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What are the commonly prescribed drugs that should be avoided in breastfeeding women?


- Ciprofloxacin

- Tetracycline

- Chloramphenicol

- Sulphonamides

- Nitrofurantoin

Psychiatric drugs:

- Lithium

- Benzodiazepines

- Clozapine




Cytotoxic drugs



A 32-year-old 1 week post-partum female presents to her local emergency department with a few days history of vaginal bleeding: initially bright red blood which has now changed in colour to become brown. She is changing her sanitary pads once every 3 hours and is worried that the caesarean section birth has caused damage to her womb. On examination she is visibly distressed but afebrile. She is normotensive with a heart rate of 95 beats per minute and a respiratory rate of 19 breaths per minute. Abdominal examination does not cause pain and reveals a caesarean section scar which is pink and not tender. What is the most appropriate management at this stage?

Reassure, advise and discharge

Insert two large bore cannula and send blood for cross matching

Start immediate IV broad spectrum antibiotics

Refer for exploratory laparoscopy

Admit for IV fluids and observations

Reassure, advise and discharge

This patient is describing lochia, the bleeding that presents for the first 2 weeks (can be up to 6 weeks) following giving birth, whether this is by vaginal birth or caesarian section. Due to the higher risk of post-partum haemorrhage in caesarian section however, a detailed history and examination should take place in this case for any concerning features.

Lochia typically takes the course of fresh bleeding, which undergoes colour changes before finally stopping. The patient can be reassured and advice should be given to her regarding lochia. Specifically, she should be told that if this begins to smell badly, its volume increases or it doesn't stop, she should seek medical help. In this case the volume is not excessive and there are no concerning features to the lochia or abnormal observations.


A 29-year-old woman presents with right iliac fossa pain. She has a past medical history of an ectopic 8 months previously with right sided salpingectomy. She had an ultrasound scan 3 days previously which demonstrated a viable intrauterine pregnancy. Clinically she is Rovsing sign positive with raised inflammatory markers. What is the most likely diagnosis?

Adnexal torsion



Mesenteric adenitis

Ovarian torsion

Rovsing sign = Appendicitis


A 29 year-old woman visits her general practitioner to discuss smoking cessation, having just discovered that she is ten weeks pregnant. She has tried to give up several times in the past using motivational interviewing sessions but was unsuccessful. She wants to know if there are any medications that might help her. Which of the following could be prescribed for this purpose?




Nicotine replacement patch


Nicotine replacement patch


Which one of the following statements regarding cervical ectropion is incorrect?

Describes an increased area of columnar epithelium

May result in post-coital bleeding

Is less common in women who use the combined oral contraceptive pill

May result in excessive vaginal discharge

Is more common during pregnancy

Is less common in women who use the combined oral contraceptive pill

On the ectocervix there is a transformation zone where the stratified squamous epithelium meets the columnar epithelium of the cervical canal. Elevated oestrogen levels (ovulatory phase, pregnancy, combined oral contraceptive pill use) result in larger area of columnar epithelium being present on the ectocervix

This may result in vaginal discharge and post-coital bleeding

Ablative treatment (for example 'cold coagulation') is only used for troublesome symptoms


Which one of the following is not a recognised adverse effect of the combined oral contraceptive pill?

Increased risk of ovarian cancer

Increased risk of deep vein thrombosis

Increased risk of breast cancer

Increased risk of ischaemic heart disease

Increased risk of cervical cancer

Increased risk of ovarian cancer


A 26 year old woman is found to be hypertensive with a blood pressure of 155/110 mmHg during labour for her first baby at 39 weeks. Urinalysis shows +++ protein. Which of these is the most appropriate way to manage her hypertension?

Administer lisinopril with target diastolic blood pressure 80-100 mmHg

Administer aspirin and intramuscular steroids

Administer intravenous nifedipine with target diastolic blood pressure

Administer intravenous labetalol with target diastolic blood pressure 80-100 mmHg


A woman who is 36 weeks pregnant is reviewed. This is her first pregnancy. Her baby is known to currently lie in a breech presentation. What is the most appropriate management?

Reassure mother baby will most likely turn to a cephalic presentation prior to delivery

Refer for external cephalic version

Admit for induction of labour and trial of vaginal delivery

Refer for radiological pelvimetry

Admit for caesarean section

Refer for external cephalic version

If less than 36 weeks you can reassure and reassess at 36 weeks. Once you hit 36 weeks, ECV should be attempted


Which of these is a possible indication for induction of labour?

