DECK 1 Flashcards
(195 cards)
1
Q
What is the risk of uterine perforation at the time of surgical evacuation?
A
1:1000
2
Q
A P0 at 36/40 referred with BP 148/97 and 2+ proteinuria. On arrival at hospital her BP is 146/95 and repeat 149/93. PCR is 37 but other bloods are NAD. CTG is normal. Next steps?
A
Ultrasound fetal size, liquor volume and UA Doppler, allow home to return in 2 days for CTG and repeat blood tests, urine PCR and BP profile.
3
Q
Recurrent thrush - multiple treatment over last 12 months + genital swabs confirm diagnosis. Vaginal swab reveals spores/pseudohyphae. Management?
A
Clotrimazole pessary 500mg weekly for 6 months.
4
Q
Severe preeclampsia complicated by HELLP - risk of developing preeclampsia in next pregnancy?
A
1:3
5
Q
Cervical smear borderline changes + HPV inadequate result. Not currently sexually active and normal smear before this test. Next steps?
A
Repeat cytology + HPV in 3 months.
6
Q
HRT advice - 50 years old, no period for 2 years, hot flushes, sweating, decreased sexual desire, P2.
A
Combined oestrogen + progesterone orally.
7
Q
Cervical cancer - large cervical cancer infiltrating right parametrium, rectovaginal examination reveals parametrial involvement but not reaching pelvic sidewall, chest XRAY/cystoscopy both clear, CTAP shows suspicious left para-aortic lymph node. Stage?
A
IIIC1
8
Q
Blood in amniotic fluid during USS-guided amniocentesis risk incidence?
A
8/1000
9
Q
Ideal target BP with treatment in pregnancy for patients with chronic hypertension?
A
135/85 or less
10
Q
In the neonate of a mother with primary herpes who delivered by CS - appropriate management of neonate?
A
Discharge home if baby well at 24 hours if well.
11
Q
On TA scan with bleeding at 7/40 the sonographer reports IUP with fetal pole measuring 9mm and no FH. Next steps?
A
Rescan in 14 days as TA scan not TVUS.
12
Q
Positive pregnancy test with Copper IUD - risk of ectopic pregnancy?
A
1/2
13
Q
Risk of uterine perforation with copper IUD insertion?
A
2/1000 or 1/500
14
Q
Patient with copper IUD - cervical smear shows evidence of actinomyces-like organisms. Next step in management?
A
Take triple swabs.
15
Q
P1 with results of quadruple test. Estriol 0.5, HCG 1.5, AFP 1, Inhibin A 1.4. Risk for Trisomy 21, 18 and 13 and NTDs is low. How would you counsel this lady?
A
Reassure that risk of trisomy 21, 18, 13 and NTDs is low.
16
Q
P0 at 33+4/40 with persistently raised BP between 140/90 to 145/99 for one week. There is no proteinuria and SFH is normal. Further management?
A
Check BP twice weekly.
17
Q
33 year old P0 presents at 34/40 with raised BP >160/110. There is no proteinuria and SFH is normal. She is admitted and started on anti-hypertensive therapy. Further management?
A
Admit, BP control, monitor BP 4 times per day, daily proteinuria and weekly blood tests until delivery.
18
Q
Long term risk of VIN progressing to cancer?
A
9%
19
Q
Heavy smoker with cervical smear result as low grade dyskaryosis. HPV test inadequate. Further management?
A
Repeat HPV test.
20
Q
28 year old with multiple sexual partners + repeated vaginal infections. Her cervical smear is reported as high grade dyskaryosis. Further management?
A
Do HPV test to support diagnosis.
21
Q
Overactive bladder treatment - what is the second line treatment after anticholinergic treatment?
A
Botulinum toxin.
22
Q
G2P1 had first baby with anencephaly. What dose of folic acid would you prescribe?
A
5 mg
23
Q
C. diff - what drug used to treat recurrent C diff?
A
Vancomycin.
24
Q
VBAC - by what proportion does the risk of uterine rupture increase?
A
2-3 fold.
25
Patient diagnosed with Group B bacteriruria on culture (>10+5 cfu/ml) and candida on HVS. She is Penicillin allergic. Treatment plan?
Treat now and then IAP (Vancomycin or Cefuroxime) and Clotrimazole.
26
With regard to BMI, which complication of pregnancy is the highest risk compared with women with a normal BMI?
VTE (9 times higher)
27
Relative risks related to higher BMI.
Risk of diabetes - 3 times higher
Risk of hypertension - 2-3 times higher
CS, stillbirth and PPH - 2 times higher
28
What is the best test to diagnose iron-deficiency anaemia?
Serum ferritin
29
What is the strongest predisposing risk factor for developing placenta praevia?
Maternal age of more than 40 years (9 times more likely).
30
A 42-year-old P2 woman is referred to your gynaecology clinic complaining of regular but heavy menstrual bleeding that is affecting her quality of life. Which of the following investigations is most appropriate at the first clinic visit?
FBC.
31
A 40-year-old woman has regular heavy menstrual bleeding. The history and investigations indicate that pharmacological treatment is appropriate. Her GP has tried tranexamic acid without success. What is the most appropriate next pharmaceutical treatment?
Levonorgestrel-releasing intrauterine system (LNG-IUS).
32
What is the criteria for a diagnosis of hospital-acquired or hospital-associated thrombosis (HAT)?
Hospital-acquired or hospital-associated thrombosis (HAT) is defined as any venous thrombosis event occurring in hospital or within 90 days of hospital admission. This accounts for 50–60% of all thromboembolic events. HAT accounted for 57.1 VTE-related deaths per 100,000 hospital admissions.
33
The obstetric team are conducting a study to evaluate whether there has been any effect on patient satisfaction following the establishment of an outpatient induction of labour (IOL) programme. Women undergoing inpatient IOL and women undergoing outpatient IOL were asked to rate their overall satisfaction with the process using a visual analogue scale from 1 (least satisfied) to 10 (most satisfied). What is the most appropriate statistical test to assess whether there is a significant difference in satisfaction between the two groups?
Mann Whitney U test.
34
You are asked to repair a vaginal tear following a normal delivery. The mother's weight is 60 kg. She is otherwise well with no allergies. What is the maximum dose of lidocaine 1% without epinephrine that you can use for perineal infiltration?
18 ml (180 mg).
The maximum dose of lidocaine is 3 mg/kg. As the woman's weight is 60 kg, the dose is 3 x 60 = 180 mg total dose. 1% lidocaine contains 1 x 10 mg/ml = 10 mg/ml. Therefore, the maximum volume is 180 /10 = 18 ml of 1% lidocaine.
35
An ST5 trainee performs an elective caesarean section for a primigravida with a breech presentation. The woman's BMI is 23 kg/m2. She has had no previous abdominal surgery. A straight transverse abdominal incision is made 3 cm below the level of the anterior superior iliac spines. The subcutaneous tissue and rectus sheath are opened in the midline and extended laterally with blunt finger dissection. Blunt dissection is used to separate the rectus muscles and enter the peritoneum. Which transverse abdominal incision is described above?
Joel-Cohen.
Pfannenstiel and Kustner are curved incisions using sharp dissection. Cherney and Maylard are muscle-cutting incisions.
36
Where is Palmer's point?
3 cm below the left costal margin in the midclavicular line.
Palmer's point should be used if there is a high suspicion of adhesions. If there are two failed attempts at insufflation then utilising Palmer's point or the open Hasson technique should be used.
37
You see a 38-year-old woman with a 2.5 cm malignant tumour on her cervi
Radical hysterectomy and bilateral pelvic lymphadenectomy.
Radical surgery is recommended in stage 1B1 disease if there is no contraindication to surgery. Radical trachelectomy can only be offered for fertility sparing in tumours less than 2 cm.
38
A 37-year-old woman is undergoing a diagnostic laparoscopy for investigation of pelvic pain. Following insertion of the laparoscope through the umbilical port you find bowel adherent to the anterior abdominal wall in the midline. You are worried that bowel may be adherent under the umbilicus. What is the recommended course of action?
Visualise the primary trocar site from a secondary port site.
If there are adhesions within the abdomen it is advisable to check the umbilical port by inspecting it, preferably through a 5 mm scope via a secondary port.
39
What do you do about HRT prior to elective surgeries?
HRT does not need to be stopped prior to elective surgery, however, it should be considered as a factor while risk assessing for VTE.
40
What factor does NOT directly increase a patient's risk of VTE?
Smoking.
41
A 35-year-old woman undergoes extensive laparoscopic surgery in the lithotomy position. She presents after 3 days with unresolved weakness of right hip extension and right knee flexion. There is associated sensory impairment below the right knee. Damage to which nerve is the most likely cause?
Femoral nerve.
42
43
A 65-year-old had a hysterectomy for endometrial cancer. She recovered well but complained of dribbling urine 2 days later and was given a course of antibiotics for a presumed UTI. On review at 4 weeks she complains of continued urinary incontinence. She has no dysuria, no sensation of urgency, needs to wear a pad at night, and intermittently voids good volumes of urine with normal flow. Urinalysis is negative. What the most likely diagnosis?
