Obstetrics and Gynaecology Flashcards

Question

A 24-year-old multiparous woman is 23 weeks pregnant. She has not had chicken pox before. She goes to a collect her 3-year-old son from a birthday party and comes into contact with a child with an infective chicken pox infection. She is naturally very anxious. What is the best course of management? A. Wait and see if she develops a rash. If she does treat with aciclovir B. Test for varicella antibodies and give varicella zoster immunoglobulin (VZIG) within the first 24 hours C. Test for varicella antibodies and give aciclovir within the first 24 hours D. Test for varicella antibodies and give VZIG within 10 days E. Reassure that there is no significant risk at present as contact was so brief

Answer 1

D. Test for varicella antibodies and give VZIG within 10 days women who contract chicken pox during pregnancy are at risk of a more significat effect on themselves as well as the risk of fetal varicella syndrome if the exposure is before 28wks. This syndrome includes eye defects hypoplasia of the limbs and neurological defects. There has been significant contact in this case, and her 3 year old may well be incubating the virus, so options A and E are inappropriate. Although she may not think she has had chicken pox, she may have developed a sub-clinical infection previously. testing for antibodies will guide your management. Aciclovir can be started within 24hours of the RASH APPEARING so C is not correct. Becuase of the cost involved you don't start VZIg straight away in case she is immune (excludes B). The guidance is that VZIg is effective within 10 days.

Answer 2

E. Small for gestational age with abnormal Doppler scan I gon't the wrong idea with answer A and thought it meant multiparous as oppossed to twin/triplet etc. Obviously that's contra indicated. Bleeding (C), major abnormalities (B), and a lack of fluid to protect the baby (D), are all absolute contra indications (E) is only a relative contra indication

Answer 3

B. Change her back to her pre-pregnancy insulin and stop the sliding scale Stopping the insulin (D) is a bit mad as she's a Type 1... As soon as the patient is eating there is no need to continue the sliding scale (A or E) Halving the dose is likely to not give her enough control (C) The only sensible option is to return to the normal insulin dose but continue to monitor.

Answer 4

B. Diabetes mellitus Pregnancy increases the chance of a flare up of SLE by 40-60%. it carries the risk of , spontaneous miscarriage, Fetal Death (D), Pre-eclampsia (C), pre-term delivery (E) and fetal growh restriction (A). All of which make sense as SLE is a systemic disease of the connective tissue. THere is no reason why a connective tissue disease would affect an endocrine system as in Diabetes Mellitus (B)

Answer 5

C. Listeria monocytogenes A - Toxoplasmosis is associated with cats, cat faeces, or unwashed fruit and veg B - Is commonly sub-clinical and found in many people. It's only an issue in the immunocompromised. No food association C - this is associated with soft cheese, pate or unpasterised milk. Causes mid-trimester loss, early meconium and pre-term labour. Flu like illness D - Non-chronic hepatitis, transmitted by faeco-oral route E - Parvovirus B19 casuses the facial rash of slapped cheek syndrome/fith disease called erythema infectiosum. It has a respiratory droplet route of transmission.

Answer 6

B. Pruritic urticarial papules and plaques of pregnancy (PUPP) Pemphigoid gestationis is a blistering condition that starts at teh umbilicus and then spreads. Impetigo herpetiformis is a febrile blistering condition that can lead to maternal and fetal death. Prurigo gestationis is a rash of the uper arms and trunkwith abdominal sparing Contact dermatitis is possible if there was a history of use of lotions or creams but unless there was a reason in the history it would not be sparing the umbilicus.

Answer 7

D. Sodium valproate Valporate should be avoided as it has the highest risk of congenital malformations of all the anti convulsants. But if it is the most appropriate agent for the patient it should be used. Acitretin is a retanoid and methotrexate is a chemical pregnancy termination agent (amougst other uses) these are both obviously a big no-no. Mebendazole is an anti worm tablet and has been shown to have toxic effects in animal studies Fluconazole is an anti fungal and is linked with many congenital abnormalities.