Bishop's score of 7

Previous induced labour

Uncomplicated pregnancy at 41 weeks gestation

Fetal growth restriction (FGR)

Breech position

Uncomplicated pregnancy at 41 weeks gestation

Women should be offered induction between 41-42 weeks of an uncomplicated pregnancy to avoid risks of prolonged pregnancy.


A 33-year-old primigravida woman of 32 weeks gestation presents to the Emergency Department with premature rupture of membranes. There have been no complications of the pregnancy so far and the woman is normally fit and well. How is she best managed?

Inform her that she should come back if she feels she is getting a temperature

Prescribe her antibiotics and inform her to come back if she feels she is getting a temperature

Admit her for at least 48 hours and prescribe antibiotics

Admit her for at least 48 hours and prescribe antibiotics and steroids

Admit her for at least 48 hours and prescribe steroids only

Admit her for at least 48 hours and prescribe antibiotics and steroids. Currently erythromycin is recommended


A 31-year-old female presents to the genitourinary medicine clinic due to four fleshy, protuberant lesions on her vulva which are slightly pigmented. She has recently started a relationship with a new partner. What is the most appropriate initial management?

Oral aciclovir

Topical podophyllum

Topical salicylic acid

Topical aciclovir


Genital wart treatment:

- if there are multiple, non-keratinised warts: topical podophyllum

- if there is a solitary, keratinised warts: cryotherapy

Cryotherapy is also acceptable as an initial treatment for genital warts


A woman complains of severe itching at 34 weeks gestation. The itching started 2 weeks previously and has been preventing her from sleeping. She is itchy all over her body, especially in her hands and feet. She has not noticed any rashes. Her mother reports similar symptoms when she was pregnant with her 2nd child. She is otherwise well. What is the most appropriate action?

Dermatology referral

Give topical steroids

Check uric acid levels

Check renal function

Check liver function tests

Check liver function tests.

It is bile acids that are raised rather than uric acid levels


A 31-year-old woman complains of intermittent pain in the left iliac fossa for the past 3 months. The pain is often worse during intercourse. She also reports urinary frequency and feeling bloated. There is no dysuria. What is the most likely diagnosis?

A. Appendicitis
B. Ovarian torsion
C. Subacute bowel obstruction
D. Endometriosis
E. Urinary tract infection
F. Ovarian cyst
G. Chronic interstitial cystitis
H. Uterine fibroids
I. Pelvic inflammatory disease
J. Ectopic pregnancy

Ovarian cyst


A 28-year-old woman who is 10 weeks pregnant comes to see you for her booking appointment. She has heard there are some vaccinations offered in pregnancy and wants more information.

Which of the following combinations of vaccinations are routinely offered to pregnant women in the UK?

Pertussis and pneumococcus

Influenza and rubella

Influenza and pneumococcus

Influenza and pertussis

Pertussis and rubella

Influenza and pertussis


A 44-year-old female has a Mirena (intrauterine system) fitted for contraception on day 12 of her cycle. How long will it take before it can be relied upon as a method of contraception?


2 days

5 days

7 days

Until first day of next period

Contraceptives - time until effective (if not first day period):

- Instant: IUD

- 2 days: POP

- 7 days: COC, injection, implant, IUS


Your next patient in an antenatal clinic is a woman who is 30 weeks pregnant. Which of the following findings during your examination would you be concerned with?

Fundus palapable above the umbilicus but below the xiphisternum

Fundal height growth of 2cm per week

Breech presentation

Able to auscultate the foetal heart

Free head of palpation

Fundal height growth of 2cm per week


The chance of a 40-year-old mother giving birth to a child with Down's syndrome is approximately:

1 in 5

1 in 10

1 in 30

1 in 100

1 in 500

1 in 100

20 years of age -- 1 in 1,500

30 years of age -- 1 in 800

35 years of age -- 1 in 270

40 years of age -- 1 in 100

45 years of age -- 1 in 50 or greater

One way of remembering this is by starting at 1/1,000 at 30 years and then dividing the denominator by 3 (i.e. 3 times more common) for every extra 5 years of age


A 35-year-old obese gravida 3 para 2 has developed a swollen and tender left leg; she is currently at 32 weeks of gestation and started on the appropriate treatment regimen. Due to her weight, the clinician decides to monitor her treatment with a specific blood test. Which blood test is this?

