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1

A 26-year-old multigravid woman is in spontaneous labour at 41 weeks. She has no antenatal risk factors with normal ultrasound scans. On examination, the head is 2/5th palpable per abdomen. She has a spontaneous rupture of membranes at 3 cm with heavily blood-stained liquor. The CTG shows significant abnormalities. The midwife performs a vaginal examination and there is no cord protruding through the cervix which is now 4 cm dilated. The mother feels no pain.
What is the most likely diagnosis?
A. Bloody show
B. Placental abruption
C. Placenta praevia
D. Uterine rupture
E. Vasa praevia

Vasa praevia -
The risk of vessels tearing is greatest when cervical dilation occurs and at rupture of membranes. A severely abnormal cardiotocograph (CTG) is seen with a small amount (,500mL) of painless vaginal blood loss. Because it is fetal blood that is lost in vasa praevia, fetal mortality is very high (35–95%) while there is little risk to the mother. A Caesarean section must be performed immediately and the neonate transfused. There is no specific investigation for vasa praevia, so the diagnosis is clinical and only confirmed when the placenta and membranes are examined after Caesarean section.

2

Which of the following conditions is an indication for routine delivery by Caesarean section?
A. Hepatitis C virus
B. Maternal request
C. Preterm birth
D. Previous Caesarean section
E. Twin pregnancy with first twin breech and second twin cephalic

Twin pregnancy with first twin breech and second twin cephalic -
A Caesarean section should be routinely offered to the following women:
† HIV with or without other concurrent infections
† Primary genital herpes in the third trimester (NB not a secondary attack)
† Placenta praevia major, i.e. grade 3 or 4
† Twin pregnancy where the first baby is breech
† Singleton breech at term but only after external cephalic version has been
offered and failed or contraindicated

These women should not routinely be offered a Caesarean section:
† Twin pregnancy where the first twin is cephalic
† Preterm birth
† Small for gestational age baby
† Hepatitis B virus without HIV
† Hepatitis C virus without HIV
† Recurrent genital herpes at term

3

A 25-year-old woman attends the GUM clinic complaining of increased vaginal discharge which has an unpleasant odour. She says sexual intercourse with her partner is uncomfortable. A swab is taken and sent to the lab. On direct microscopy a flagellated protozoan is seen.
Which is the most likely pathogen?
A. Candida albicans
B. Chlamydia trachomatis
C. Gardnerella vaginalis
D. Neisseria gonorrhoeae
E. Trichomonas vaginalis

Trichomonas vaginalis -
Trichomoniasis is a sexually transmitted infection caused by the flagellated protozoan Trichomonas vaginalis, which invades superficial epithelial cells of the vagina, urethra, glans penis, prostate and seminal vesicles. Affected females present with an offensive frothy greeny-grey discharge, vulval soreness, dyspareunia, dysuria, vaginitis and vulvitis, although some are asymptomatic. On examination, the cervix may have a punctate erythematous (strawberry) appearance. Males are mostly asymptomatic. Diagnosis is by direct microscopy or culture of vaginal exudate. Treatment is with metronidazole.

4

A 57-year-old woman presents with a history of having to run to the toilet and occasionally not getting there in time. She needs to wear pads every day and this is negatively impacting on her life. She also complains of waking up two or three times per night to pass urine. She has had two children by normal delivery and has never had any surgery on her bladder. She says she has been doing occasional pelvic floor exercises with little success.
Considering her diagnosis, what is the first-line treatment?
A. Bladder training
B. Botulinum toxin
C. Oxybutynin
D. Pelvic floor exercises with a trained physiotherapist
E. Tolteridone

Bladder training -
This lady is suffering from an overactive bladder (OAB), also known as detrusor instability, unstable bladder or hyperactive bladder. First-line treatment is bladder training for 6 weeks.

5

You are looking at a CTG of a woman of 39 weeks gestation who has come to the antenatal day unit as she has had reduced fetal movements. There is a baseline rate of 170. There are four accelerations in a 20-minute section. The variability is over 10 beats. There are no decelerations.
What could explain the features of this trace?
A. Maternal pyrexia
B. Normal trace
C. Pre-terminal trace
D. Sleep pattern of fetus
E. Thumb sucking of fetus

Maternal pyrexia

6

You are examining a woman in established labour with the midwife and she asks you to tell her how you would describe the examination. The cervix is fully dilated. Anteriorly you feel a diamond-shaped fontanelle and if you follow a line posteriorly you can then feel a Y-shaped depression in the skull bones.
How is the position best described?
A. Brow
B. Left occipitotransverse
C. Occipitoanterior
D. Occipitoposterior
E. Right occipitotransverse