Answer 8

E. Pregnancy-induced hypertension (B) is a diagnosis of exclusion and shouldn't be resorted to without another identifiable cause (A) Pre-eclampsia is a diagnosis of raised blood pressure and proteinuria, a PCR of less than 30 is considered normal. So this is not the diagnosis in this case (D) there's nothing here to suggest Conn's The fact that the hypertension has been identified in the context of pregnancy makes this (E) not (C).

Answer 9

C. Post meal 1-hour sugar \<7.8 μmol/L Gestational diabetes mellitus is diagnosed as a blood sugar of greater than 7.8 μmol/L one hour after the oral glucose test. As such this is the control level to be aimed for. The pre-meal blood sugars should be less than 5.5μmol/L

Answer 10

D. 10 per cent chance of developing type 2 diabetes over the next 10 years the risk of developing DM type 2 is actually 35-60% over the next 10-15 years. All the other statements are correct

Answer 11

C. Caesarean section Due to this woman's viral load being high we want to avoid vertical transmission, caesarean section has evidence that it does reduce the risk. For the same reasons prolonged rupture of membranes and any artificial rupture should be avoided (B and E) A normal delivery can be advised, but only if the viral load is undetectable (less than 50 copies/ml) this excludes options A and D in this case. N.B. Amniotomy = artificial rupture of membranes

Answer 12

D. Complete abortion Threatened abortion = any bleeding before viability (24 weeks currently). after this point bleeding is ante-partum haemorrhage Missed Miscarriage = The loss of a pregnancy without the passage of products of conception or bleeding. Septic Abortion = The loss of a pregnancy with evidence of infection, the infection is of the retained conceptus. must be managed actively as there is still a high mortality Incomplete abortion = The loss of a pregnancy with bleeding and/or passage of some, but not all, products of conception. it can be managed conservatively, medically (misoprostol), or through 'surgical management of miscarriage' (previously called evacuation of retained products of conception, ERPC)

Answer 13

D. Intravenous crystalloids, oral antiemetics The triplet pregnancy is a risk factor for the development of Hyperemesis gravidarum. The ketonuria also points to this diagnosis as a indicator of dehydration. The mild back and abdo pains are normal for this stage in pregnancy. The management of HG is to rehydrate and provide antiemetics (D) Without diarrhoea or sepsis we shouldn't be leaning towards viral gastroenteritis or appendicitis (C, E), and it's certainly not appendicitis with a mild pain. Tetracyclines (Doxy) and Quinolones (cipro) are both teratogenic

Answer 14

D. A pregnancy of uncertain viability Vaginal bleeding in early pregnancy is common but not normal, it has a miscarrige rate of 20%. This scenario by definition is a threatened miscarrige. Without a fetal pole or a pulsatation we canot say for certain that this is a viable pregnancy (A) At 6 weeks we would expect to see a heartbeat, but the dates may be wrong. C and E are the same thing, it is a gestational sac without a fetal pole or yolk sac. There is a yolk sac in this case. A psudosac (B) is the development of decidual reaction in an ectopic pregnancy, there would be no yolk sac, and this isn't ectopic.

Answer 15

C. Blood test for beta human chorionic gonadotrophin (hCG) now and in 48 hours time If the sac in the uterus is a psudosac then it points to an ectopic pregnancy, this is supported by the RIF pain. The woman is, however, heamodynamically stable and has a SNT abdomen so an urgent referral is not needed at this stage (A) as long as she is able to understand red flag symptoms. She needs a bhCG level now and then again in 48hrs. If there is a 67% rise in bhCG then it indicates that the sac in the uterus is a viable pregnancy, and following an ultrasound scan to confirm in ten days, a TOP can be offered to this woman if she wishes. If the rise in bhCG is less than this she should be seen for further assesment in hospital _An interuterine pregnancy should always be confirmed prior to offering a TOP._

Answer 16

B. Methotrexate This woman has risk factors for an ectopic pregnancy, PID, and previous terminations. Other risks include tubal surgery, previous ectopics and IVF. A salpingectomy would be definitive but is an extreme step to leave a 28 year old woman with one tube. An open [rocedure is definitely not needed as she is stable. A salpingotomy (opening the tube but leaving in in situ) may just increase the risk of further ectopic pregnancys. The criteria for methotrexate use in an ectopic are that it is a small ectopic with no fetal pulse, no clinical compromise, and no free fluid on the pouch of Douglas. This woman is an ideal candidate. Monitoring the bhCG in 48hrs would indicate if this pregnancy is failing spontaneously. Given that she is a candidate for methotrexate it is the most definitive management.