Platelet count

Prothrombin time (PT)

Activated Partial Thromboplastin Time (APTT)

Anti-Xa activity

International Normalised Ratio (INR)

Anti-Xa activity

Routine measurement of peak anti-Xa activity for patients on LMWH for treatment of acute VTE in pregnancy or postpartum is not recommended except in women at extremes of body weight (less than 50 kg and 90 kg or more) or with other complicating factors (for example, with renal impairment or recurrent VTE). Routine platelet count monitoring should not be carried out.


A 22-year-old female has a Nexplanon inserted. For how long will this provide effective contraception?

12 weeks

12 months

3 years

5 years

7 years

3 years


A 22 year old woman is 14 days postpartum. She is formula feeding her baby. She attends her GP requesting emergency contraception as she had unprotected sexual intercourse (UPSI) 2 days ago. Which of the following would you recommend?

Levonorgestrel (Levonelle)

Ulipristal acetate (ellaOne)

No emergency contraception required

Mirena coil

Copper intra-uterine device (Cu-IUD)

No emergency contraception required

Emergency contraception (EC) is not required before day 21 postpartum. The earliest date of ovulation in a non-breastfeeding woman is thought to be day 28 postpartum. Therefore, contraception is required from day 21 onwards, as sperm can survive for up to 7 days. Woman who are exclusively breastfeeding will take longer to ovulate, however contraception should still be advised if pregnancy is not desired.

After day 21 postpartum, progesterone only EC (Levonelle and ellaOne) can be used in both breastfeeding and non-breastfeeding woman.

The Cu-IUD should not be inserted before day 28 postpartum, due to the increased risk of uterine perforation if inserted before this time.


A 20-year-old woman comes to your clinic complaining of three missed periods, although home pregnancy tests have been negative (which is confirmed today in clinic). She has noticed her skin has become spottier and she has more hair growing on her face than normal. What one investigation would best diagnose her condition?

MRI brain

Serum testosterone and prolactin

Serum LH/ FSH levels

Fasting blood glucose

Ovarian ultrasound

Ovarian ultrasound


A 31-year-old female presents to the antenatal clinic for a booking appointment. Which of the following should be identified as a risk factor for pre-eclampsia?

Her age (31 years old)

1 previous successful pregnancy

Body mass index of 29kg/m^2

History of smoking

Pre-existing renal disease

Pre-existing renal disease

The following are risk factors that should be determined:

Aged 40 years or older
Pregnancy interval of more than 10 years
Family history of pre-eclampsia
Previous history of pre-eclampsia
Body mass index of 30kg/m^2 or above
Pre-existing vascular disease such as hypertension
Pre-existing renal disease
Multiple pregnancy


A 32-year-old female with long standing hypothyroidism is confirmed as pregnant at 8 weeks gestation. She is taking 75 micrograms of levothyroxine and this dose has remain unchanged over the past 18 months. Blood tests show the following:

fT4 11.7 pmol/L
TSH 2.77 mU/L

What is the most appropriate action in relation to this woman's levothyroxine dose?

Increase to 100 micrograms daily

Maintain at 75 micrograms per day

Reduce to 50 micrograms per day

Change to liothyronine

Reduce to 25 micrograms per day

Increase to 100 micrograms daily


An 18-year-old woman is diagnosed with epilepsy and started on carbamazepine. She currently takes the combined oral contraceptive pill for contraception. She tells her GP that she is sexually active and would like to continue to use some form of contraception. She does not want a coil as she has states her friend 'had a bad experience'. What would be the best form of contraception for her?

Continue on the combined contraceptive pill

Switch to progesterone only pill

Switch to the progesterone implant (Nexplanon)

Switch to the combined contraceptive patch

Switch to progesterone injection (Depo-Provera)

Switch to progesterone injection (Depo-Provera)

Carbamazepine is an enzyme inducer and it can decrease the effectiveness of the combined oral contraceptive pill and progesterone only pill when taken at normal doses. The progesterone implant (Nexplanon) is also not recommended as it has a low dose of progesterone that is released into the bloodstream and this low amount can be effected by enzyme inducing drugs such as Carbamazepine.