Occipitoposterior

7

In which anatomical location does fertilization normally occur?
A. Ampulla of fallopian tube
B. Cervix
C. Fimbriae of fallopian tube
D. Infundibulum of fallopian tube E. Uterus

Ampulla of fallopian tube

8

A 21-year-old lady at 40 weeks þ 12 days is being induced. She has received two doses of prostaglandins after examination revealed a low Bishop score. She is experiencing mild contractions with good fetal movements. Her CTG trace is reactive. She is fed up, tired and is becoming angry with the midwives as she thought she would have delivered sooner. On abdominal palpation there is cephalic presentation with two-fifths palpable. On vaginal examination after the second dose of progesterone she is 3 cm dilated with a partially effaced cervix.
What would be the next course of action?
A. Artificial rupture of membranes
B. Caesarean section
C. Further prostaglandin
D. Observation alone
E. Oxytocin

Artificial rupture of membranes -
Induction of labour is offered if pregnancy continues past 40 weeks þ 12 days. The process involves vaginal prostaglandins with artificial rupture of membranes (ARM) and use of oxytocin. This lady has received two doses of vaginal prostaglandins (PGE2) to initiate contractions and encourage cervical ripening. The tablets are 3 mg and are given 6–8 hourly with a maximum dose of 6mg/day. They have clearly worked as she has progressed from a low Bishop score to a cervical dilation of 3 cm. If women are progressing well with strong contractions no other action is needed, however if there is slow progress with minimal contractions (in this case) an ARM can be performed and an oxytocin infusion is used to maintain the contractions after membrane rupture. Further prostaglandins are contraindi- cated due to the risk of hyperstimulation as she already feels some uterine activity.

9

Which measurement is the most reliable indicator of gestational age in the first trimester?
A. Biophysical profile
B. Biparietal diameter
C. Crown–rump length
D. Femur length
E. Nuchal translucency

Crown–rump length

10

A 32-year-old lady returns to the gynaecology clinic to find out the results of her cervical screening test. You see her report says moderate dyskaryosis.
What would be the next stage in her management?
A. Colposcopy
B. Recall in 6 months
C. Recall in 1 year
D. Recall in 3 years
E. Repeat the test today

Colposcopy -
If a woman aged 25 to 49 years has a normal smear they are called back in 3 years. A woman may be recalled if there are inadequate cells for the study – this would normally be in 6 months. If a diagnosis of mild dyskaryosis is made a repeat is needed in 6 months as these cells often revert to normal without any treatment. If on the repeat test at 6 months the cells still show mild dyskar- yosis, colposcopy will be required. A single diagnosis of moderate or severe dyskaryosis indicates referral to colposcopy. Obviously a diagnosis of invasive carcinoma would require immediate specialist referral. Immunocompromised patients require annual screening.

11

Which one of the following factors increases your risk of developing ovarian cancer?
A. Early menopause
B. Late menarche
C. Multiparity
D. Nulliparity
E. Oral contraceptive pill

Nulliparity -
Like all cancers there are numerous risk factors for its development. It may be related to ovulation, due to the repair of the ovarian epithelium required follow- ing each ovulation. This means the more you ovulate the more you increase your risk of developing cancer of the ovary. Hence nulliparity, infertility, late meno- pause and early menarche all increase your risk, whereas risk is lowered by the contraceptive pill, breastfeeding and pregnancy. Pelvic surgery decreases the risk (including hysterectomy, unilateral oophorectomy and sterilization) for reasons that are not fully understood.
The risk of ovarian cancer is slightly increased with a positive family history and this much more significant if there was early onset and more than one primary relative affected. Around 5 to 10% of ovarian cancers have a direct genetic link with the most significant being BRCA1 and BRCA2. Affected women have a life- time risk of up to 50% of developing ovarian cancer, hence close monitoring is needed using CA125 and pelvic ultrasounds.