Answer 17

C. Urgent referral to the gynaecology clinic The easily bleeding cervix is the alarming factor here. The woman's significant history of sexually transmitted infections could lead you to think of PID or another infection, for which A,B,D and E are all management options, the cervix bleeding easily is a concern for cervical cancer. At the age of 24 she is not included in the cervical screening program This concern should be investigated urgently (C)

Answer 18

E. Transvaginal ultrasonography The severe LIF pain and shoulder tip pain strongly indicates an ectopic pregnancy that has potentially ruptured and the free fluid is irritating the diaphram and causing the reffered shoulder tip pain. An early pregnancy should be visable if the bhCG is above a 1000 so a TVUS should see an interuterine pregnancy if this sisn't an ectopic. The Laparoscopy (A) would only be first line if she was unstable. At this stage it should be performed if the TVUS confirms an ectopic. CT is too teratogenic (C) The serial bhCG (B) would only give useful information after 48hrs, given the picture it's not wise to wait that long. Clinical assesment (D) would not be definitive

Answer 19

C. Ruptured tubal pregnancy - collapse and circulatory compromise (low BP, tachycardia) - A bhCG over 1000 would be a visible pregnancy in the uterus on TVUS, it is not visable. Therefore ectopic - Fluid in the pouch of douglas indicates a degree of rupture The ruptured cyst (A) and torsion (E) would both have sudden onset but no haemodynamic compromise. of the two the cyst would have pain that improves with simple analgesia and time, the torsion would not get better.

Answer 20

A. There is evidence that HRT prevents coronary heart disease oestrogen increases the risk of ovarian and breast Ca (D and C) There is a small increased risk of stroke (B) and a small increase in DVT risk (E)

Answer 21

C. Diagnostic laparoscopy A cornual pregnancy is a specific ectopic (see image). This patient has a confirmed ectopic and she is haemodynamically compromised, urgent curative action is needed. A TVUS doesn't add anything when we have a diagnosis (A) Likewise a bhCG doesn't change anything either, it's purely diagnostic and we have a diagnosis already. (B) option D is too conservative, fluid resucitation won't improve the situation. Finally E is the same situation, no curative effect.

Answer 22

A. Ruptured theca lutein cyst This pain has localised to the wrong side for appendicitis (B) Diverticulitis is extremely unlikely in this age group (C) A complete miscarriage would not have a positive bhCG or have gestational sacs on the scan (D) A UTI would have urinary symptoms and classically would localise to the suprapubic area (E) A functional ovarian cyst is common in women of child bearing age and a theca lutein cyst of cyst is more common in multiple pregnancy. In this case it seems to have ruptured and bleed slowly into the peritonium.

Answer 23

E. Encourage volunatary admission to the antenatal and repeatedly explain the benefits of caesarean delivery The patient has made a solid case that she has capacity and that she is not suffering from an active psyciatric condition at this time. If she has capacity and is not sufferin from a mental health condition then there is no place for the MH act or the MC act. E is the only possible option here On a side note, in the UK you can never legally act on the best interests of a fetus.(option D)

Answer 24

B. The risk of damaging the bladder is one in 20 A 5% risk is grossly exagerrated here, the real risk is 1:1000 the rest are all correct. 6% is a standar infection risk, there is a chance the baby will suffer a laceration and the scar on the uterus can lead to placenta praevia. The incrreased risk of still birth was found in a 2014 Danish study, I couldn't find a mechanism for this.

Answer 25

E. Transfuse the woman with group-O negative blood and immediately transfer to theatre in order to be accepted a legally valid advance directive needs to be seen by the clinician in person. The husbands asertation cannot be taken in to account. Te clinicain must act in the patient's best interests. The woman is severly compromised and needs resucitation with blood, any avoidance of transfusion completely (B and C) is completely out. Blood is the best option to stabilise prior to immediate transfer to theatre.