Fistula.
The majority of urinary tract fistulae occur following hysterectomy (both vaginal and abdominal) and caesarean section.
Leakage starting in the immediate postoperative period suggests direct damage. Leakage that starts 1-2 weeks postoperatively is due to avascular necrosis.
44
A 48-year-old woman presents 1 week after a total abdominal hysterectomy. She has persistent weakness of hip flexion and paraesthesia over the anterior and medial aspects of her left thigh. Damage to which nerve is the most likely cause?
Femoral nerve.
Gynaecological surgery, especially abdominal hysterectomy, is the most common cause of iatrogenic femoral nerve injury, and injury to the femoral nerve is the most common nerve injury in gynaecological practice.
45
Which investigation would you arrange to confirm and locate any ureteric injury?
Computerised tomography intravenous urogram.
An acute injury usually presents within 48 hours with diffuse abdominal pain, distension and ileus. The chemical peritonitis has more subtle symptoms compared with peritonitis secondary to faeces or infection. A CT scan with contrast will usually demonstrate a uroperitoneum and may show direct evidence of the injury. MRI is useful in late presentations where a fistula is suspected.
46
A 25-year-old woman develops a wound infection after a straightforward elective subtotal hysterectomy. What is the single most likely causative organism?
Staphylococcal aureus.
47
What is the most appropriate initial dose of intramuscular adrenaline?
0.5 mg (0.5 ml of 1:1000).
If there is a suboptimal response to initial dose, then injections should be repeated every 10 minutes.
48
A 35-year-old woman has recently undergone gastric bypass surgery. She is planning a pregnancy. How long should she be advised to delay conception for?
1 year.
49
A 25-year-old pregnant woman with sickle cell disease attends the antenatal clinic at 8 weeks of gestation. What prenatal testing should be discussed in the first instance?
Partner testing.
50
A 28-year-old primigravida presents at 36+3 weeks of gestation in the antenatal clinic with a breech presentation. There are no obstetric or fetal contraindications to external cephalic version (ECV). An initial ECV without tocolysis failed 2 days earlier. What is the most appropriate management option?
Another ECV with tocolysis.
ECV should be offered after 37 weeks of gestation in multiparous women and after 36 weeks of gestation in primiparous women. Another ECV can be offered if the first one fails. The use of tocolysis increases the success rate after a failed initial attempt. If a caesarean secton is offered it needs to be after 38+6 weeks of gestation.
51
A 34-year-old primigravida presents to the maternity assessment unit with a second episode of decreased fetal movements at 34+4 weeks of gestation. She is known to be low risk and has had an otherwise uneventful pregnancy. What is the most appropriate management option?
Perform a CTG and arrange a scan.
52
A woman presents for booking in the first trimester. She is taking lithium for her mental health. How often should her serum lithium levels be checked?
Every 4 weeks until 36 weeks of gestation.
Lithium levels should be monitored every 4 weeks until 36 weeks of gestation, and then weekly until delivery. Lithium levels should be checked again within 24 hours of delivery and the dose should be adjusted to maintain a level in the lower part of the therapeutic range.
53
A primigravida presents at the antenatal clinic with a monochorionic diamniotic (MCDA) twin pregnancy at 24 weeks of gestation. Ultrasound shows that twin 1 has oligohydramnios with absent end-diastolic flow in the umbilical artery (UA) doppler. Twin 2 has polyhydramnios with positive end-diastolic flow in the UA doppler. What would be the best management for this finding?
Urgent referral for laser ablation of the placental bed.
The twins have developed twin to twin transfusion syndrome (TTTS) due to vascular placental anastomoses which are almost universal in monochorionic twin pregnancies
54
A 28-year-old woman attends for pre-pregnancy counselling. Her maternal grandfather and her mother's brother have haemophilia A. Her husband is healthy and there is no history of haemophilia in the family. What is the risk that any daughter of hers will have haemophilia A?
0%.
The patient's mother must be a carrier. She will have inherited the gene from her father. However the patient's grandmother must also be a carrier since the patient's uncle has the disease but her mother did not inherit the gene since she is well. The patient has a 50% chance of being a carrier, but with a healthy husband it is very unlikely any daughter of hers will have the disease since she will only inherit an affected gene from her mother unless her husband's sperm has a new mutation.
55
An 18-year-old woman is pregnant with a male fetus. She has cystic fibrosis and her partner is a carrier. She is worried that the baby will inherit cystic fibrosis. What is the likelihood that the baby will be affected?
50%.
The woman is heterozygous so will inevitably pass on the CF gene and there is a 50% chance of her baby acquiring the gene from her partner. The child will be either a carrier or affected.
56
A 21-year-old primigravida is admitted for induction at 35 weeks of gestation. She presents with reduced fetal movements and the fetus is thought to be small for gestational age. An ultrasound scan shows that the estimated weight is below the 10th centile and there is reduced end diastolic flow. Which condition is this baby most at risk of?
Polycythaemia.
57
A woman attends the antenatal clinic at 30 weeks of gestation and discloses that she had suspected whooping cough 2 months earlier. What is the single best recommendation regarding pertussis immunisation?
Maternal vaccination should be given now.
As we know that high levels of antibodies are made following vaccination, offering vaccine from 16 weeks of pregnancy should ensure that optimal antibody levels can be passed to her baby.
58
Which of factor does NOT increase the risk of a vaginal breech birth?
High estimated fetal weight (more than 3.5 kg). Estimated fetal weight is only an influence if it is above 3.8 kg.
59
A patient with a history of three previous preterm births at less than 28 weeks of gestation attends the preterm birth clinic for antenatal counselling. When should a history-indicated cerclage be inserted in this patient?
11–14 weeks.
A history-indicated suture is performed as a prophylactic measure in asymptomatic women and usually inserted as a planned procedure at 11–14 weeks of gestation. A finding of cervical shortening indicates a cervical cerclage is inserted at 16–20 weeks of gestation. A rescue cerclage can be inserted up to 27+6 weeks. .
60
A 32-year-old woman, G3P2, presents to the obstetric triage at 35 weeks of gestation as she noticed mild vaginal bleeding when she woke up. She has no contractions or abdominal pain. Her ultrasound at 32 weeks confirmed placenta previa covering internal os. Her pregnancy otherwise has been uncomplicated thus far, with regular antenatal visits. On examination, her vital signs are stable, and the CTG is normal with no active vaginal bleeding. Her blood group is O negative, and she has no known allergies. What is the most appropriate next step in the management of this patient?
Administer anti-D immunoglobulin.
Administration of anti-D immunoglobulin is recommended following any episode of antepartum haemorrhage to prevent Rh sensitisation.
The routine use of antenatal corticosteroids beyond 34+6 weeks of gestation is generally not recommended, as the benefits for fetal lung maturity diminish at later gestational ages, and the potential risks to both the fetus and neonate increase. In very late preterm gestation women (from 35+0 weeks), the use of antenatal corticosteroids should be considered in light of the balance of risks and benefits.
Management should include monitoring maternal and fetal wellbeing, considering corticosteroids for fetal lung maturity if preterm delivery is anticipated, and preparing for potential emergency delivery if there is severe or recurrent bleeding.
61
A primigravida with 36 weeks+ 0 days of gestation who is a smoker attended for routine antenatal care at the consultant clinic. An obstetric scan revealed that the fetus had an estimated fetal weight (EFW) and abdominal circumference at the 8th centile with end-diastolic flow present (EDF) present on umbilical artery doppler, and the pulsatility index (PI) values were within normal range. When would you consider inducing labour for this patient?
At 39+0 weeks, after discussion with the woman and her partner.
For fetuses within EFW or abdominal circumference less than the 10th centile where FGR has been excluded, birth or the initiation of induction of labour should be considered at 39+0 weeks, after discussion with the woman and her partner/family/support network. Birth should occur by 39+6 weeks.
62
A 23-year-old woman attended antenatal clinic at 23 weeks of gestation. Her first trimester screening test showed a PAPP-A level < 5th centile. She subsequently had an abnormal uterine artery doppler at 22 weeks of gestation. The ultrasound also indicated an estimated fetal weight (EFW) below the 10th centile, including abdominal circumference on the 7th centile. What fetal growth surveillance pathway should be recommended?
Discussion with the fetal medicine unit.
63
A 33-year-old G3P0 woman has been diagnosed with a first-trimester miscarriage. The history reveals two previous first-trimester miscarriages. Which of the following options includes the most appropriate investigations to offer this patient?
Testing for lupus anticoagulant and anticardiolipin antibodies, cytogenetic analysis of pregnancy tissue, 3D transvaginal ultrasound and thyroid function tests.
Cytogenetic analysis should be offered on pregnancy tissue of the third and subsequent miscarriage(s) and in any second-trimester miscarriage.
64
A 40-year-old woman is referred by her Community midwife at 34 weeks of gestation for an ultrasound due to symphysis fundal height measuring smaller than expected. The ultrasound confirms an estimated fetal weight below the 10th percentile for gestational age, consistent with a diagnosis of small for gestational age (SGA). According to the latest RCOG guidelines, what is the most appropriate next step in the management of this patient?