12

A 22-year-old woman attends the labour ward for induction of labour as she is 40 weeks þ 12 days. She has had an uncomplicated pregnancy. She has no pain in her abdomen and says that the baby is moving but less than normal. A CTG is performed and the baseline is 135, variability is over 10, accelerations are present and there are no decelerations. You examine her and find a cephalic presentation and a long and closed cervix.
What would you like to do next?
A. Artificial rupture of membranes
B. Elective Caesarean section
C. Emergency Caesarean section
D. Oxytocin
E. Prostaglandin

Prostaglandin -
Prior to IOL the woman’s cervix should be assessed using the Bishop score. If the Bishop score is very low, like this case, IOL involves vaginal prostaglandins (PGE2) as either tablets or gels to initiate contractions and encourage cervical ripening. The tablets are 3 mg and are given 6 to 8 hourly with a maximum dose of 6 mg. The CTG has to be reassuring for prostaglandins to be given and there should be no pain or evidence of contractions otherwise you increase the risk of uterine hyperstimulation.
If women are progressing well they can be left to labour; however, if there is slow progress or the cervix is already dilated on initial examination an artificial rupture of membranes can be performed along with an oxytocin infusion to maintain the contractions. If there has been pre-labour rupture of membranes, the oxytocin can be started regardless of the state of the cervix.

13

A 27-year-old woman is of 19 weeks gestation. She has a 3-day history of flu-like symptoms with a macular rash over her body. Her doctor takes serological testing. When he has the results he tells her that her baby is at increased risk of sensorineural deafness, cataracts, congenital heart disease, learning difficulties, hepatosplenomegaly and microcephaly.
What is the underlying causative agent?
A. Chickenpox
B. Cytomegalovirus C. Listeria
D. Parvovirus
E. Rubella

Rubella -
Women develop a non-specific flu-like illness with a macular rash covering their trunk (20 to 50% infections are asymptomatic). Diagnosis is confirmed by serological anti- body testing. Rubella antibodies are checked at booking and postnatal vacci- nation is offered to those with low titres. There is an 80% risk of infection to the fetus if rubella develops in the first trimester, dropping to 25% at the end of the second trimester. Teratogenic effects are worse at earlier gestations, with a 50% risk of abnormalities if the fetus is under 4 weeks, 25% at 5 – 8 weeks, 10% at 9–12 weeks and 1% over 13 weeks. The characteristic abnormalities from maternal rubella infection are sensorineural deafness, cataracts, congenital heart disease, learning difficulties, hepatosplenomegaly, jaundice, microcephaly and spontaneous miscarriage.

14

The midwife is delivering a term baby. The head has been delivered. Which movement should the midwife wait for before delivering the shoulders?
A. Descent
B. Extension
C. External rotation
D. Flexion
E. Internal rotation

External rotation -
Stages of labour: Descent – literally descent of the head into the pelvis which usually occurs in the last few weeks of pregnancy in a nulliparous woman but much later in multiparous women
† Engagement – when the maximum transverse diameter of the head has passed below the pelvic inlet. Engagement is when less than two-fifths of the head can be palpated above the pelvic brim abdominally
† Flexion – as the head descends through the pelvis it flexes to give the smallest diameter for easy passage through the pelvis. The posterior fonta- nelle should be palpable vaginally with maximum flexion
† Internal rotation – this is the rotation of the head that occurs in the mid-pelvis from the left occiput transverse (LOT) position it enters the pelvic inlet to the OA position required for easy delivery
† Extension–the head only extends as it reaches the perineum and ‘crowns’ as delivery is imminent
† External rotation (restitution) – on delivery the fetal head reverts back to its earlier transverse position
† Lateral flexion – this is the movement needed for the shoulders and trunk to be delivered

15

Which of the following hormones stimulate the growth of primary follicles?
A. Activin
B. Follicle-stimulating hormone
C. Inhibin
D. Oestrogen
E. Progesterone

Follicle-stimulating hormone -
The action of FSH along with LH is to stimulate the growth of 6–12 primary follicles each month during the follicular phase of the cycle (days 1 to 14). As the follicles mature there is a rise in oestrogen due to increased production from the granulosa cells of the developing follicles and this increase in oestrogen inhibits the release of FSH and LH (negative feedback). This mechanism avoids hyperstimulation of the ovary and the resultant maturation of multiple follicles. Thus only one of these follicles will reach full maturation at the mid-follicular phase with the others undergoing atresia.

16

A 31-year-old primigravid woman with a body mass index of 31 had a positive glucose tolerance test at 28 weeks consistent with gestational diabetes mellitus. Although she was advised to change her diet she did not do this and her glucose control has been suboptimal. An ultrasound scan demonstrated macrosomia.
Which emergency condition does this put her at a greater risk of?
A. Amniotic fluid embolisation
B. Disseminated intravascular coagulation
C. Shoulder dystocia
D. Uterine inversion
E. Uterine rupture

Shoulder dystocia -
Other risk factors for shoulder dystocia include a past history of dystocia, maternal obesity, prolonged first stage of labour, secondary arrest >8 cm cervical dilation, mid-cavity arrest and forceps/ventouse delivery. Consider shoulder dystocia if the head delivers slowly or with difficulty and the neck does not appear, or if the chin retracts against the perineum (the turtle sign).

