes, previous macrosomic baby of \>4.5 kg, and a BMI \>30. If a woman has one risk factor, they are offered an oral glucose tolerance at 24-28 weeks.

Question 55

A 28 year old primiparous woman is in active labour. She has been coping well with labour, however she is becoming exhausted and the foetal heart rate is concerning (100bpm). The obstetric registrar decides to attempt an operative delivery in the room using Keilland's forceps. She asks you to draw up 20ml of 1% Lidocaine in preparation for the procedure. Prior to attempting an instrumental delivery, the registrar performs a nerve block to provide regional analgesia. **Which nerve is blocked in this circumstance?**

Answer 55

**Pudendal nerve** To perform a pudendal nerve block, Lidocaine is injected 1–2cm medially, and below the right and left ischial spines transvaginally with a specially designed pudendal needle. This provides effective regional anaesthesia to the perineum, including the external genitalia and external anal sphincter.

Question 56

A 35 year old woman presents to the day assessment clinic complaining of a two week history of severe nausea and vomiting as well as some mild abdominal pain. She is in her 14th week of pregnancy and her early ultrasound scan last week revealed a twin pregnancy. Her booking bloods were unremarkable. On examination she is afebrile but tachycardic and appears visibly fatigued. Urinalysis reveals the presence of ketones in the urine and bloods show hypokalaemia and hypoglycaemia. **How should this woman be immediately managed?**

Answer 56

* Normal saline * potassium chloride * cyclizine Administration of normal saline with potassium chloride to correct dehydration and cyclizine to reduce nausea and vomiting is the most appropriate management.

Question 57

A 29 year old G2P1 presents to the antenatal clinic for review at 22 weeks gestation. She is worried that her previous baby had developed a Group B streptococcus (GBS) infection shortly after delivery. She enquires about what what can be done for her present pregnancy. **Which of the following steps is the most appropriate treatment for this patient?** **What is the infective agent?**

Answer 57

**Intrapartum antibiotics** **Group B Streptococcus (GBS) infection is due to the bacterium streptococcus agalactiae.** **Benzylpenicillin is the antibiotic of choice.** Group B Streptococcus is a bacterium, which can colonise in the vagina. The biggest risk factor for a baby developing GBS is the mother having a previous baby with a GBS infection. About 50% of infants born to women who carry GBS will go on to become carriers and less than 1% become ill with the infection themselves. According to NICE guidelines, maternal antibiotic prophylaxis is to be offered to women with a previous baby with a GBS infection.

Question 58

A young pregnant mother fails to disclose full medical history including medications to her doctor. She is known to suffer with severe rheumatoid arthritis only. At birth, her child displays the following abnormalities; Anencephaly and a cleft lip/palate. What likely teratogen has the mother been exposed to?

Answer 58

**Folic acid antagonist** The young mother is likely to be on Methotrexate. Methotrexate is a folic acid antagonist which could result in the following defects at birth; anencephaly, hydrocephalus, cleft lip/palate, skull defects.

Question 59

A 25-year-old woman is seen in the antenatal clinic for the first time. She has been actively trying to conceive and reports that she had a positive home pregnancy test. She informs that she missed her period 5 weeks ago and recalls the date of her last menstrual period (LMP). **What is the method of calculating her expected date of delivery (EDD) at this initial appointment?**

Answer 59

**Naegele's Rule** * the EDD is calculated by adding 9 months to the LMP plus 7 days. Alternatively, add a year to the date of the first day of the last menstrual cycle, subtracting 3 months, then adding 7 days. In the first antenatal appointment this is enough and an obstetric ultrasound is usually performed at 12 weeks to establish the gestational age of the pregnancy more accurately.