Answer 26

B. The termination is necessary to prevent grave permanent injury to the physical or mental health of the pregnant woman answers C and D refer to terminations before 24 weeks and so are out completely. There is no evidence here to support option E. We are at this point left with A or B as options. Legally speaking it is easier to justify that the woman will cause grave harm to herself in this scenario, there is probably a risk of death but it is not as likely as grave harm. For this reason B is the correct answer, although this is a seriously dodgy scenario, terminating a potentially viable fetus.

Answer 27

C. No action. Allow fetus to die This one is grimly straigtforward. The woman does not appear to be suffering from a mental health condition and so the MH act would not be appropriate. THis act also only convers treatment for mental health conditions. Any caesarean without consent would be a criminal act, unfortunately answer C is the only option here.

Answer 28

B. Perform the examination with a chaperone present and explain that parental consent is not necessary in this situation The girl is over 16 so is considered competent to consent to a procedure as per the same criteria as an adult. This means that any Gillick/Fraser considerations are not relevant. (D and E) A necessary clinical examination should not be delayed due to the father's (actually irrelevant) viewpoint. At this point I disagree with the book answer of B, normalising the examination and performing the exam with a chaperone seems the less confrontational option here (A). The book argues that option A breeches the girl's confidentiality but I do't see how that is true.

Answer 29

D. Immediate caesarean delivery In such an emergency the best interests of the patient is all that matters, the husband's wishes are irrelevant. The patient's wishes are unlikely to become any clearer in the time she has remaining (A) Replacing with fluid (A) or blood (B) will only buy a little time Transfering the patient to theatre (E) or ITU (C) is very risky as the patient may arrest en route. The use of inotropes (C) will only partially help as it won't replace lost volume. The primary aim of a perimortem caesarean delivery is to save the mother's life. The procedure reduces the volume of the gravid uterus which reduces venous return and so pre-load on the heart.

Answer 30

C. The onset of their condition There are several considerations in regards to assesing how to provide information. A,B,D, and E are all legitimate considerations. Option C is an incorrect statement and should be 'the nature of thier condition' Without these five considerations there is an argument that a patient is not fully informed, and thus cannot give adequate consent.

Answer 31

A. Audit This is a descrition of an audit. Clinical governance is a wide ranging term that covers audit, researchand a framework for care care improvement Clinical Reasearch is research that seeks to answer a specific scientific question Intergrated governence is the combination of clinical and financial governance Clinical effectiveness is clinical research that also assesses if the novel treatment is acceptable to patients and represents good value for money.

Answer 32

D. Prescribe the morning after pill, give contraceptive advice and immediately alert your consultant and the Safeguarding Children Team This girl fulfills the fraser guidelines in that she understands the advice given, cannot be persuaded to tell her parents and is likely to continue having sexual intercourse, which will cause her health to suffer without contraception being provided. So options A and B are immediately incorrect. You cannot tell her parents as this is a breach of confidentiality (E) This leaves options C and D, but only D addresses the issue of Female 'circumcision', more correctly termed female genital mutilation in this country. This is a serious offece under UK law and needs to be addressed.

Answer 33

D. Atrophic vaginitis Dyspareunia is pain on intercourse, either deep or superficial.With any dyspareunia it is important to rule out a sexually trasmitted infection, intrapelvic conditions (appendicitis, ovarian pathology), or cervical pathology. The vaginal lining of post menopausal women gradually atrophies without the influence of eostrogen. STD is uncommon (but not unplausabile) in this age group pH changes in the vagina rule out BV in this age group (E) malignancy (A) is not sugessted by this presentation. Discoid Lupus (C) is unlikely as there are no features here of such a systemic disease, the age of onset would also be younger (in her 30's)

Answer 34

A. Acute appendicitis It's important ot be able to distinguish between gynecological and surgical issues as in this case. The negative beta hcG rules out an ectopic (B) Ovarian torsion (E) would present with sudden pain that was completely unrelenting and classically only responds to opioid analgesia. The pain in this case is fluctuant, and there is a leukocytosis. Tubo-ovarian abscess (D) and PID (C)would present with a fever as well as the leukocytosis. The abcess patient would also be much more significantly unwell than this patient.