The patient has stated that she does not want an intra-uterine method (coil) at this time and so Depo-Provera is the best choice. Depo-Provera can be used as a first-line contraception in younger women as long as other methods have been discussed with the patient and are considered to be contraindicated or unacceptable to the patient.


A 39-year-old woman, para 4+1, presents to the antenatal clinic for her booking appointment at 12+2 weeks gestation. Her body mass index is 39 kg/m2. She states that she is a non-smoker. She does not have a past history of blood clots or any other health problems. Her family history does not include any thrombophilia or blood clots. She reports no issues with her pregnancy thus far. She is assessed for her risk of venous thromboembolism. What is the correct management?

Low molecular weight heparin from 28 weeks until 6 weeks post-natal

Low molecular weight heparin now until 6 weeks post-natal

Oral warfarin

Oral aspirin

No prophylaxis needed

Low molecular weight heparin from 28 weeks until 6 weeks post-natal

This woman is at an increased risk of deep vein thrombosis. Her antenatal risk factors include:

- Body mass index more than 30 kg/m2

- Parity more than 3

- Age more than 35

RCOG guidelines suggest that any woman with three risk factors for venous thromboembolism during pregnancy be treated with low-molecular weight heparin from 28 weeks until 6 weeks postnatal.


A 20-year-old pregnant lady is found to be anaemic 10 weeks gestation. A full blood count is ordered:

Hb - 85 g/L
MCV - 95 fL

The lab also reports a high reticulocyte count. A blood film shows target cells and Howell-Jolly bodies. What is the most likely cause of the anaemia?

Folate deficiency

Anaemia of chronic disease

Iron deficiency

B12 deficiency

Sickle cell disease

Sickle cell disease

The full blood count confirms a normocytic anaemia. Folate and B12 deficiency cause megaloblastic anaemia which is characterised by macrocytosis. Iron deficiency and thalassaemia typically cause microcytosis. Therefore, based on the MCV it can be inferred that sickle cell disease is the most likely answer.

In addition, the Howell-Jolly bodies suggest hyposplenism which can occur in Sickle cell disease due to splenic infarctions.

The high reticulocyte count suggests increased destruction (e.g. haemolysis) or increased loss (e.g. bleeding) of red cells. Sickle cell disease results in a chronic haemolytic anaemia due to premature destruction of abnormally shaped red cells. This would result in a high reticulocyte count.


At her booking visit, a woman mentions to her midwife that she has been previously diagnosed with immune thrombocytopenic purpura (ITP). Which procedure carries the greatest risk of haemorrhage in the newborn?

External cephalic version

Forceps delivery

Prolonged ventouse delivery

Fetal blood sampling

Caesarean section

Prolonged ventouse delivery


A hepatitis B serology positive woman gives birth to a healthy baby girl. She is surface antigen positive. What treatment should be given to the baby?

Hep B vaccine

Hep B vaccine and 0.5 millilitres of HBIG within 12 hours of birth

0.5 millilitres of HBIG within 12 hours of birth only

Hep B vaccine and 0.5 millilitres of HBIG within 12 hours of birth with a further hepatitis vaccine at 1-2 months and a further vaccine at 6 months

No treatment required

Hep B vaccine and 0.5 millilitres of HBIG within 12 hours of birth with a further hepatitis vaccine at 1-2 months and a further vaccine at 6 months


A 27 year-old lady is day 1 post emergency caesarean section for failure to progress in the first stage. She has been complaining of pain and heavy vaginal bleeding since delivery and in the morning was noted to have heavy, offensive lochia and a boggy poorly contracted uterus above the umbilicus.

What is the most appropriate treatment?

Urgent ultrasound scan

Speculum examination

Examination under anaesthesia

IV antibiotics and review after first dose

Urgent MRI scan

Examination under anaesthesia

This is a typical history of retained products, which can happen after caesarean section if care is not taken to make sure that all the placental membranes are removed. The uterus does not contract down well as the products are still in the cavity, and the discharge is offensive suggesting that the products have become infected.


17-year-old girl who is nine weeks pregnant has a surgical termination of pregnancy. She feels well a few hours after the procedure. Which of the following risks is most common following a TOP?



Uterine perforation

Cervical trauma