Question 60

A baby is born to a 25 year old G3P3 at term. There were no specific concerns throughout the pregnancy and the 3 year old sibling is well. At the newborn check, he has a tense fontanelle. Fundoscopy reveals posterior uveitis. **What question would be likely to reveal the diagnosis?** **What is the triad of this disease?**

Answer 60

**Congenital toxoplasmosis. This is usually acquired through exposure to cat faeces.** **This** **child** **has:** * hydrocephalus * chorioretinitis * intracranial calcifications

Question 61

A 20 year old woman at 38+5 weeks gestation attends the maternity unit in labour. She is having regular contractions every 6 minutes, lasting 30-60 seconds. The midwife performs a vaginal examination to assess the progress of labour. She finds the cervix anterior, approximately 1cm in length and of a soft consistency. The cervix is 1cm dilated and she can feel the foetal head 1cm above the ischial spines. **What is this woman's Bishop's score?**

Answer 61

8 **The modified Bishops score assesses the following:** * Position of the cervix * Length of the cervix * Consistency of the cervix * Dilatation of the cervix * Station of the presenting part (distance in cm in relation to the ischial spines)

Question 62

A 26 year old woman is three weeks post partum and attends her GP to ask about which contraceptive method would be suitable for her. She is partially breastfeeding, has no contraindications to oral hormonal contraceptives and is keen for an effective method she can start today, as she does not wish to become pregnant in the near future. Her periods have not returned yet. Her partner has difficulty using condoms. Which method of contraception would be appropriate?

Answer 62

**Progesterone only hormonal contraceptive pill (POP)** The progesterone only pill can safely be started at any time following childbirth. She can start this today, and will be protected against pregnancy in two days' time. * A mirena cannot be fitted until 4 weeks after birth

Question 63

A 22 year old woman presents at 28+6 weeks gestation in her first pregancy with a history of a gush of clear fluid from the vagina about one hour ago and a constant trickle since then. She is otherwise well. There are no signs or symptoms of labour and foetal movements remain normal. **Which of the following is most likely to form part of this woman's ongoing management?**

Answer 63

**12mg Betamethasone intramuscularly, two doses 24 hours apart.** This woman has had a pre-term pre-labour rupture of membranes (PPROM). Steroids are given to aid in advancing foetal lung maturity as this woman is likely to deliver preterm

Question 64

A 28 year old G2P2 presents to the antenatal clinic at 24 weeks gestation. She is inquiring about the safety of having a vaginal birth after having had a previous caesarean section. **Which of the following is an absolute contraindication for vaginal birth after caesarean (VBAC)?**

Answer 64

**Classic caesarean section scar (vertical)** Classic caesarean section scar is an absolute contraindication to VBAC due to a high risk of uterine rupture, which is an obstetric emergency carrying a significant maternal and foetal mortality and morbidity. Other contraindications to VBAC include: * previous history of uterine rupture

Question 65

A 30-year-old woman (G2P1+0) attends obstetric clinic for routine antenatal check at 41 weeks gestation. She does not have any signs of labor or Braxton Hicks contractions. Cardiotocography (CTG) is performed and is reassuring. She is worried that she may not go into spontaneous labour and asks if anything can be done to start labour. **What advice is most appropriate?**

Answer 65

**Offer sweeping of membranes now** This is the correct answer. Post-term pregnancy is associated with adverse fetal outcomes. Induction of labor should be offered to all women between 41 and 42 weeks, usually when patient is 12 days post due date (NICE 2008). A membrane sweep may help production of local uterine production of prostaglandins and therefore reduces the need for other methods of induction of labor. In this, a finger is placed inside the cervix and a sweeping, circular movement is made to separate the membranes from the cervix. If labor does not start 24-48 hours after this, an additional membrane sweep can be performed prior to formal induction. It is also important to explain that a membrane sweep does not adversely affect the fetus. A membrane sweep is not recommended if waters have broken.

Question 66

What are Braxton Hicks contractions?

Answer 66

Question 67

A 28 year primigravida woman presents to general practice. She is at 6 weeks gestation. She suffers from a history of back pain and has taken paracetamol and ibuprofen regularly for pain relief. As her back pain has worsened recently, she is wondering what pain relief would be safe to take in pregnancy. **Which of the following advice is appropriate with regards to analgesia in pregnancy?**

Answer 67

**Codeine phosphate can be taken at low doses if needed** It is generally recommended to take paracetamol for pain relief during pregnancy as a first-line measure. However, codeine phosphate can be taken at low doses to control pain as it is considered safe in pregnancy. However, if used during delivery, there is a risk of neonatal respiratory depression and withdrawal symptoms, therefore, caution must be taken.