Answer 35

D. Breast cancer PCOS is a diagnosis based on 2 of 3 of; oligo/amennhorea, polycystic ovaries, and clinical and/or biochemical signs of hyperandrogenism. Everything listed except (D) is a risk of PCOS. There is no link between PCOS and breast or ovarian cancer.

Answer 36

B. She should have a thrombophilia screen prior to starting HRT A thombophillia screen is not offered routinely to women starting HRT as it's not cost effective. With a family history of VTE it would probably be sensible. All the other points here are correct.

Answer 37

A. Establish large-bore venous access, commence fluid resuscitation and cross-match four units of packed red cells This woman has a normocytic anaemia as a result of blood loss. Her history rules out pregnancy (ectopic) and so the approach in (B) is inappropriate. She should be apropriately resuscitated straight away so the delay invloved in (E) and (D) is inapropriate. She may decompensate rapidly so a large bore cannula is needed. At this stage teh risk of giving a blood product is not justified and so fluids is the safest initial management while units are cross matched (takes about 45 mins)

Answer 38

D. Conservative management There are several factors to consider with risk stratifying an ovarian cyst. Features that are concerning for malignancy include; bilateral cysts, multiloculated, solid components, ascites and metastases. This is combined with teh Ca125 to give a risk of malignancy index (RMI). In this case the cyst is simple and less than 5cm, there is also a ca125 less than 30U/ml. This means that conservative managemtn is the best course of action, this will involve 4-monthly scans and ca125 levels for a year.

Answer 39

C. Pelvic ultrasonography Post menopausal bleeding must always be investigated for cancer. In this patient's case the smear history is normal and she is past the age range for screening so it is unlikely to be cervical (E). Endometrial cancer must be ruled out with an ultrasound. (C) She is sexually active and so triple swabs (B) is a sensible part of the plan but not the first step. This woman has no other menopausal symptoms and so HRT is not indicated. (D) Vagifem (A) might be appropriate but endometrial cancer must be ruled out before prescribing oestrogen.

Answer 40

B. Triptorelin Danazol (A) is an anti-oestrogenic and anti-progesteronic, it is licenced for 3-6 months Triptorelin (B) is a GnRH agonist that induces a temporary artificial menopause. it is an excellent option for up to 6 months before bone densisty loss becomes an issue. Microgynon 30 (C) is a combined oral contraceptive Tranexamic acid (D) is an antifibrinolytic used for menorrhagia. Medroxyprogesterone acetate (E) is a progestogen. This question relies on you knowing the management for this individual patient. She needs to be on medical management and then have a second laparoscopy to remove any residual disease. Triptorelin is the best option for this.

Answer 41

A. Elleste Solo The abscence of periods for over 12 months indicates this woman is menopausal. Her symptomatic issues here require the consideration of HRT, which requires a careful examination of her history. If the woman still has her uterus then she needs constant or cyclical progesterone to avoid endometrial hyperplasia or malignancy. In this case the patient has the mirena coil to provide this and so only needs a source of oestrogen as per (A). (B) is a combination thereapy and so is (E), so they wouldn't be appropriate. Vagifem (C) is a topical treatment for atrophic vaginitis and would do nothing for her vasomotor symptoms. Oestrogen implants (D) are supraphysiological levels of oestrogen and would help with the symptoms but there would be rapid rebound when they ran out.

Answer 42

A. Enhances endometrial receptivity Endometrial growth (B) occurs prior to ovulation in response to rising oestrogen. progesterone increasing during the follicular stage prepares the uterus for implantation (A). C,D, and E are all well charecterised effects of oestrogens.

Answer 43

A. Levonorgestrel-releasing intrauterine system this woman needs symptom control from heavy menstrual bleeding. The NICE reccomended first line treatment for HMB is a IUS, such as Mirena, this is only in cases without uterine abnormality. Tranexamic and Mefenamic are second line treatments for HMB. Tranexamic acid is usually prescribed alone as it has less of a side effect profile. A hysterectomy is an option offered to women who have not had resolution from other methods and have completed thier families. Vaginal approach is preferred when there are no complications.