Doppler assessment weekly, estimated fetal weight (EFW) fortnightly.
65
A 32-year-old primigravida attends the antenatal clinic at 14 weeks of pregnancy. She is a known epileptic on lamotrigine 200 mg BD. Her last seizure was 3 years prior to conception. She has a normal BMI. Her dating scan is normal. You have been asked to see her in the clinic. What would be the correct management plan for this patient?
Continue lamotrigine 200 mg BD with monitoring of plasma drug concentrations, arrange anatomy scan at 20 weeks and serial growth scan from 32 weeks.
The fetal anomaly scan at 18+0–20+6 weeks of gestation can identify major cardiac defects in addition to neural tube defects. All should be offered a detailed ultrasound and Serial growth scans are required for detection of small-for-gestational-age babies and to plan further management.
The levels of most AEDs are known to fall in pregnancy and the levels of lamotrigine are known to fall by up to 70% in pregnancy.
With the exception of lamotrigine, levetiracetam, carbamazepine and oxcarbazepine, plasma level monitoring is not required unless there is a change in seizure frequency, poor compliance is suspected or there are concerns regarding toxicity.
66
Which class of drugs can cause 'floppy baby syndrome'?
Benzodiazepines.
Benzodiazepines can cause 'floppy baby syndrome' and/or neonatal withdrawal if there is prolonged use in the third trimester, or they are given around the time of delivery.
67
Which age category has the highest incidence of molar pregnancy?
50 years or more.
The incidence of GTD is associated with age at conception, being higher in the extremes of age (women aged less than 15 years, 1 in 500 pregnancies; women aged more than 50 years, 1 in 8 pregnancies).
68
A 24-year-old woman, who is now 21 weeks pregnant, had a LLETZ procedure 1 year ago for abnormal smear. Following a cervical length ultrasound showing a cervix 20 mm in length, she underwent the insertion of a transvaginal cervical cerclage. She is hoping to have a vaginal birth. What is the most appropriate aftercare advice to provide on discharge?
Elective removal of cerclage between 36+1 and 37+0 weeks of gestation.
69
A patient was diagnosed with early syphilis after booking late at 22 weeks of pregnancy. She received appropriate treatment at 25 weeks of gestation and her partner was also treated. She has a normal vaginal delivery at 38 weeks. What is the most appropriate management for her baby?
Infant syphilis serology should be performed and repeated 3 months postnatally.
This patient's baby would be classed as low risk for congenital syphilis as the mother has been appropriately treated > 4 weeks prior to delivery and there is no stated risk of reinfection. In these cases, both mother and infant serology should be tested at birth and the infants followed up with further serological testing at 3 months of age.
Infant serology from a serum sample is used as opposed to cord blood samples.
Infants would not routinely be treated with antibiotic therapy unless congenital syphilis is diagnosed (symptoms of congenital syphilis on examination and positive syphilis serology).
70
A 25-year-old pregnant patient at 20 weeks of gestation was brought in by ambulance to the emergency department following a major road traffic accident. She was resuscitated and has now been stabilised. What is the gold-standard imaging investigation you would recommend for her at this early stage?
Whole-body computed tomography (CT).
71
Advice about aerobic activity in pregnancy?
- 30 minutes of activity per day.
- 75 minutes of intense activity per week.
- 150 minutes of moderate intensity activity per week.
- Active for most days of the week, with no session lasting longer than 60 minutes.
72
A pregnant woman is identified as being susceptible to rubella from her first-trimester booking blood results. When discussing this result at the next antenatal clinic appointment, what is the most appropriate advice that she should be given?
A single dose of MMR should be offered immediately postnatally, with a second dose at the 6-week postnatal check.
The clinical diagnosis of rubella is unreliable and since the risk to the fetus is in the first 16 weeks of pregnancy, it is important that the woman is immunised before she can become pregnant again.
73
A 34-year-old woman attends her 20-week anomaly scan. A uterine artery Doppler is performed as her last pregnancy was complicated by pre-eclampsia, and she delivered a small for gestational age baby with a birthweight on the 1st centile. The uterine artery Doppler is normal, and the growth is on the 50th centile. What is the most appropriate management option?
Serial scans for estimated fetal weight and umbilical Dopplers from 32 weeks.
If the uterine artery Doppler is abnormal; that is, the PI is greater than the 95th, additional monitoring scans are recommended. However, if the uterine artery Doppler and growth are normal this is reassuring that the risk of early IUGR is low, and serial scan monitoring can start at 32 weeks of gestation.
74
A 32-year-old woman, gravida 2, 13 weeks of gestation, Rh negative, underwent medical termination of a partial molar pregnancy. Tissue was sent for histological examination and reports are pending. What is the role of Anti-D in this situation?
Anti-D 250 IU.
Complete molar pregnancy doesn't need Anti-D due to absent D antigen. However, partial molar pregnancy needs Anti-D. Since the diagnosis of a complete molar may not happen until sometime after surgical removal, it can delay Anti-D. Hence the recommendation is to give to all molar pregnancies following their removal. The dose is 250 IU for < 12 weeks and also for 12–20 weeks of gestation.
75
A 28-year-old woman dies at 47 days postpartum following aspiration during an epileptic seizure. She had a 10-year history of epilepsy. What is the classification of this maternal death?
Late indirect maternal death. A maternal death that occurs 6 weeks following childbirth is termed as late maternal death. If death occurs of a pre-existing medical condition it is called an indirect maternal death.
76
Which cardiac biomarker is most reliable for diagnosing acute myocardial infarction during labour and delivery?
Troponin I.
77
A woman who is 24 weeks pregnant contacts the maternity day unit reporting possible exposure to facial shingles 4 days earlier. The pregnant woman believes she has had chickenpox when she was a child. What advice should she be given?
Reassure her that no further action is necessary as she is likely to be immune.
If a woman has a past history of chickenpox or shingles or 2 doses of a varicella-containing vaccine, and is not immunosuppressed, protection can be assumed and reassurance given. If there is no history of past chickenpox or shingles and the woman is not fully vaccinated (2 doses), the woman's susceptibility should be determined urgently.
78
A 25-year-old primigravida presents at 32 weeks of gestation with itching. Following a blood test, she is diagnosed with obstetric cholestasis. Which pharmacological agent would be the most effective treatment?
Ursodeoxycholic acid.
79
A 29-year-old primigravida presents with chest pain and is diagnosed with myocardial infarction. Her BMI is 29 and she does not have any significant medical or family history. What is the most likely cause of acute myocardial infarction in this case?
Coronary artery dissection.
Cardiac disease remains a significant cause of maternal death with 54 deaths per 100 000 maternities.
The most common cause is atherosclerosis, and diabetes and smoking are significant risk factors. In women with no cardiovascular risk factors, coronary artery dissection may occur. It is thought that this results from changes in the vessel wall related to high progesterone levels.
80
What is the most appropriate test for the diagnosis of malaria?
Thick and thin blood film for parasites.
81
A 25-year-old woman is found to have a platelet count of 110 x 10*9/l when tested routinely at 28 weeks of gestation. Her platelet count at 12 weeks of gestation was 352 x 10*9/l. She has no history of illness. What is the most likely diagnosis from the list below?
Gestational thrombocytopenia.
If the count is greater than 100 x 109/l no further investigations are required but other disorders should be considered. If the count falls below this, further investigations are indicated including blood film, coagulation screen, renal and liver function tests, antiphospholipid antibodies and anti-DNA antibodies.
82
A 32-year-old primigravid woman attends the antenatal clinic complaining of persistent mild pruritus due to atopic eruption of pregnancy. Which is the first line treatment in reducing pruritus and providing relief of her symptoms?
Emollients.
The two most common skin problems in pregnancy are atopic eruption of pregnancy and polymorphic eruption of pregnancy. Atopic eruption of pregnancy may require topical steroids and antihistamines, but can often be managed with emollients.
83
ou have been asked to review a postnatal woman with known type 1 insulin dependent diabetes mellitus who was successfully delivered overnight. She is now eating and drinking normally and the postdelivery capillary blood glucose readings are all between 4 and 7 mmol/l. The plan is to stop the intravenous insulin/dextrose sliding scale and recommence subcutaneous insulin. She wishes to breastfeed her baby. What is the most appropriate advice for the woman regarding recommencing her subcutaneous insulin?
Reduce her prepregnancy insulin dose by 25%.
Once women with type 1 diabetes are eating normally, subcutaneous insulin should be recommenced at a 25% lower dose of her prepregnancy dose if she intends to breastfeed.
84
A 26-year-old P1+0 woman booked under midwife-led care develops a confirmed chickenpox infection at 38+6 weeks of gestation. She is a non-smoker and is otherwise low risk. Clinically, the fetus appears appropriately grown for gestation and is in a cephalic presentation. She previously had an uncomplicated normal delivery of a 3.7 kg baby following induction for postmaturity. What is the most appropriate advice for her ongoing management?