Question 68

You examine a woman admitted to labour ward 8 hours ago and find that her cervix is 3cm in length, dilated 2cm and is in the mid-anterior position. You estimate that she is at station -2 and note that her cervix is firm. **In light of this patient's Bishop's score, what is the most appropriate course of action?**

Answer 68

**Administer prostaglandin E2 PV** * This patient has a Bishop's score of 4 which indicates that the cervix is not 'ripe' for vaginal birth. * Administration of PGE PV can encourage cervical ripening and increase the likelihood of a vaginal delivery

Question 69

**A 20 year old primiparous woman goes into labour at 38 weeks gestation on the labour ward.** During the second stage of labour, the midwife recognises that the baby is having difficulty descending further and displays the “turtle neck” sign. She immediately pulls the emergency bell and places the mother in the McRobert’s position. **What is the likely diagnosis?** **What is a recognised risk factor of this obstetric emergency?**

Answer 69

**Shoulder dystocia** **Macrosomia** This is a case of shoulder dystocia, demonstrated by failure to progress and “turtle neck sign” caused by retraction of the fetal head against the perineum. Macrosomia refers to a birthweight of greater than 4kg. This is a recognised risk factor for shoulder dystocia and is commonly a result of uncontrolled maternal gestational diabetes. McRobert’s manoeuvre is designed to aid passage of the fetus by maximising the diameter of the pelvic outlet.

Question 70

A 33 year old G1P1 comes in for a routine 6 week post-partum check-up after uneventful pregnancy with an uncomplicated vaginal delivery. She reports no problems and is getting on well with the care of the baby. Her bimanual examination shows an irregular, firm, and non-tender uterus at about 14 week size. **Which of the following is the most likely explanations for this finding?**

Answer 70

**Fibroids** Fibroids are abnormal growths of tissue occurring in the uterus. They are highly vascular and often cause heavy bleeding. The examination findings are most consistent with uterine fibroids as they cause the uterus to be enlarged, irregular, and firm.

Question 71

A 25 year old primiparous woman has an antenatal check at 31 weeks gestation. She feels well and has had no bleeding, pain or other complications during the pregnancy so far. On physical examination the symphysis-fundal height is 27cm. **On palpation of the abdomen the fetal parts feel abnormally prominent.** **What is the most likely diagnosis?** **What are the following risk factors? (4)**

Answer 71

Causes of **oligohydramnios**: * Uteroplacental insufficiency leading to intrauterine growth restriction. This may be due to maternal disease such aschronic hypertension or pre-eclampsia, maternal smoking and placental abruption. * Abnormalities with the foetal urinary system(amniotic fluid is derived mainly from foetal urine). Examples include renal agenesis, polycystic kidneys or urethral obstruction. * **Premature rupture of membranes** * **Post-term gestation**

Question 72

A 30 year old woman is in her 12th week of pregnancy and has presented to the antenatal clinic with a week history of mild flu-like illness. A viral screen is carried out and serum PCR shows that she has an acute CMV infection. Antibody screening shows no previous immunity to CMV. **Which of the following is the fetus at risk of developing?** **(3)**

Answer 72

* Hearing loss * visual impairment * learning disability Most women will have contracted CMV infection in this past and thus be immune. However, if CMV is contracted during the pregnancy it can lead to infection in the fetus. Congenital CMV infection typically can present with hearing loss, visual impairment and also learning disability in later life. Other features include low birth weight, jaundice, neurological abnormalities, pneumonia and ptechial rash.