17

A 32-year-old woman complains of longstanding painful, heavy periods. She has had two normal vaginal deliveries after difficulty conceiving with both pregnancies. She suffers from significant pain on intercourse. On further questioning she also states she has had occasional rectal bleeding during her menstrual cycle throughout her life. Her past history includes an appendicectomy aged 10. Pelvic examination reveals a fixed retroverted uterus that is tender.
What is the most likely explanation for her pain?
A. Adhesions from surgery
B. Chronic pelvic inflammatory disease
C. Endometriosis
D. Fibroid degeneration
E. Ovarian cyst

Endometriosis -
Endometriosis is the most likely diagnosis, with the typical symptoms of abdomi- nal pain, dyspareunia, secondary dysmenorrhoea and subfertility. Bimanual palpation in this case has revealed a tender fixed uterus but there can also be uterosacral nodules, endometriomas, uterine or ovarian enlargement or adnexal tenderness.

18

A 43-year-old woman has conceived naturally for the first time despite two failed IVF attempts. She is very concerned about Down’s syndrome and would like a test performed as soon as possible that would give a firm diagnosis. She is currently at 11 weeks gestation.
What test would be most appropriate?
A. Amniocentesis
B. Chorionic villus sampling
C. First trimester ultrasound scan
D. Nuchal translucency test
E. Serum triple test

Chorionic villus sampling

19

A 26-year-old woman with a twin pregnancy has developed twin-to-twin transfusion syndrome at 34 weeks gestation.
What type of twins is she likely to have?
A. Dizygotic dichorionic diamniotic
B. Dizygotic dichorionic monoamniotic
C. Dizygotic monochorionic monoamniotic
D. Monozygotic dichorionic diamniotic
E. Monozygotic monochorionic diamniotic

Monozygotic monochorionic diamniotic - Twin-to-twin transfusion is where, due to anastomosis of vessels in the single placental mass of a monochorionic twin pregnancy, one twin gains at the other’s expense. One twin becomes anaemic, hypovolaemic, oligohydramniotic and growth-restricted while the other one develops polycythaemia, hypervolae- mia, polyuria and polyhydramnios. It occurs in varying degrees in up to 35% of monochorionic twins and accounts for 15% of perinatal mortality. Ultrasound scan is used to look at fetal wellbeing and to identify any abnormalities such as liquor volume that may suggest twin-to-twin transfusion. Therapeutic amnio- centesis may be used to reduce the amniotic fluid pressure. Laser ablation of placental vessels can be useful although there are risks of fetal demise or con- genital abnormalities. Vanishing twin syndrome is where a fetus in a multiple- gestation pregnancy dies in utero and is subsequently reabsorbed by the mother (either partially or completely).

20

A 32-year-old woman is 40 weeks þ 6 days and is having induction of labour for mild pre-eclampsia. She has had a total of 6 mg prostaglandin tablets per vagina. On abdominal examination the head is 5/5 palpable and on vaginal examination she is 3 cm dilated with intact membranes and a station of –3. She has mild contractions. The plan is to undertake an artificial rupture of membranes.
Which emergency condition does this put her at a greater risk of?
A. Cervical shock
B. Cord prolapse
C. Shoulder dystocia
D. Uterine inversion
E. Uterine rupture

Cord prolapse -
As seen in this case, cord prolapse is more likely in cases where there is not a close fit between the presenting part and the pelvic inlet such as a high head, malpresentation such as transverse or oblique lie, breech presentation parti- cularly footling breech, prematurity, polyhydramnios and fetal growth restri- ction. It is also seen where there is a long umbilical cord or in a 2nd twin. Of course it can occur without risk factors and a vaginal examination should be done if there are CTG abnormalities after spontaneous rupture of membranes to rule out a cord prolapse.