Await the onset of spontaneous labour and give the newborn varicella zoster immunoglobulin if delivered within 7 days following the onset of the maternal rash.
If the woman presents within 24 hours (at over 20 weeks of gestation) it is worth prescribing acyclovir. The baby is at most risk if delivered within a week of the development of the infection. After 7 days the maternal antibodies will protect the baby.
85
35-year-old woman with persistent tachycardia has thyroid function tests at 18 weeks of gestation. The results are TSH < 0.02 mU/l (normal range 0.4–5.0) and T4 of 67 pmol/l (normal range 10–20). What is the most likely cause for her hyperthyroidism?
Graves disease.
95% of cases of hyperthyroidism in pregnancy are due to Graves disease.
In assessing thyroid function in pregnancy, free T3 and T4 levels reflect thyroid function rather than total T3 and T4 levels.
86
You see a woman who is 35 weeks pregnant in your day assessment unit. She presents with nausea, anorexia and generalised malaise. Her liver function test demonstrates an alanine transaminase (ALT) of 634. Which of the following features is most useful in distinguishing acute fatty liver of pregnancy (AFLP) from HELLP syndrome?
Hypoglycaemia.
87
Which contraceptive should be avoided in obstetric cholestasis?
Combined oral contraceptive pill.
88
A pregnant woman with severe von Willebrand's disease attends the antenatal clinic. She is nonsensitised Rh-negative. What is the recommend management regarding routine antenatal anti-D prophylaxis?
Administer intravenous anti-D.
89
A 30-year-old woman, Para 0, is referred for a growth scan. The pregnancy has been uncomplicated so far. The ultrasonographer reports that the estimated fetal weight is on the 5th centile for gestation, there is normal liquor and the umbilical artery Doppler waveform is normal but the fetal head circumference is less than the 1st centile for gestation. What is the most likely infective cause?
Cytomegalovirus.
90
A primigravid woman presents to the antenatal diabetic clinic at 28 weeks of gestation. She has just been diagnosed with gestational diabetes on a 75-g 2-hour oral glucose tolerance test. The fasting plasma glucose was 7.2 mmol/l. The scan has revealed polyhydramnios and a baby that is large for gestational age. What is the most appropriate treatment for this woman?
Immediate treatment with insulin and/or metformin.
91
A pregnant woman who is known to have poorly controlled epilepsy is found dead at her home at 22 weeks of gestation. According to the MBRRACE 2014 report, what is the most likely cause of her death?
Sudden unexplained death in pregnancy.
92
A 30-year-old pregnant woman is diagnosed with primary cytomegalovirus (CMV) infection at 13 weeks of gestation. Which of the following is the most appropriate intervention to reduce the risk of congenital CMV infection?
Valaciclovir therapy.
93
What is the percentage risk of poor neonatal adaptation syndrome for the baby of someone taking citalopram?
Up to 30%.
The background risk is 10%.
94
A 36-year-old woman with a background of schizophrenia has had a spontaneous vaginal birth at term and wishes to breastfeed. Which antipsychotic medication contraindicates breastfeeding due to risk of neonatal agranulocytosis?
Clozapine.
Aripiprazole can lower serum prolactin which can interfere with milk production, but is not transferred in breast milk.
95
When should lithium levels be measured during pregnancy?
Monthly until 36 weeks then weekly until delivery.
96
Management of pregnant patients taking lithium:
- 2% risk of cardiac malformations (background risk is 0.6–1.2%) – fetal echo advised at 18–22/40.
- maternal diabetes insipidus, risking fetal polyuria and polyhydramnios – serial growth scans in 3rd trimester are advised to assess growth and liquor volume.
- risk of maternal and neonatal nephrotoxicity due to renal excretion of the drug, with narrow therapeutic window – advised to avoid nephrotoxic medication, deliver in the hospital where renal function can be monitored, and monitor drug levels monthly until 36/40, then weekly until delivery (or if a new indication arises, e.g. PET, hyperemesis).
- interaction with neuromuscular blocking agents – advised to have anaesthetic review.
- high transfer into breast milk so advised not to breastfeed due to risk of neonatal toxicity.
97
What is the percentage risk of fetal cardiac malformations in a woman taking lithium?
2%
98
What is the first-line antibiotic regime to treat syphilis?
Benzathine penicillin G 2.4 IU IM single dose.
99
When breast cancer is diagnosed in women aged 30 years or less, 10–20% of cases may be associated with pregnancy or occur within 1 year postpartum. Surgical treatment of breast cancer can be undertaken during pregnancy. To minimise the risk of any adverse effect towards the pregnancy:
Surgical treatment, including loco-regional clearance, can be undertaken in all trimesters.
100
A 26-year-old Caucasian primigravida at 30+1 weeks' gestational age was noted to have 1+ glycosuria during urine reagent testing for the first time in her routine antenatal care. Her body mass index is 20.6 kg/m2. She has no history of weight loss or polyuria and has not had any glucose testing in this pregnancy. Her grandmother was diagnosed with type 2 diabetes mellitus and hypertension. On examination, the symphysio-fundal height is normal and within the expected centile trend. What would be the most appropriate management?
Reassure her that a single finding of 1+ glycosuria is not specific for gestational diabetes mellitus, and arrange an oral glucose tolerance test if it is noted once more.
101
Risk factors for gestational diabetes:
* BMI above 30 kg/m2
* previous macrosomic baby weighing 4.5 kg or more
* previous gestational diabetes
* family history of diabetes (first-degree relative with diabetes)
* an ethnicity with a high prevalence of diabetes
Consider further testing to exclude gestational diabetes in women who have the following reagent strip test results during routine antenatal care:
* glycosuria of 2+ or above on 1 occasion
* glycosuria of 1+ or above on 2 or more occasions.
102
A 30-year-old woman at 34 weeks of gestation in her first pregnancy presents with severe itching. Bile acid levels were found to be raised at 110 micromol/l (normal range < 19 micromol/l). What further management would be most suitable for this patient?
Offer induction of labour at 36 weeks of gestation.
In women with severe intrahepatic cholestasis of pregnancy with peak bile acids of 100 micromol/l or more, consider planned birth at 35–36 weeks of gestation. Prevalence of stillbirth is 3.44% in this group (national rate 0.29%).
103
Nausea and vomiting of pregnancy (NVP) and hyperemesis gravidarum (HG) are associated with numerous electrolyte imbalances and metabolic disturbances. Which of the following changes are most likely to occur?
Hyponatremia, hypokalemia, low serum urea, raised haematocrit, raised T4, low TSH with with a metabolic hypochloraemic alkalosis.
In 2/3 women with HG, abnormal TFTs may result due to a structural similarity between TSH and hCG, causing a raised T4 and low/normal TSH level. Therefore, a raised T4 and low TSH do not need treatment in straightforward NVP/HG where the cause is clear and the patient is responding to treatment.
104
What should we tell women with obstetric cholestasis?
Advise women that there are no treatments that improve pregnancy outcome (or raised bile acid concentrations) and treatments to improve maternal itching are of limited benefit .
In women with peak bile acids 19–39 micromol/l and no other risk factors, advise them that the risk of stillbirth is similar to the background risk.
Advise women with ICP that the presence of risk factors or comorbidities (such as gestational diabetes and/or pre-eclampsia and/or multifetal pregnancy) appear to increase the risk of stillbirth and may influence decision-making around timing of planned birth.
Do not routinely offer ursodeoxycholic acid for the purpose of reducing adverse perinatal outcomes in women with ICP.
Confirm the diagnosis of ICP in the postnatal period at least 4 weeks after birth, with resolution of itching and liver function tests returning to normal including bile acids.
105
A 32-year-old primigravida is admitted to labour ward at 39 weeks of gestation. She is having four strong contractions every 10 minutes, and on vaginal examination her cervix is 5 cm dilated. Her pregnancy has been complicated by severe hyperemesis gravidarum. In order to manage this she was started on 10 mg of prednisolone twice daily from 28 weeks of gestation. She has needed to continue this dose throughout her pregnancy to control her symptoms. What steroids would you prescribe for her on admission?
Intravenous hydrocortisone 50 mg every 6 hours in labour until 6 hours postnatal.
As she takes more than 5 mg of prednisolone a day for over 3 weeks she is likely to have a degree of adrenal suppression.
As there is poor oral absorption in labour, IV hydrocortisone is preferred to double dose oral prednisolone.
50 mg IV hydrocortisone every 6 hours in labour is considered sufficient for a vaginal birth, however if this patient was having a planned caesarean section, 100 mg IV hydrocortisone prior to skin incision would be advised. Regardless of mode of delivery, a follow-up dose of 50 mg of IV hydrocortisone is recommended at 6 hours postnatal.
106
Most common site of extrapulmonary tuberculosis in pregnancy?
Cervical lymph nodes, accounting for approximately 31%.
107
32-year-old woman is in labour in her second pregnancy. Her previous delivery was by caesarean section. What is the most consistent indicator of uterine rupture for this woman?
Abnormal CTG.