Question 73

You are attending a 38-year-old woman (para II, gravida II) on labour ward. Her 4 hourly vaginal examination reveals that she is no more dilated than when you saw her previously and her membranes are not broken. Abdominal examination and CTG show no evidence of foetal distress. **Which of the following is the best course of management?**

Answer 73

**Perform an amniotomy and reassess in 2 hours** Less than 2cm dilatation in 4 hours indicates a failure to progress. In multiparous women with no sign of foetal compromise, an amniotomy is a sufficient first line intervention

Question 74

A 25 year old woman G1P0 presents to Accident and Emergency at 15 weeks gestation with vaginal bleeding, nausea and vomiting. Antenatal exam reveals a large for dates uterus. Other findings are normal. Ultrasound scan shows a snowstorm appearance with a hyperechoic area interspersed with a multitude of cysts within the uterine cavity. **What is the most likely diagnosis?**

Answer 74

**Trophoblastic disease** Trophoblasic disease is when trophoblast cells grow inside the uterus after conception. It classically presents after 14 weeks of pregnancy and symptoms include vaginal bleeding and vomiting due to the high levels of human chorionic gonodotrophin (b-HCG), which has a thyroid-stimulating hormone-like activity. The uterus is larger for dates and the ultrasound classically shows a "**snowstorm**" appearance with hyperechogeneity reflecting molar disease. The diagnosis is confirmed with histological study of the products of conception.

Question 75

A 30 year old primiparous woman presents to the labour ward at 33 weeks gestation with regular painful uterine contractions occurring every 15 minutes. A vaginal examination reveals that the cervix is 4cm dilated and the membranes have ruptured. All maternal observations are normal and there is no vaginal bleeding. Fetal cardiotocogram is reassuring. What pharmacological therapy should be offered to this woman?

Answer 75

**Erythromycin and betamethasone** This lady is in established pre-term labour. Erythromycin and betamethasone would be an appropriate combination to use in this lady. The betamethasone is used to accelerate fetal lung maturation in preterm births. Erythromycin is used a antibiotic prophylaxis in preterm birth. **Also, the patient is in established labour and therefore tocolysis is contra-indicated.**

Question 76

A 35 year old female is brought into the emergency department having a seizure. She is 34 weeks pregnant and her blood pressure is 181/89. What is the most appropriate initial management for this patient?

Answer 76

**IV magnesium sulphate 4g** This patient is suffering from an eclamptic seizure, which is life-threatening and needs urgent treatment and assessment by obstetricians and anaesthetists. The initial treatment in these patients is intravenous magnesium and consideration of delivery.

Question 77

A 27 year old woman attends the family planning clinic for advice about conceiving. She has suffered from generalised epilepsy since a young age and is currently taking an antiepileptic regime of sodium valproate, lamotrigine and clobazam. She takes no other medications. Her last seizure was 4 months ago. She has never been pregnant before but is now very keen to start a family with her new partner. **What is the most appropriate pre-conceptual management plan for this patient?**

Answer 77

**Aim for monotherapy with lamotrigine** This is the most appropriate management. Lamotrigine is considered one of the safest antiepileptic drugs to use during pregnancy, whereas sodium valproate is contraindicated as it carries the highest risk of causing congenital malformation.

Question 78

A 30 year old woman at 14 weeks gestation presents to the antenatal clinic with vaginal bleeding and is diagnosed with a hydatidiform mole and treated with evacuation of the products of conception. However, she returns 4 weeks later still feeling unwell and her b-hCG levels has continued to rise. **What is the most likely diagnosis?** **(2)**

Answer 78

**Choriocarcinoma** Choriocarcinoma is a rare tumour which is part of the spectrum of gestational trophoblastic disease. It arises when the fertilized ovum forms abnormal trophoblastic tissue instead of a foetus. Choriocarcinoma is the malignant form of the gestational trophoblastic disease. **After evacuation of a hydatidiform mole, the levels of b-hCG are expected to fall and pregnancy should be avoided for 1 year.** However, if they fail to drop, malignant choriocarcinoma should be suspected. Treatment involves specialist referral and methotrexate based chemotherapy is known to be effective.

Question 79

A 25 year old female presents to the antenatal clinic at 8 weeks gestation for her booking visit. All findings and examinations are normal. She is wondering when her early scan to confirm dates would be. **At what date is the early scan to confirm dates is usually performed?**

Answer 79

**10 - 13+6 weeks​**

Question 80

A 23 year old woman attends at 12 weeks for her booking appointment and has had her routine antenatal bloods taken. The midwife explains that one of the blood tests is to check the mother's rhesus status. She is found to be rhesus negative. Which scenarios would require the administration of Anti-D to this rhesus negative woman?