Answer 44

B. Vitamin C Premenstrual syndrome is defined as a condition associated with distressing physical, behavioural and psychological symptoms, but in the abscence of organic or underlying psychiatric disease. It also recurs regularly during the luteal phase of each menstrual cycle, and disappears or significantly regresses at the end of menstruation. First line treatments include: SSRIs (A), Vitimin B6, Improved diet and physical exercise (C), CBT (D), and a trial of Yasmin or Cilest (COCs)(E). There is no evidence to support vitinmin C as a treatment. Complimentary therapies that have some evidence include; St John's wart, Ginko Biloba, and Evening Primrose Oil

Answer 45

C. IM ceftriaxone, oral doxycycline and oral metronidazole This woman is unwell with PID (bilateral adenexal tenderness, abnormal discharge, fever over 38c, PV bleeding, deep dyspareunia and cervical motuion tenderness). Options A, B and D are all IV antibiotics for use in sever PID with evidence of sepsis, a tubo-ovarian abcess or in pregnancy (obviously avoiding teratogenic tetracyclines). In this woman's case she does not have signs of peritonism, fever systemic infection or abscess, so option C is preferred. Option E is not a recognised treatment for PID in the UK.

Answer 46

D. Epidural injection This woman had a very long latent stage of labour (over 24hrs), she is now in the active phase. This is likely to be a long labour due to the occipto-posterior fetal position. All the options here are used in labour Remifentanil (A) is an infusion given where there is a contraindication to a spinal or epidural. Pethidine (B) has already been given before with little effect so it is unlikely to be acceptable. Diamorphine (C) is much the same as pethidine and different units use different opiates. Primarily opiates have a sedative efect in labour, rather than an analgesic effect. Entonox (E) is a good adjunct to pain relief but is unlikey to be enough for the remainder of her labour. An epidural (D) is the best course of action based on the likely length of the upcoming labour and the likely need for augmentation.

Answer 47

D. Suspicious CTG – perform fetal blood sampling and deliver if abnormal A pathological CTG has two or more non-reassuring features or one abnormal feature. A suspicious CTG has one non-reassuring feature. THis woman's CTG shows a non-reassuring lack of variability and so is suspicious. This rules out answers A and E. option B is wrong because at this stage we don't know if delivery is the best option. Option C would only be correct if we thought there was a fetal blood supply compromise, which given the normal heart rate is unlikely.

Answer 48

E. Ischiocavernosus The ischiocavernousus runs from the crus of the clitoris to the ischial tuberosity, the episiotomy should avoid this.

Answer 49

B. Human papilloma virus (HPV) HIV (A) and Hep C (E) are blood bourne viruses, a FBS will increase the risk of vertical transmission. (C) and (D) are both potentially also present in the fetus and put it at risk from excessive bleeding. Only HPV (B) has no risk associated with a FBS.

Answer 50

D. Call for help and prepare for an instrumental delivery Feeling the cord below the presenting part with ruptered membranes is the definition of cord prolapse, an obstetric emergency. The most important thing here is to call for help. The woman needs to be taken to theatre and delivered as soon as possible, with the use of instruments likely. The elevation of the presenting part is important as this will take pressure off the cord. this needs to be done by filing the bladder with saline rather than using packs. (E) The woman is fully dilated so a caesaren is not indicated (B) An episiotomy will not be sufficient in this case (C) Although option (A) is partially correct there needs to be steps towards a definitive plan - the instrument delivery.

Answer 51

E. Start an oxytocin infusion, commence continuous monitoring and reassess within an appropriate time span In this scenario we have a delay in the first stage of labour. Active labour is usualy defined as the point after the cervix is 3cm dilated, as in this case. This question also highlights the fundamentals of assesing labour, that is, assessing the passage, passenger and power. This womans labour has arrested (the power) as she is only contracting 2 in 10. The passage has been assessed in the vaginal exam, there is no moulding (change in shape of the head) and a mild caput (swelling of the head). The abdominal exam indicates that the 'passenger' is of normal size. All of these factors indicate that the problem is with the strength of contractions and action should be taken. Option A isn't appropriate as its not active management. The next step here is to offer an augment of labour as oppossed to caeserean (B) Any labour augmentation will require continous monitoring so (C) is incorrect. She is now in labour so there is no place for further PGE2 (D) This makes option E the best answer.