An abnormal CTG is the most consistent finding in dehiscence, occurring in 55–87% of cases.
Vaginal birth after an uncomplicated lower segment caesarean section is successful in 72–76% of women. The risk of uterine rupture is 22–74/10 000 (0.22–0.74%). This is lower if the woman labours preterm (34/10 000 vs 74/10 000).
108
A primigravida wishes to opt for epidural analgesia in labour at term but she has heard that regional analgesia increases the risk of operative vaginal delivery which she is keen to avoid. Assuming she opts for an epidural analgesia, how can the second stage of labour be managed to reduce this risk for her?
Allow up to two hours for passive descent.
109
Preterm labour complicates up to 8% of pregnancies in the UK. A 28-year-old woman, gravida 1 para 0, is at 31 weeks of gestation and presents to the antenatal clinic with complaints of irregular painful tightening of her vagina. To confirm the diagnosis of imminent or preterm labour, phIGFBP-1 vaginal swab test is performed. The sensitivity of the test is 90%, and the false positive rate is 5%. Her swab test returns positive. Given her positive swab test, what is the likelihood that she is in true preterm labour?
60%.
In a sample of 1,000 women, 80 will be affected by preterm labour and 920 will not. With a sensitivity of 90%, 72 out of 80 women will test positive for preterm labour using this vaginal swab test, and 8 will test negative (false negative). Out of the 920 women, 5% will be incorrectly tested positive, which amounts to 46 women. Therefore, among all positive swab results (46+72=118), 72 will be true positive, making the positive predict value 72/118 or about 60%.
110
A 25-year-old primigravida is admitted to the midwifery led unit at 39 weeks' gestation, in spontaneous labour at 5 cm. Her blood pressure is 140/90 mmHg. She has no proteinuria. The patient has no symptoms of pre-eclampsia. After 30 minutes, her repeat blood pressure remains 140/90 mmHg. The midwife caring for the patient phones you for advice. What would you advise as the most appropriate next step in management?
Transfer patient to obstetric-led care unit.
111
A 32-year-old primigravida with DCDA twin pregnancy at 37 weeks of gestation had a spontaneous onset of labour and delivered the first twin as cephalic presentation at 09:30 am. The second twin was confirmed as cephalic presentation by US scan (after delivery of first twin) and had ruptured membranes at 10:00 am. The time is now 10:30 am and she is contracting, with 3–4 contractions every 10 minutes. On examination she is fully dilated, with vertex at -1, OP position, no caput or moulding. CTG is classified as suspicious. What is the most appropriate plan?
Discuss with the woman and her family regarding performing caesarean section.
112
A 36-year-old woman attends the antenatal clinic at 20 weeks of gestation. She has had three previous caesarean sections and has a normal placental site. She consented for another caesarean section. What is the most likely surgical complication?
Blood loss requiring transfusion.
113
When consenting her for elective caesarean section, what should you state is the risk of emergency hysterectomy?
1 in 670.
The risk of emergency hysterectomy in planned caesarean birth is 150 per 100,000 (approximately 1 in 670).
114
A 30-year-old woman, gravida 2 para 1, is at 37 weeks of gestation with a dichorionic diamniotic twin pregnancy. Both twins have been growing appropriately. The first twin was in a cephalic presentation and has just been delivered vaginally. It has been 20 minutes since the delivery of the first twin. The second twin is in a breech presentation, and the woman is concerned about the potential risks associated with the delivery of her second twin, particularly the need for a caesarean section. What is the approximate risk of requiring a caesarean section for the second twin in this clinical scenario?
4%.
115
A patient with a history of one previous caesarean section is undergoing an elective caesarean section for a placenta praevia. You have been asked to counsel her regarding the possible risks. What is her risk of undergoing an emergency hysterectomy?
27 in 100.
Patients with a placenta praevia and a history of caesarean section have a risk of up to 27 per 100.
The risk of hysterectomy in women with one previous caesarean section (without placenta praevia) is 2 in 100.
In all women with placenta praevia, it is 11 in 100.
116
You are asked to review a woman following a forceps delivery. She presents with left lateral calf paraesthesia, sensory loss between her first and second toes and foot drop with inversion. Which nerve compression is the likely cause of her symptoms?
Common peroneal nerve.
The common peroneal nerve is prone to compression at the fibular head during positioning in stirrups.
117
Which symptoms would concern you the most and lead you to the diagnosis of postpartum psychosis?
Confusion, bewilderment and perplexity are worrying symptoms and should alert you to the diagnosis of postpartum psychosis.
Baby blues affects 30–80% of births in the first week postpartum.
118
A 29-year-old woman has just given birth to her first baby via a spontaneous vaginal delivery. She is noted to have significant trauma and you are asked to formally assess the tear. On examination, more than 80% of the external anal sphincter is torn. The internal anal sphincter and anorectal mucosa are intact. What is the classification of the perineal tear described and what is the most appropriate suture material for repair?
3b tear and 3-0 PDS.
When repair of the external anal sphincter and/or internal anal sphincter muscle is being performed, either monofilament sutures such as 3-0 PDS or modern braided sutures such as 2-0 polyglactin can be used with equivalent outcomes.
119
What is the recommended dose range of IM lorazepam in postnatal women?
1–2 mg.
lorazepam 1–2 mg (max 4 mg in 24 hours) – first-choice benzodiazepine, rapid onset, short-acting, low placental transfer.
haloperidol 2–5 mg (max 20 mg in 24 hours).
olanzapine 5–10 mg (max 20 mg in 24 hours)
120
A 16-year-old girl presents to the gynaecology outpatient clinic with primary amenorrhea. She is 148 cm tall and weighs 54 kg (BMI 24.7). Breast development is assessed as Tanner stage 2 and her pubic hair is noted to be sparse. Further examination identifies cubitus valgus. She has no other dysmorphic features. What is the most likely diagnosis?
Turner syndrome.
The karyotype is 45 XO in Turner syndrome. It is the most common cause of gonadal dysgenesis. These patients may have additional renal and cardiac anamolies. Some women may menstruate due to mosaicism, but premature ovarian failure is more common.
121
A 17-year-old girl presents with a 12 hour history of lower abdominal pain. She had unprotected intercourse a week ago, which was 6 days after her last period. Her pulse is 110 beats per minute, her blood pressure is 110/70 mmHg, her temperature 37.8°C and she is tender over her lower abdomen, especially in the right iliac fossa where there is rebound tenderness. There is cervical excitation. Her Hb is 137g/l (normal 115–165) and her white cell count 17.6 x 10*9/l (normal 4–11). What is the most likely diagnosis?
Acute appendicitis.
122
A 65-year-old postmenopausal woman attends the clinic having been found to have a 4.9 cm simple cyst arising from the right ovary. There is no other abnormality on scan. Her Ca 125 is 29. She is asymptomatic and the cyst was picked up on investigation for haematuria. What is the most appropriate management?
Repeat scan and Ca 125 test in 4 months.
The risk of malignancy index (RMI) is zero since the cyst is simple and it measures less than 5 cm. Therefore, monitoring for 12 months is all that is required.
123
A 46-year-old nulliparous woman has been referred by her GP having been treated for heavy regular menstrual bleeding with cyclical progestogens for a period of 6 months. The treatment has failed to improve her symptoms. What is the most appropriate next line of management?
Endometrial biopsy.
Endometrial biopsy should be performed if a women over 45 years of age fails to respond to first line treatment.
124
A 51-year-old woman attends your clinic with history of severe vasomotor symptoms (hot flushes, night sweats). She has a family history of breast cancer and would like to avoid hormone replacement therapy (HRT). Which non-hormonal medication is most likely to control her symptoms?
Venlafaxine.
125
A 65-year-old woman is referred to the gynaecology outpatient department with left-sided lower abdominal discomfort. A bimanual examination reveals discomfort in her left iliac fossa. She is concerned that she may have ovarian cancer. What is the most appropriate radiological investigation for this woman?
Transvaginal ultrasound.
126
You see a 28-year-old patient with a possible diagnosis of premenstrual syndrome. She has had normal gynaecological investigations to date and has no history of mental health disorders. She has struggled to complete her symptom diary. How would you recommend she completes her symptom diary?
Prospectively over two cycles.
127
A 16-year-old girl presents to her GP with primary amenorrhoea. She experienced normal pubertal development, with breast development at age 12 and pubic hair at age 13. She denies cyclical lower abdominal pain and has no significant weight changes, stress, or symptoms of depression. She exercises moderately, has a BMI of 22 kg/m2, and her family history is unremarkable for genetic anomalies. Physical examination is normal, and she is not on any medications. What is the most appropriate next step in the management of this patient?
Check endocrine profile FSH and LH levels, serum prolactin, thyroid-stimulating hormone and estradiol.
the initial evaluation of primary amenorrhoea involves assessing gonadotrophin levels (FSH and LH) to differentiate between hypogonadotropic hypogonadism (low or normal FSH and LH) and hypergonadotropic hypogonadism (elevated FSH and LH). Elevated levels suggest primary ovarian insufficiency, while low or normal levels might indicate hypothalamic or pituitary causes.