Answer 80

Sensitisation events are those which carry a risk of foetal blood crossing the placenta into the material circulation and triggering formation of these antibodies. Sensitisation events include: * Antepartum haemorrhage * Significant abdominal trauma * Ectopic pregnancy * Miscarriage * Termination * Intrauterine death * External cephalic version * Invasive uterine procedures e.g. chorionic villus sampling or amniocentesis * Delivery of foetus (vaginal or by caesarean section)

Question 81

A 24-year-old lady, G1P0, presents to A&E at 11 weeks gestation with one-day history of abdominal cramping and vaginal bleeding. There is no history of fever, dysuria or urinary frequency. Pelvic examination showed mild active bleeding in the vaginal vault and cervical os was closed. **What is the most likely diagnosis?**

Answer 81

**A threatened miscarriage is a term used to describe vaginal bleeding and abdominal pain that occurs while the pregnancy is still viable.** Cervical os is closed in threatened miscarriage.

Question 82

**_Facts about spinal anesthesia_** **_(4)_**

Answer 82

Spinal anaesthesia may wear off if the procedure lasts longer than ~2 hours Hypotension can be more profound with spinal anaesthesia than with epidural anaesthesia Typically bupivicaine and fentanyl are used together in spinal anaesthesia The needle is inserted into the subarachnoid space

Question 83

A 35 year old woman is preparing for an elective Caesarean section at 38 weeks for a breech presentation birth. This is her second pregnancy, her first baby was delivered via an uncomplicated vaginal delivery at 37 weeks. This pregnancy has been otherwise uncomplicated. Her blood pressure is 128/85mmHg, temperature is 37ºC and rhesus status is positive. She has not begun to labour and there has been no rupture of membranes. **What pharmacological agent should be given to this woman prior to the surgery?**

Answer 83

**Omeprazole** Pregnant women are physiologically at increased risk of gastric reflux compared to the normal population. **Thus, a prophylactic proton pump inhibitor such as omeprazole is routinely given before** Caesarean section to reduce maternal gastric volume and acidity. **This reduces the risk of aspiration of gastric contents during surgery and subsequent aspiration pneumonitis.**

Question 84

A 30 year old woman is routinely seen by her midwife at 28 weeks gestation. She is well and the pregnancy has been uncomplicated. She has no symptoms to report. On examination, her blood pressure is 148/108 mmHg, pulse is 75 bpm, visual fields are intact, abdomen is soft, non-tender and fundus measures appropriately for 28 weeks. Urinalysis is normal. The midwife performs a blood pressure profile, which reveals an average blood pressure reading of 142/102 mmHg. **Her booking blood pressure was 120/80 mmHg.** **What is the most likely diagnosis?**

Answer 84

**Pregnancy-induced hypertension** Pregnancy-induced hypertension (or gestational hypertension) is diagnosed when blood pressure is higher than 140/90mmHg in a pregnant woman who had normal blood pressure at booking, who is asymptomatic, and has no evidence of proteinuria. This woman likely requires antihypertensive therapy and close monitoring with blood pressure and urinalysis performed once or twice a week. She also needs blood tests for full blood count, urea and electrolytes, liver function tests and coagulation profile.

Question 85

A 35 year old woman presents to the day assessment unit with an episode of vaginal bleeding which is bright red and fresh in nature. She is 30 weeks pregnant and the pregnancy has been uncomplicated so far. She has one other child who was born via elective caesarean section at 37 weeks because of malpresentation. She feels well and reports no abdominal pain or loss of liquor. ABC assessment shows that she is stable and all maternal observations are normal. **What is the most likely diagnosis?**

Answer 85

**Placenta praevia** Placenta praevia is the most likely diagnosis as it typically presents with bright red, fresh vaginal bleeding which is painless in nature. This should be suspected in any woman presenting with antepartum haemorrhage after 24 weeks of gestation. **Bloody show is commonly described as mucous-like and darker red and so does not fit with this history. Also, there is no suggestion that she is going into labour.**