Answer 52

A. High sensitivity and low specificity CTG monitoring was developed to identify cases of fetal acidosis, in reality it's only evidence is for preventing neonatal seizures. It does, however, have a high false positive rate because of it's high sensitivity and low specificity (A). Option B and E would both be very useful tests but there is no such est for this scenario. Options C and D would both be pretty useless tests. C would basically be only slightly better than guesswork, option D would be accurate but would miss many pathological cases and would lead to deaths.

Answer 53

E. Caesarean section Diabetes is a risk factor for stillbirth, as in this case. The usual practice for induction of labour for interuterine death is to use mifepristone to ripen the cerix and misoprostol to induce contractions (A and B). Dinoprostone can also be used for induction of labour (D). Misoprostol alone (C) will not ripen the cervix so is not used alone. Unfortunately this is not a normal case of induction of labour following a fetal loss. The fetus is lying transverse and with little liquor there is no possibility to manuvour the fetus. Attempting a vaginal delivery in this case has a large risk of uterine rupture or other adverse outcomes. A caesarean is the only option here (E)

Answer 54

A. Pull the emergency bell and place the woman in McRobert’s position This is what is known as 'turtleneck' sign, which is when the head delivers and ten apparently retracts. It is an obstetric emergency, and one which a mother with gestational diabetes is particularly prone due to macrosomia. A series of of manuvours need to be performed in a set order in this scenario. THe most important first step is to place the woman in McRobert's position (knees and legs maximally flexed) as this gives the pelvic outlet the maximum size. The majority of cases wil deliver spontaneously in this position. (B) and (C) are valid manuvours for shoulder dystocia but are not first line. A caesarean is a method used if all otheres have failed. Applying fundal pressure (D) is definitely a bad idea as this increases the risk of a brachial plexus injury.

Answer 55

D. Immediate caesarean delivery The signs here are very worrying, regular contractions that suddenly stopped, combined with a sever continous abdominal pain are indicitive of uterine rupture. The CTG being unable to detect contractions and a difficult fetal HR to identify are supportive of the diagnosis of rupture, as the uterus is no longer contracting in a organised way. (A) and (B) are useful tools in suspicious CTG traces, but we are beyond that in this case. (C) is inappropriate as the woman is nowhere near dilated enough (E) is not a good choice here as increasing the strength and frequency of contractions will only make matters worse here and may well cause fatal blood loss. An immediate caesarean is the only sensible management here.

Answer 56

B. Hypotension Hypotension is always a concern with anaestesia, which acts to lower BP further, in the case of an epidural this is an absolute contraindication. Other absolute contraindications include; Patient refusal, allergies to the drugs in question, systemic infection, skin infection over the site, bleeding disorders, platelet count less than 80000/ml, and uncontrolled hypotension. Conditions that are a relative contraindication include conditions that impede the heart's ability to compensate; HOCM, Aortic stenosis or mitral stenosis. Also anotomical abnormalities; spina bifida, or previous spinal surgery, may make things more technically difficult, but are not contraindications. Condistions like MS may be excacerbated by the epidural, but this is not a contraindication.

Answer 57

E. Genital branch of the genitofemoral nerve If you remember your anatomy the genitofemoral nerve runs through the inguinal canal so is not associated with the pudendal nerve. It arises from L1 and L2. The first branches of the pudendal nerve are the inferior anal and inferior haemorrhoidal. the other branches listed here also arise from the pudendal nerve.

Answer 58

C. Resuscitation according to ATLS guidelines and fetal assessment with the patient in left lateral tilt Transferring the patient in this condition is not a wise move, this rules out (A) and (B). There is no need for steroids at 37 weeks (E) Opting for a premorbid caesaren is a serious step, and in this case the woman still has a cardiac output that may well respond well to resuscitation. As such option (D) is not warranted here. The book answer: Placing the woman in the left lateral positon will help with venous return (Edit: assuming no spinal trauma I hope). Fetal assesment will help with determining a management plan.