Other investigations include:
pelvic ultrasound (if physical examination does not confirm the presence of a vagina and uterus, or in young girls who are not sexually active)
serum prolactin
thyroid-stimulating hormone
estradiol
total testosterone (if features of androgen excess are present)
screening for coeliac disease
128
What percentage of menstrual cycles are anovulatory in the first year after menarche?
50%.
129
Following investigation for heavy menstrual bleeding, a 25-year-old woman was found to have a subserosal uterine fibroid on ultrasound scan. In counselling this patient about the impact on reproductive outcomes, compared with a patient without a subserosal fibroid, what advice would you provide?
There is no significant impact.
130
A 46-year-old woman, who carries the pathogenic BRCA2 variation, underwent risk reduction surgery in the form of laparoscopic bilateral salpingo-oophorectomy 2 months ago. Continuous combined HRT was commenced immediately postoperatively. She reported unexpected vaginal bleeding. Examination revealed normal abdominal and pelvic findings. Her BMI is normal and she is up to date with her cervical screening. What is the most appropriate next step?
Assess cancer risk factors and bleeding pattern, identify HRT regimen, duration, compliance.
Offer genital swab only if indicated. Arrange urgent ultrasound scan if there are risk factors for endometrial cancer (urgent) or bleeding persists even after adjusting HRT (non-urgent). Hysteroscopy and/or endometrial biopsy is done if endometrium is thickened (> 4 mm for continuous combined HRT).
131
A 40-year-old woman presents to the gynaecology clinic with cyclical symptoms of depression, extreme irritability, bloatedness and mastalgia which persist for 2 weeks before periods and are relieved after the onset of periods. Her symptom diary is highly suggestive of premenstrual dysphoric disorder. She has tried lifestyle modification with regular exercises but has had no symptomatic relief. She is a non-smoker. What would be the next best management option for her?
Continuous combined oral contraceptive pills.
When treating women with PMS, drospirenone-containing COCs may represent effective treatment for PMS and should be considered as a first-line pharmaceutical intervention.
132
A 48-year-old woman presented with PV bleeding on sequential HRT. She started her HRT 6 months ago. Her BMI is 29.5 kg/m2. Abdominal and pelvic examination was normal. She is up to date with her cervical screening, which was negative. Lower genital tract swabs did not show any growth. An urgent ultrasound scan reported a double endometrial thickness of 4.9 mm. Which is the most appropriate option to manage unscheduled bleeding on HRT?
Reassure as the risk of endometrial cancer is low.
Women with unscheduled bleeding, in the presence of a uniform endometrium which is fully visualised and measures ≤ 4 mm with ccHRT or ≤7 mm with sHRT, can be reassured that the risk of endometrial cancer is low.
133
A 24-year-old female presents to the general gynaecology clinic with premature ovarian insufficiency and has been commenced on HRT. She is sexually active and does not plan to start a family. What is the most appropriate advice for this patient regarding contraception?
Contraception is required in addition to HRT.
Whilst premature ovarian insufficiency does have a significant impact upon fertility and reproduction, leading to infertility, spontaneous pregnancy can occur in up to 5–10% of women. RCOG guidance on risk considers this to be 'common' (1 in 10 to 1 in 100).
134
What is the most appropriate advice for patients regarding spontaneous conception in premature ovarian insufficiency in this patient?
Spontaneous conception is common in premature ovarian insufficiency.
135
A 70-year-old woman is referred to your rapid access clinic for painless postmenopausal bleeding. She noticed red spots in her underwear on a couple of occasions, not postcoital. Her pelvic ultrasound showed an endometrial thickness of 3.5 mm. On pelvic examination, you notice a red, soft, smooth, fleshy polypoidal lesion of less than 1 cm in diameter at the posterior margin of the urethral meatus. She has no urinary symptoms and no palpable inguinal lymphadenopathy. What is the next best management step?
Advise a course of vaginal estrogen.
The lesion is a urethral caruncle, commonly associated with estrogen deficiency and often managed conservatively with topical estrogen in asymptomatic cases.
136
A 45-year-old diabetic woman, smoker, with BMI 50 kg/m2, was admitted for inpatient management of pelvic inflammatory disease. She has a latex allergy and requires graduated compression stockings (GCS) to reduce VTE risk. Which condition contraindicates GCS for her?
Peripheral arterial disease.
137
A 38-year-old woman presented to the Subfertility clinic with an 18-month history of menstrual irregularities. She gives a history of reduction in the frequency of her cycles and her last period was 6 months ago. She is nulliparous and trying to conceive with her partner, who is 42 years old. She also reports lack of libido, mood disturbances, forgetfulness and sleeplessness.
A urine pregnancy test is negative. Her FSH levels, which were repeated 6 weeks apart, are 50 IU/l and 49IU/l. Her LH levels are 40 IU/l and 39 IU/l. Her estradiol level is 30pg/ml. Her AMH level is 0.2pmol/l. Her BMI is 24.5 kg/m2 and she is a non-smoker. She is very keen to conceive and would like to manage her menstrual irregularities along with systemic symptoms as a matter of importance.
What is the best pharmacological management to suit her needs?
Transdermal micronised 17b estradiol 50 micrograms (14 days) followed by transdermal micronised 17b estradiol 50 micrograms + transdermal 170 micrograms norethisterone per 24 hours (Evorel Conti™) from 15–28 days.
This patient has all the diagnostic criteria for Premature Ovarian Insufficiency (POI). In women who seek to achieve pregnancy and plan to be a oocyte recipient, there are more favourable outcomes with sequential HRT compared with continuous HRT. This patient also has oligomenorrhea, which makes her more suitable for sequential compared to continuous HRT. Transdermal HRT is preferred over oral HRT because the patient gives a history of increasing forgetfulness.
138
A 40-year-old woman has regular heavy menstrual bleeding. The history, physical examination and ultrasound are not suggestive of any underlying pathology. What is the most appropriate first-line treatment?
Levonorgestrel-releasing intrauterine system (LNG-IUS.
139
A 36-year-old P4 woman with a BMI of 31 kg/m2 who smokes ten cigarettes a day underwent an uncomplicated elective caesarean section for a transverse lie at term. There is no relevant past medical, family or surgical history. She plans to bottle-feed her healthy newborn. What VTE prophylaxis will she need postnatally?
Commence daily LMWH by subcutaneous injections for at least 6 weeks.
140
A fit 26-year-old woman with a BMI of 24 kg/m2 with no antenatal history of note delivered a boy by an emergency lower uterine segment caesarean section at 5 cm dilated for fetal distress. Her son weighed 3.5 kg and had Apgar scores of 9 and 9. Her section and recovery have been unremarkable. What VTE prophylaxis will she need postnatally?
Prescribe LMWH by subcutaneous injections daily for at least 10 days.
141
A 19-year-old nulliparous single woman with a BMI of 21 kg/m2 gave birth to a healthy male infant by rotational forceps delivery complicated by a 1200 ml postpartum haemorrhage. She received antenatal daily LMWH subcutaneous injections as she has a strong family history of thromboembolic disease and has a factor V Leiden gene mutation (heterozygote), although she has never had a thrombotic episode. She is adamant that she does not want to continue to inject herself while breastfeeding and caring for her baby. What VTE prophylaxis will she need postnatally?
Warfarin treatment for at least 6 weeks maintaining maternal international normalised ratio levels between 2.0 and 2.5.
142
A 34-year-old ex-smoker with a BMI of 18 kg/m2 gave birth to her daughter by elective lower uterine caesarean section because of a breech presentation. She had a measured blood loss of 900 ml during surgery. She was adopted and her family history is not known. What VTE prophylaxis will she need postnatally?
Early mobilisation.
143
A 44-year-old nulliparous woman with type 2 diabetes and a BMI of 37 kg/m2 is shown to have endometrial hyperplasia without cellular atypia following a hysteroscopy and uterine curettage for intermenstrual and prolonged vaginal bleeding. A recent cervical smear was normal. Treatment?
Levonorgestrel-IUS (Mirena™).
144
A 52-year-old woman, P3 with a BMI of 32 kg/m2 presents to her general practitioner with irregular vaginal bleeding. A transvaginal ultrasound scan of the pelvis demonstrates an endometrial thickness of 18 mm and the histology of an outpatient biopsy of the endometrium revealed hyperplasia with no cellular atypia. Abdominal and pelvic examination is normal apart from a grade 1 cystocele. Treatment?
Hysteroscopy and endometrial curettage.
145
A 48-year-old woman, P1 with a BMI of 27 kg/m2, had an endometrial ablation for heavy menstrual bleeding and was found to have endometrial hyperplasia with moderate cellular atypia on a biopsy taken at the time of the procedure, although the pre-treatment hysteroscopy was recorded as normal in the operative notes. The pelvic examination at the same time was unremarkable. Treatment?
Hysterectomy with bilateral salpingo-oophorectomy.