Question 86

A 19 year old woman presents to the emergency department at 35 weeks gestation with a history of a gush of yellow watery foul-smelling fluid from her vagina. She has been feeling unwell with abdominal pain, a fever and chills for two days and she notes her baby has been less active today. **Her observations are:** * Heart rate: 120bpm. * Blood pressure 125/82. * Respiratory rate: 20. * SpO2: 99%. * Temperature: 38.2. **What is the most likely diagnosis?**

Answer 86

Chorioamnionitis Chorioamnionitis is an infection of the membranes in the uterus. Typical symptoms are of a fever, abdominal pain, offensive vaginal discharge and evidence of preterm rupture of membranes. Typical signs are of maternal and foetal tachycardia, pyrexia and uterine tenderness. Chorioamnionitis is an indication for admission and delivery. This woman also requires intravenous broad spectrum antibiotic therapy as part of the sepsis six protocol.

Question 87

A 28 year old woman attends the maternity clinic for a routine check at 40 weeks gestation. This has been an uncomplicated pregnancy and the woman is hoping for a vaginal delivery with minimal intervention. Her symphysial-fundal height is 40cm, the lie is cephalic and the head is 4/5ths palpable abdominally. Foetal movements are felt and CTG is reassuring. She has not had any intervention to facilitate labour thus far. **What is the most appropriate management option to offer this woman?**

Answer 87

**Membrane sweep** All women should be offered a vaginal examination and membrane sweep at 40 weeks gestation. This is considered an adjunct to labour rather than an actual induction method. The cervix is assessed and if possible, a finger is passed into the cervical os to stretch it and separate the chorionic membranes from the cervix. Note that a pregnancy is 'term' from 37+0 until 41+6. 'Post-term' is 42+0 weeks and above.

Question 88

A 24 year old woman attends at approximately 37 weeks gestation having received no antenatal care. She says she has never attended for medical care since childhood as she has a fear of doctors. She says she has no medical conditions and has had no problems during pregnancy. **Which of the following blood results would be an indication for an elective caesarean section?**

Answer 88

**Indications for elective caesarean section include:** * Abnormal presentation e.g. breech or transverse. * Twin pregnancy if first twin is not cephalic. * Maternal HIV. * Primary genital herpes in third trimester. * Placenta praevia. * Anatomical reasons.

Question 89

A patient presents to the Early Pregnancy Unit at 13+3 weeks gestation. She has been experiencing abdominal cramping for 2 days and noticed blood on her underwear several hours ago. Speculum examination reveals that the cervical os is open. **What is the likely diagnosis?** **How should this patient be managed?**

Answer 89

**Vaginal misoprostol** The history and examination point to a diagnosis of miscarriage. As the patient is beyond 13 weeks gestation, medical management is recommended. This involves the administration of either vaginal or oral misoprostol. Mifepristone is not recommended in the management of miscarriage in the UK. Surgical management of miscarriage is usually performed if a patient is having heavy or persistent bleeding for \>2 weeks. Suction evacuation is not recommended beyond 13 weeks

Question 90

A 32 year old G2P1 female at 14 weeks gestation is brought Accident and Emergency complaining of vaginal bleeding, extreme morning sickness, heat intolerance, and anxiety. Ultrasound examination reveals a "snowstorm" appearance. **What is the most likely diagnosis?** **What is the most useful marker to monitor the treatment of this patient?**

Answer 90

**Molar pregnancy** **Beta human chorionic gondatotropin (b-HCG)** The symptoms of extreme morning sickness, heat intolerance, anxiety, and vaginal bleeding all suggest molar pregnancy which classically presents after 14 weeks gestation. b-HCG is present in high levels in molar pregnancy, which explains the extreme morning sickness. The heat intolerance and anxiety is most likely due to the b-HCG mimicking TSH properties, inducing a state of hyperthyroidism. The diagnosis is also confirmed by the "snowstorm" appearance on ultrasound. Monitoring b-HCG is the most important for in molar pregnancy to ensure that there is no foetal tissue remaining after evacuation of the products of conception to minimize the risk of developing choriocarcinoma.