21

You are asked to examine a woman’s perineum after she has delivered vaginally. You see that the perineal skin and muscles are torn. On examination of the anus, the external anal sphincter is torn but less than 50% so.
What degree of perineal tear has this woman sustained?
A. 1st degree tear
B. 2nd degree tear
C. 3rd degree tear 3a
D. 3rd degree tear 3c
E. 4th degree tear

3rd degree tear 3a -
First degree – injury to perineal skin only. There is no need for routine suturing unless haemostasis is a problem
† Second degree – injury to perineum involving perineal muscles only without involvement of the anal sphincter. These should be sutured to ensure correct apposition of the perineal muscles and skin and to secure haemostasis. Many midwives will suture second degree tears
† Third degree – injury to perineum involving the anal sphincter complex. These must be sutured in theatre with adequate analgesia, spinal or epi- dural top-up, by a trained surgeon normally the obstetric registrar or con- sultant. The anal sphincter must be repaired to avoid incontinence
W 3a – less than 50% external anal sphincter (EAS) thickness torn W 3b – more than 50% EAS thickness torn
W 3c – both EAS and internal anal sphincter (IAS) torn
† Fourth degree – injury to perineum involving the anal sphincter complex and anal epithelium. These must be repaired in theatre by a trained obste- trician with the assistance of a general surgeon if required

22

Which hormone, produced by the corpus luteum, is low in the follicular phase and maximal in the luteal phase?
A. Follicle-stimulating hormone
B. Inhibin
C. Luteinizng hormone
D. Oestradiol
E. Progesterone

Progesterone-
Progesterone is a steroid hormone produced by the corpus luteum. The corpus luteum is the remnant of the Graafian (ovarian) follicle after the oocyte and cumulus oophorus have been expelled. After ovulation the remnants are penetrated by capillaries and fibroblasts while the granulosa cells undergo luteinization to collectively form the corpus luteum (yellow body).

23

A 29-year-old woman is in spontaneous labour at 40 weeks. The CTG is reactive. She has had one previous lower segment Caesarean section. On abdominal examination, the head is 0/5 palpable. On vaginal examination, she has been 10 cm dilated for 20 minutes. There is an occipitoanterior presentation with a flexed head. The head is at station þ1 and there is no caput and no moulding.
How should the baby be delivered?
A. Elective Caesarean section
B. Emergency Caesarean section
C. Kielland’s forceps
D. Normal delivery
E. Neville Barnes forceps

Normal delivery -
This case describes very good conditions for a normal delivery. Most importantly the cardiotocograph is normal so labour can continue without intervention.

24

A 31-year-old pregnant woman was involved in a minor road traffic collision where she banged her abdomen on the steering wheel. Serious injury has been excluded but she is concerned about the baby. She has good fetal movements and has had no bleeding per vagina. The fetal heart is heard and is regular. She is 25 weeks gestation and is RhD negative. She has had no previous children.
What action needs to be taken with regards to anti-D prophylaxis?
A. Give antenatal anti-D prophylaxis 250 iu
B. Give antenatal anti-D prophylaxis 500 iu
C. Give postnatal anti-D
D. Give routine antenatal anti-D prophylaxis at 28 weeks
E. No action needed at present

Give antenatal anti-D prophylaxis 500iu -
The RCOG guidelines describe when anti-D prophylaxis must be given. All women who are RhD –ve are offered anti-D prophylaxis 500 iu at 28 and 34 weeks regardless of sensitizing events or previous administration of anti-D.
RhD –ve women are offered antenatal anti-D prophylaxis at the time of any possible sensitizing event (as described above) where fetal blood could enter the maternal circulation such as antepartum haemorrhage, closed abdominal injury, external cephalic version of the fetus, invasive prenatal diagnosis (amnio- centesis, chorionic villus sampling, fetal blood sampling), other intrauterine pro- cedures (insertion of shunts, embryo reduction) or intrauterine death. The dose is 250 iu before 20 weeks and 500 iu after 20 weeks gestation.

25

You examine a lady who has attended a labour ward for induction of labour at term þ 12 days. She has a cephalic presentation which is three-fifths palpable. The cervix is not dilated at all, is 3 cm long, of average consistency and is in a mid-position. The station is –2.
What is her Bishop score?
A. 0
B. 2
C. 4
D. 6
E. 8

4 -
The Bishop score is a classification system used to describe the ‘favourability’ of the cervix. A higher score is associated with an easier, shorter labour that is less likely to fail. Although it is a universal system it is subject to examiner variation. Therefore the same person should examine the woman to assess progress.