146
A 53-year-old woman, P2 with a BMI of 25 kg/m2, presents with light vaginal bleeding following 6 months of amenorrhoea. Abdominal and pelvic examinations are normal apart from a slightly enlarged uterus. A transvaginal ultrasound scan of the pelvis shows several small sub-serosal fibroids with a regular endometrial thickness of 3.9 mm. She is concerned because there is a family history of Lynch syndrome (hereditary non-polyposis colonic cancer).
Hysteroscopy and endometrial curettage.
147
A 44-year-old nulligravid woman with type 2 diabetes and a BMI of 37 kg/m2 is shown to have endometrial hyperplasia without cellular atypia after a hysteroscopy and uterine curettage investigating intermenstrual and prolonged vaginal bleeding. A recent cervical smear was normal and she is known to have a significant uterine Müllerian fusion defect associated with a structural renal tract abnormality with normal renal function.
Medroxyprogesterone acetate 10 mg tablet daily for 90 days.
This is a classic sequence of anovulatory bleeding with the endometrial consequence of unopposed endogenous estrogens, which should be treated with continuous rather than cyclical progestagens to differentiate the endometrium and stop cellular proliferation. Clearly, prolonged powerful gestagen therapy is required. Here, the key is that the examiner is ensuring that the intrauterine system is not suitable because of the uterine structural abnormality.
148
A 40-year-old woman, P2, is taking tamoxifen following surgery for an estrogen receptor- and progesterone-positive breast cancer 2 years ago. She is referred by her breast surgeon for consultation because she has been experiencing irregular vaginal bleeding for the last few months. The histology following a hysteroscopy and curettage shows endometrial hyperplasia with mild cellular atypia and segments of a benign endometrial polyp. She has been sterilised and her last routine cervical smear was normal.
Hysterectomy with bilateral salpingo-oophorectomy.
149
A 34-year-old woman, P3, presents with some vaginal bleeding at 16 weeks of gestation and a pelvic ultrasound scan confirms a diagnosis of a partial molar pregnancy. On examination the uterus is palpated at the level of the umbilicus; the cervix looks normal and is closed; there is fresh blood and clots in the vaginal. Investigation results are as follows:
full blood count: haemoglobin 9.2 g/l, otherwise normal
liver and renal function tests normal
blood group: AB Rh positive
serum hCG: 148 457 IU/l; TSH: 3.1 mU/l
Medical evacuation of the uterus.
The next issue is that it is 16 weeks' gestation. The Green-Top Guideline states "Suction curettage is the method of choice for parrial molar pregnancies except when the size of the fetal parts deters the use of suction curettage and then medical evacuation can be used".
150
A 24-year-old parous woman presents with some vaginal bleeding at 10 weeks of gestation and a pelvic ultrasound scan indicates a diagnosis of a molar pregnancy. On examination the uterus is 14-week sized; the cervix looks normal and is closed; there is fresh blood and clots in the vagina. Investigation results are as follows:
full blood count: haemoglobin 10.2 g/l, otherwise normal
liver and renal function tests: normal
blood group: AB Rh negative
serum hCG: 148 457 IU/l; TSH: 1.9 mU/l
Suction evacuation of the uterus.
The uterus needs to be emptied as safely (experienced operator) and as quickly as possible to avoid significant haemorrhage. The Green-Top Guideline states that prolonged cervical preparation, particularly with prostaglandins should be avoided. Here the woman is parous and a very difficult entry through the cervix into the uterus without preparation is not anticipated. Anti-D immuno-prophylaxis is recommended for Rhesus-negative woman despite there being no fetal issue in a complete mole in case the histology, obtained at a later time, reveals a partial mole that does have fetal red cell antigens.
151
A 27-year-old woman, P1, presents with heavy vaginal bleeding and crampy period-like pains after evacuation of the uterus for molar pregnancy at 12 weeks of gestation. On examination she looks pale; her blood pressure is 100/60 mmHg; pulse rate, 104 beats per minute; the uterus is 8-week sized; the cervix is open and there is a lot fresh blood and clots in the vagina. Investigation results are as follows:
full blood count: haemoglobin 7.9 g/l, otherwise normal
hCG 8125 IU/l
blood group: O Rh positive
Suction evacuation of the uterus.
The answer is suction evacuation of the uterus. While repeat evacuation of the uterus when the hCG is more than 5000 IU/l seems to have little benefit, this is an emergency situation and emergency care suggests that an evacuation of the uterus would be preferable in the treatment than uterotonic drugs that may facilitate embolisation of trophoblast.
152
A 39-year-old woman, P4, presents at 10 weeks of gestation with recurrent vomiting. On examination, the uterus is palpated at approximately 16-week sized. A pelvic ultrasound scan indicates a twin pregnancy with a likely diagnosis of a partial molar pregnancy in one of the twins. Investigation results are as follows:
full blood count: haemoglobin 9.2 g/l, otherwise normal
liver and renal function tests: normal
blood group: AB Rh positive
serum hCG: 348 457 IU/l;
thyroid function – free T4: 26 pmol/l; free T3: 6.3 pmol/l; TSH <0.1 mU/l
Prenatal invasive testing for fetal karyotype.
Karyotyping (for triplody) is recommended when there is doubt (likely) about the normality of one of the pregnancies and the result will enable informed management recommendations with realistic predictions of fetal outcomes. It is impossible to give an irrefutable diagnosis of a partial molar pregnancy on scan alone.
153
A 23-year-old woman presents with ongoing prolonged vaginal bleeding 2 weeks after an evacuation of the uterus for a partial hydatidiform mole. Investigation results are as follows:
full blood count: haemoglobin 10.2 g/l, otherwise normal
blood group: AB Rh positive
serum hCG: 4170 IU/l
ultrasound scan: 15 mm × 15 mm × 10 mm area of tissue in the cavity at the uterine fundus
thyroid function: normal
Suction evacuation of the uterus.
In this case, the woman is symptomatic, has small discrete tissue and an hCG of less than 5000 U/l with a partial mole. Pragmatically, this is one case when a repeat evacuation would be useful.
154
Women with atypical endometrial hyperplasia refuses hysterectomy. What is your next step?
Endometrial biopsy in 3 months.
155
What is the recurrence rate of shoulder dystocia?
10-fold.
156
A 32-year old nulliparous with BMI 30 comes for fertility treatment. You notice she has endometrial hyperplasia without atypica 12 months ago. What is your next step?
Outpatient hysteroscopy and biopsy as urgent.
157
What is the incidence of uterine rupture before labour in the case of previous scar with classical uterine incision?
2%
158
Patient is in second stage of labour and you want to infiltrate the perineum with lidocaine without vasopressin. How much do you give?
3mg/kg
Lidocaine - 3mg/kg (7mg/kg with adrenaline) to max dose 200mg (500mg with adrenaline)
Bupivacaine 2mg/kg (max dose 150mg)
159
What is the rate of infra-umbilical adhesions after midline incision in a laparotomy?
75%
No previous operation - 0.5%
Pfannenstiel incision - 23%
160
A 45 year old complains of vaginal bleeding and biopsies were taken; biopsy shows there is endometrial hyperplasia with atypic. She is refusing surgery and what to follow up. How do you follow this patient up?
3 months time.
161
What is the risk of postpartum psychosis for a pregnant woman with bipolar disorder?
1:4 (25%)
If previous postpartum psychosis, risk is 50%.
35-65% of women with postpartum psychosis will develop bipolar disorder.
162
A 32 year old woman in labour is noted to have multiple shallow ulcers. What is the percentage of the risk of Herpes simplex virus transmission to the fetus in the 3rd trimester in a patient who wants a vaginal delivery?
40-50%
Risk of neonatal herpes with vaginal delivery in recurrent herpes is 0-3%. In primary herpes infection, it is around 41%. You can offer vaginal delivery in recurrent herpes.
Pregnant woman with chickenpox:
- Immediately contact GP.
- Avoid contact with susceptible individuals until lesions have crusted over, usually about 5 days from onset of rash.
- Symptomatic treatment and hygiene to prevent secondary bacterial infection of lesions.
- Oral acyclovir 800mg five times a day for 7 days. If women present within 24 hours of onset of rash and if >20 weeks gestation. Theoretical risk of teratogenicity if taken < 20 weeks gestation.
163
A 26 year old woman comes to antenatal clinic at 14 weeks gestation with a PMH of two consecutive first trimester miscarriages. USS shows cervical length of 10mm. What is your management?
Do serial USS.
164
A 65 year old presents to A&E complaining of vaginal bleeding. TAH + BSO was done and results shows there is an endometrial cancer stage 1 with invasion of endometrium less than 50%. What is the next step?
No need for treatment.
165
The RCOG exam has two components, written and OSCE. How would you describe both components?
Summative - Summative
166
A 34 year old delivered by SNVD which was complicated by infection. In sepsis which analgesics are to be avoided?
NSAIDs
167
The commonest site for uterine perforation during surgical evacuation is?
Anterior uterine wall - 40%
Cervical canal 36%
Right lateral wall - 21%
Most common instruments to cause perforation:
Suction cannula - 51%
Hegar dilater - 24%
168
Pregnant women with hypermesis coming into A&E are given what as the first line of treatment?