Question 91

A newborn on the postnatal ward develops respiratory distress a day after birth. The delivery was an uncomplicated vaginal birth. On examination she is pyrexial, tachycardic and has laboured breathing. She also appears floppy and lethargic, but there are no dysmorphic features. The mother is distressed and confesses to eating copious amounts of Camembert cheese during the pregnancy due to cravings. **Which is the most likely causative organism?**

Answer 91

**Listeria Monocytogenes** Listeria monocytogenes is the most likely causative pathogen as it is commonly found in unpasteurised dairy products and soft cheeses. If these foods are not avoided during pregnancy there is increased of transmission to the fetus and early onset neonatal infection.

Question 92

A 35 year old woman presents to the labour ward at 35 weeks + 5 days gestation with a 2 hour history of bright red vaginal bleeding which has stained her underwear. Before the onset of bleeding she felt a gush of blood and fluid. She felt previously well but has now begun to experience intermittent abdominal pain. Her blood pressure is 135/85 mmHg, heart rate is 90bpm and temperature is 36.5ºC. Fetal movements have been normal and a cardiotocogram is reassuring. Speculum examination shows a cervical os which is 2cm dilated with moderate amounts of blood in the vagina. Her antenatal ultrasound scans reported a Grade III placenta praevia. **What is the most appropriate management plan for this patient?**

Answer 92

**Urgently take her to theatre for an emergency Caesarean section** This is a patient with a known placenta praevia, presenting with what appears to be a rupture of membranes, subsequent antepartum haemorrhage and also onset of labour contractions. Vaginal delivery is contraindicated with placenta praevia due to risk of significant haemorrhage and thus she must be urgently taken to theatre for an emergency Caesarean section.

Question 93

**Which of the following statements is correct about HIV and pregnancy??** **(3)**

Answer 93

If a patient has a viral load of \<50 copies/ml and is taking multiple antiretroviral medications, they can be offered a vaginal delivery Breastfeeding is not recommended to HIV positive mothers in the UK Whilst a Caesarean section may be indicated in many cases where a woman is HIV positive. HIV positive status alone does not represent an absolute contraindication to vaginal delivery

Question 94

A 25 year old para 4 woman presents in active labour at 39+2 weeks gestation. She has had an uncomplicated pregnancy and her previous four pregnancies were delivered vaginally at term. She is contracting well, every 4-5 minutes and her cervix is 7cm dilated. Her cardiotocography (CTG) has been entirely reassuring throughout labour. Suddenly she experiences a gush of fluid and the foetal heart rate suddenly drops to 80pm and is showing deep decelerations. **What is the most likely diagnosis?** **What is the treatment?**

Answer 94

**Umbilical cord prolapse** Umbilical cord prolapse occurs when the cord descends through the cervix prior to delivery of the foetus. **This results in the cord becoming compressed, and placental blood flow to the foetus becomes compromised, manifesting as a foetal bradycardia and decelerations.** Risk factors for umbilical cord prolapse include multiparity, polyhydramnios, malpresentation and artificial rupture of membranes. This is an obstetric emergency. If possible, the presenting part of the foetus should be manually elevated back through the cervix, and the woman's legs elevated to prevent descent, **whilst the patient is prepared for an emergency caesarean section.**

Question 95

A patient has been admitted with severe pre-eclampsia and has been advised that she will need regular blood tests and asks for more information about these. ## Footnote **Which of the following represents the tests she will need and their frequency? (4)**

Answer 95

**U&E, FBC, transaminases** **bilirubin three times per week** Patients with severe pre-eclampsia should have blood tests three times per week to anticipate if a patient is developing HELLP syndrome, a complication of pre-eclampsia involving haemolysis, elevated liver enzymes and low platelets.

Question 96

After which week does pre-eclampsia occur

Answer 96

**Preeclampsia typically occurs after 20 weeks of pregnancy** **up until labour, when it is just "eclampsia"**

Question 97

A 30 year old primiparous woman presents to the day assessment unit at 22 weeks gestation with an episode of vaginal bleeding. The bleed occurred this morning about 4 hours ago and presented as a small bright red stain on her underwear. There is no associated abdominal pain. She has had no further episodes since. She mentions that she had intercourse last night. Her pregnancy has been uncomplicated so far and she feels well. Her most recent smear was last year and was normal. On examination she is haemodynamically stable, the uterus is non-tender and fetal heart is normal. Speculum examination shows a closed cervix which appears reddened and irritated but there is no active bleeding present. Which of the following is the most likely diagnosis?