26

A 43-year-old woman has recently been diagnosed with cervical cancer.
Which of the following are risk factors for the development of cervical cancer?
A. Early menarche
B. Early menopause
C. Increased number of sexual partners
D. Nulliparity
E. Progesterone-only pill

Increased number of sexual partners -
Other risks include smoking and the oral contraceptive pill

27

A 39-year-old primigravid woman who has had no antenatal care attends a labour ward at 39 weeks gestation. She complains of heavy, unprovoked, painless vaginal bleeding. On examination, she has a soft non-tender abdomen and the head is not engaged. She is passing clots per vagina. She has a pulse rate of 112/min and her blood pressure is 96/56 mmHg. The CTG is non-reassuring.
What is the most likely diagnosis?
A. Cervical ectropion
B. Placental abruption
C. Placenta praevia
D. Uterine rupture
E. Vasa praevia

Placenta praevia -
Clinically, there is sudden-onset painless unprovoked or postcoital fresh red blood per vagina in the second or third trimester. On abdominal examination there is a soft non-tender uterus with a high head or malpresentation as the placenta blocks the passage of the presenting part into the pelvis. The clinical condition of the mother correlates with the visible blood loss (unlike uterine abruption). Maternal blood is lost so there is little risk to the fetus unless the mother becomes hypovolaemic.

28

A 23-year-old woman with a positive pregnancy test complains of lower abdominal cramping with what she describes as a period-type bleed at home. On abdominal palpation there is mild suprapubic discomfort. On speculum examination a small amount of blood is seen in the vagina and the cervical os is closed. Urine dipstick is unremarkable.
What is the most likely diagnosis?
A. Complete miscarriage
B. Incomplete miscarriage
C. Inevitable miscarriage
D. Menstruation
E. Threatened miscarriage

Threatened miscarriage -
This scenario describes a threatened miscarriage. There can be cramping lower abdominal pain with vaginal bleeding. On examination the cervical os is closed. Only 25% of threatened miscarriages eventually miscarry. A scan should be arranged to investigate the bleeding and to confirm the viability of the pregnancy. This can be done in an early pregnancy assessment unit.

29

A 34-year-old woman who has had four previous normal deliveries attends the antenatal day unit at 40 weeks complaining of abdominal pain asso- ciated with fevers and sweating. Initially she thought she was in labour as she had spontaneous rupture of membranes four days ago, but she says the pain has become increasingly worse. On examination, her uterus is very tender and the cervix is long and closed with an associated yellow– green discharge. Her temperature is 39.78C. She has raised white cell count and C-reactive protein.
What is the likely diagnosis?
A. Abruption
B. Acute pyelonephritis
C. Chorioamnionitis
D. Uterine rupture
E. Urinary tract infection

Chorioamnionitis - Chorioamnionitis is infection of the amniotic cavity and the chorioamniotic membranes. Causative pathogens include Escherichia coli, Streptococcus and Enterococcus faecalis. Both mother and fetus can develop potentially life- threatening septicaemia. It is normally seen after rupture of membranes parti- cularly if this has been over a prolonged period of time, although it can occur with intact membranes. Other risk factors include prolonged labour, preterm labour, internal fetal monitoring, cervical examinations or urinary tract or vaginal infection.
A woman with chorioamnionitis presents with abdominal pain, uterine tender- ness, maternal pyrexia and tachycardia, raised C-reactive protein and white cell count, meconium or foul smelling liquor. There could be fetal tachycardia or a non-reassuring cardiotocograph. If there is any suspicion of chorioamnionitis the baby must be delivered without delay (ideally by Caesarean section unless labour is well-established). Antibiotics are needed for the mother and baby and the paediatricians should be present at the delivery.

30

A 33-year-old woman attends the emergency department complaining of an aching pain in her left iliac fossa. This has been present intermittently for a few months. She says the pain is significantly worse today but remains focused in the left iliac fossa. She has vomited four times. She denies being sexually active. On examination, she is tender in the left iliac fossa with some voluntary guarding. Speculum examination revealed no abnormalities. There is left adnexal tenderness on vaginal examination but no cervical excitation. Her observations show heart rate 112/min, blood pressure 98/62 mmHg and temperature 36.88C. A urine result is awaited.
What is the most likely diagnosis?
A. Appendicitis
B. Mittelschmerz
C. Ovarian cyst torsion
D. Pelvic inflammatory disease
E. Renal colic

Ovarian cyst torsion -
This case describes an intermittent ovarian cyst torsion which has become an acute problem. Torsion of an ovarian cyst results in a sudden-onset severe, unilateral, colicky or twisting pain with intermittent pain if torsion is incomplete. Vomiting is common and tachycardia, hypotension and pyrexia are found on examination. This must not be missed as delay can lead to irreversible ischaemia of the ovary. An urgent laparoscopy is needed where a cystectomy may be com- pleted, but signs of ischaemia or necrosis warrant oophorectomy.