Cyclizine 50mg PO IM or IV over 8 hours.
Other first line agents:
Prochlorperazine 5-10mg 6-8 hourly PO; 12.5mg 8 hourly IM/IV; 25mg PR daily.
Promethazine 12.5-25mg 4-8 hourly PO/IM/IV/PR
Chlorpromazine 10-25mg 4-6 hourly PO/IV/IM; 50-100mg PR 6-8 hourly.
Second line:
Metoclopramide 5-10mg 8 hourly PO/IV/IM (max 5 days)
Domperidone 10mg 8 hourly PO; 30-60mg PR 8 hourly.
Ondansetron 4-8mg 6-8 hourly PO; 8 mg over 15 minutes 12 hourly IV
Third line:
Corticosteorids: Hydrocortisone 100mg BD IV and once symptoms improve convert to Prednisolone 40-50mg daily PO gradually tapered.
169
How are the different PUQE scores managed?
Pregnancy-Unique Quantification of Emesis and Nausea. Max score = 15
PUQE 3-12 and nil complications:
Antiemetics in community
Lifestyle and dietary changes
PUQE 13 and above and nil complications and not refractory to anti-emetics:
Ambulatory daycare management until no ketone-uria
- Fast IV fluids with normal saline + potassium
- Anti-emetics + thiamine
PUQE of any score with complications or unsuccessful ambulatory daycare management:
- inpatient management
- As for ambulatory daycare management plus: VTE medication, consider steroids, MDT approach
170
What is the role of Mifepristone for IOL in intra uterine fetal death?
Reduced time interval.
171
A 56 year old woman is found to have a 6cm left ovarian multi-locular cyst with solid nodules. Ca-125 = 65. What is the RMI?
585
RMI = ultrasound score x CA-125 x menopausal state
USS score = 1 point for each of the following characteristics - multilocular cysts, solid areas, metastases, ascites and bilateral lesions. U = 0 for an ultrasound score of 0; U = 1 for an ultrasound score of 1; U = 3 for an ultrasound score of 2-5.
Menopausal status = 1 = premenopausal and 3 = postmenopausal.
172
What are the characteristics of a simple cyst on TVUS?
- round or oval shape
- thin or imperceptible wall
- posterior acoustic enhancement
- anechoic fluid
- absence of separations or nodules
USS identification of a simple cyst establishes a benign process in 95-99% of postmenopausal women.
173
What are the characteristics of a complex cyst on TVUS?
- complete separation (i.e. multilocular cyst)
- solid nodules
- papillary projections
174
A pregnant woman in the first trimester who complains of amenorrhea. How will you calculate the gestational age from the scan findings of CRL 94, HC 111, AC 32, BPD 24?
HC
175
Uterine sarcoma was diagnosed on histopathology of a patient who had TAH + BSO for fibroid uterus. What will be your advice?
PET scan.
176
Primigravida at 33 weeks presents with primary herpes at 34 weeks gestation. What is your management?
Acyclovir 400mg TDS until delivery by C-section.
177
A 37 year old pregnant woman at 14 weeks gestation is referred by her midwife to consultant clinic with results of down's screening as NT 1.3, AFP 1.06 (all was normal). What is the next step?
Reassurance.
178
What is the most common complication of PCOS?
Obstructive sleep apnea. 30-fold increase in PCOS patients.
179
A 38 year old has the following results: FSH 30. Which important investigation do you need for her diagnosis?
Repeat FSH.
High FSH levels >20 on two occasions are suggestive of premature ovarian failure in women < 40. Low or normal FSH levels are found with weight loss, stress and excessive exercise. Increased LH/FSH ratio is found in PCOS - 2:1 or 3:1 ratio.
Definition - 4 months of amenorrhoea and two FSH levels of 30 or higher at an interval of at least 1 month. Ovarian follicular function fluctuates in about 50% of women with POF and 5-10% of women may eventually conceive.
180
Regarding chlamydia investigations, what are the most sensitive swabs?
Vulvovaginal swabs. A NAAT swab should be inserted approximately 5cm into the vagina and rotated for between 10-30 seconds.
181
What is the most common cause for transfer from midwifery to consultant led unit?
Delay during first or second stage of labour.
Second: abnormal fetal heart rate
Third: request for regional analgesia
182
What is the strongest predictive factor of gestational diabetes?
Previous gestational diabetes.
- 2 hour 75g OGTT is gold standard.
- Women who have had previous GDM - early self monitoring of BG or OGTT as soon as possible after booking and further OGTT at 24-28 weeks if results of first one are normal.
183
An HIV positive pregnant patient on HAART with a viral load of 36 SROMs at 35 weeks. What is the management?
Immediate IOL.
- In all cases of term pre-labour SROM delivery within 24 hours is indicated.
- If viral load < 50 - immediate IOL recommended who have pre-labour SROM with delivery indicated within 24 hours.
- If viral load 50-399 immediate CS is recommended but should take into account actual viral load, trajectory of viral load, women's wishes, length of time on treatment, adherence issues, obstetric factors.
- If viral load >399, immediate CS.
184
Where does the bleeding come from in an abruption?
Decidua basassi
185
A patient is a known Jehovah's witness who has a severe PPH. O/E she is pale, pulse 110, BP 65/45 and she has signed an advanced directive but has now lost consciousness and her husband requests to give her a blood transfusion. What will be your action?
Adhere to the advanced directive.
Advanced directives:
- Up to date
- Specific situation
- Made when patient had capacity
- Signed and witnessed
- If treatment refused, AD must have included phrase "even if my life is at risk."
Lasting power of attorney:
- registered with office of public guardian
- Proxy consent and refusal both valid
- LPA revoked if person not acting in patient's best interests and if there is a disagreement between them and healthcare professional then a second opinion is sought or court of protection.
Best interests decision
- Patient's views
- Family discussion (views considered but NOT determinate)
186
A 17 year old girl is a Jehovah's witness and at 39 weeks gestation does not want to receive any blood products even if she ends up in a life threatening situation. There is an advanced directive in place. What do you do?
Get court advice.
If a young person refuses treatment, which may lead to their death or a severe permanent injury, this can be overruled by the court of protection. This is the legal body that oversees the operation of the mental capacity act 2005.
187
A patient has been sexually assaulted and she came to hospital 3 days after. What are the absolute minimum samples required in a case of sexual assault if your consultant was busy and the police are waiting for intervention?
Vaginal and rectal swabs.
- Oral swab within 2 days.
- Anal swab with 3 days.
- Vaginal swab within 7 days.
- Toxicology screen will be sent from blood within 3 days and from urine within 14 days if a drug-facilitated crime is suspected.
188
A 57-year old patient presented to the ED with a 3-day history of severe watery diarrhea, nausea, vomiting. Her mental status had deteriorated. Blood gas analysis revealed severe, high anion gap metabolic lactic acidosis: pH <7.2, bicarbonate 2, O2 sats normal, Co2 normal, marked reduction in bicarbonate <10 with a lactate concentration >5. What is your diagnosis?
Metabolic acidosis sepsis.
189
What is the commonest cause of anaphylactic shock in the UK?
IV antibiotics.
190
Patient underwent a CS and uterus excised vertically. What's the most common site in future of uterine wall rupture?
Scare dehiscence pre-labour.
191
Pre-term labour at 31 weeks, delivered vaginally. Postnatally, early imaging done for the newborn. What is the most specific lesion of severe Hypoxic-ischemic encephalopathy to predict long term neurodevelopment outcome?
Periventricular leukomalacia.
192
A study was conducted by an ST5 to compare between 2 groups using 2 different mesh techniques to see the effects. What is a suitable test?
Chi-squared test.
193
A patient with a rectal mucosa injury - what is the most suitable suture?
Continuous with 3-polyglycin.
Site
Anal mucosa - continuous or interrupted with 3-polyglycin
EAS - end to end with monofilament (e.g. 3.0 PDS) or modern braided (e.g. 2.0 polyglactin - vicryl)
IAS - interrupted mattress with monofilament (e.g. 3.0 PDS) or modern braided (e.g. 2.0 polyglactin - vicryl).
- Burying of surgical knots beneath the superficial perineal muscles is recommended to minimize the risk of knot and suture migration to the skin.
194
A pregnant patient with her son has contacted influenza. What is the first line treatment?
Oseltamivir (tamiflu)
Two regimens recommended: Zanamivir 10mg inhaler daily OR Oseltamivir 75mg PO daily.
195
Pregnant lady at 8 weeks of gestation has a past history of contact with a patient with rubella. Investigations were done and the result shows IgM antibodies positive. What is the management?
Counsel to terminate pregnancy.
Rubella is more likely to infect the fetus earlier in pregnancy.
- If in the first 12 weeks of pregnancy, the fetus has about a 9 in 10 chance (85%) of getting infected.
- If at 13-16 weeks, fetus has about a 1:2 chance (50%).
If at the end of second trimester or later, fetus has about a 1:4 change (25%).