Answer 97

**Cervical ectropion** Cervical ectropion is the most likely diagnosis in this case due to the history of post-coital bleeding and speculum examination findings. Cervical ectropion is common during pregnancy as well as with use of the combined oral contraceptive pill. Important uterine causes such as placenta praevia and placental abruption should still however be excluded before this lady is discharged.

Question 98

A 30 year G1P0 female at 34 weeks gestation comes in to the antenatal clinic for a routine check up. She has had an uneventful pregnancy so far. On examination, she appears well and her blood pressure is 155/95 mm/Hg. Her booking blood pressure was 130/80 mm/Hg Her urinalysis shows 2++ proteinuria but is otherwise normal. **What is the most likely diagnosis?**

Answer 98

**Preeclampsia** Preeclampsia has a multifactorial aetiology and not well understood. However, it is characterized by elevated blood pressure after 20 weeks of gestation. It usually presents with abdominal pain, headache, visual disturbance and proteinuria. However, in some cases, it can be initially asymptomatic as well. In order to be diagnosed patient must have a high blood pressure of \>140/90 mmHg and proteinuria. If left untreated it can lead to eclampsia, HELLP syndrome and death. In this case because the patient has an elevated blood pressure of 155/90 and proteinuria, it is considered moderate and she would be admitted to the hospital and commenced on labetolol therapy.

Question 99

A 30 year old primiparous woman presents to the labour ward at 33 weeks gestation with regular painful uterine contractions occurring every 15 minutes which started 3 hours ago. A vaginal examination reveals that the cervix is 3cm dilated. On questioning, she believes her membranes ruptured two days ago. Her blood pressure measures 120/80 mmHg and temperature is 38.3ºC. Fetal cardiotocogram is reassuring. **For what reason is tocolysis contraindicated in this woman?**

Answer 99

**Suggested infection due to presence of fever and potential premature rupture of membranes** This is the correct answer. The history of premature membrane rupture (\>24 hours prior to onset of labour) and presence of fever suggests that this woman may potentially have chorioamnionitis or intrauterine infection. This is a contraindication to tocolysis.

Question 100

A 32-year-old woman with sudden onset, severe abdominal pain is brought to A&E by her partner. She tells you that she is 33+4 weeks pregnant and has no medical or surgical history aside from a surgical TOP 3 years previously. On examination, she has a tender, woody uterus with no PV bleeding. Her BP is 95/78 and her HR is 99. **Given the above information, what is the most likely diagnosis?**

Answer 100

**Placental abruption** The observations reveal the patient is shocked. This is compatible with concealed bleeding in placental abruption. Further, 'woody uterus' in pathognomoic of placental abruption

Question 101

A 28 year old attends the antenatal clinic for a routine appointment at 16 weeks gestation. As this is her first pregnancy, she is concerned because her mother has diabetes. She is feeling well in herself and denies any symptoms. Her blood pressure is within normal ranges and urinalysis is unremarkable. Her uterus is the correct size for her dates. **What is the next best step in management of this patient's concerns?**

Answer 101

**Perform an oral glucose tolerance test at 24-28 weeks.** Gestational diabetes is when women develop high levels of blood sugar levels during pregnancy. It is usually diagnosed at 24-28 weeks of gestation on the basis of elevated blood glucose levels on glucose tolerance tests. NICE recommends that with women a risk factor besides previous gestational diabetes should be offered an oral glucose tolerance test at 24-28 weeks. Risk factors include family history of diabetes, previous macrosomic baby of \>4.5 kg, and a BMI \>30. If a woman has one risk factor, they are offered an oral glucose tolerance at 24-28 weeks. In the case of previous history of gestational diabetes, they are offered an oral glucose tolerance test as soon as possible after the booking visit followed by an additional test at 24-28 weeks if the first one is normal.