Answer 59

E. Maternal age The answer in the book is somewhat garbled. this is the explaination of 3rd degree tears; 1% of all vaginal births result in a 3rd degree tear, these should be identified at delivery and repaired appropriately. a 3a tear invloves less than 50% of the external anal sphincter, a 3b involves more than 50%. A 3c tearinvolves the external and internal anal sphincters. The use of instruments and ventouse is a risk factor for obvious reasons (A and D) A long second stage puts a greater mechanical strain on the area so is a risk factor (B) and shoulder dystocia (C) is always bad news, and will put a much larger strain on the perineum. That leaves maternal age (E), which according to some published research is also a risk factor for 3rd degree tears. The evidence for this is equivocal though, and so, of a set of answers it is the best.

Answer 60

C - Increased PT, Incresed aPTT, increased bleeding time, Reduced Platelets, Active haemorrhage. If you remember that DIC is a consumptive coagulopathy then this is a straightforward question. Because DIC activates teh intrinsic and extrinsic pathways and consumes the materials involved it leads to an increase in BOTH the aPTT and PT. Straight away there are only two possible answers (C and D) Only (C) includes the decreased platelet count found in DIC, in fact it is the only answer of the 5 that does, so only knowing that DIC involves reduced platelets gets you the answer. Of note, answers A and B don't really make sense and E describes a congenital condition such as von Willebrand's, which reduces platelet adhesion.

Answer 61

D. Hysterectomy This woman is in serious trouble, the placenta acreta has led to her losing 5l of blood (effectively her entire circulating volume). Syntocinon (A) helps the uterus contract which acts to shut off the blood vessels in the uterus. A B-lynch suture (B) is an external uterine suture which helps to contract the uterus. Internal illiac [sic] artery ligation (C) would reduce blood flow to the uterus, but there is still a suply from the ovarian arteries. An intrauterine balloon (E) acts to tamponade the blood flow, much like the surgeon's hands, the so-called factor XIV... All of the above could have formed part of the management plan earlier in this case, but teh extreme blood loss means that only one plan could result in saving this woman's life.

Answer 62

C. Peri-partum cardiomyopathy This woman's tachycardia, tachypnoea, low grade pyrexia and cough are suggestive of a LRTI (A) but the hypoxia would point towards a PE type picture (B). The abscence of chest pain and respiratory alkolosis goes against this. She does not meet the diagnostic criteria for SIRS (D) as there is no proof of infection. Her Hb is low but not low enough to be expected to be symptomatic. (E) This leaves a peri-partum cardiomyopathy (C), a diagnosis of exclusion. It is a rare condition associated with; multiple pregnancy, advanced maternal age, and hypertension in pregnancy. It has hallmarks of congestive cardiac failure. It is most common in th elast month of pregnancy and up to 5 moths post partum.

Answer 63

C. Puerperal psychosis This woman is clearly psychotic, and the cause can be determined by looking at the options here. Psychotic symptoms in sever depression will be nihilistic rather than paranoid, this makes (A) unlikely. There is no history of Bipolar affective disorder (B) here, it is a long standing diagnosis, not 2 weeks. Psychosis in mania also tends to be delusional. There is also no mention of depressive symptoms. Schizophrenia (D), by definition has to be enduring over 6 months. An acute confusional state (E) is a fluctuating mental state due to an underlying condition such as an infection. There is nothing here to sugesst it's fluctuating and no mention of infection. This has to be a Puerperal psychosis (C), AKA a post partum psychosis. risk factors include caesaren section, emergeny delivery, and primiparity (all present here)

Answer 64

D. Pulmonary artery vasoconstriction This quesion is poorly written, I selected option D straight away without much thought. THis is because the question says 'at birth'. the ductus (E) closes over the course of the first couple of days of life, conversely the foramen ovale closes on the first breath after birth. Anyway, the best answer is (D) as it is absolutely incorrect. the pulmonary arteries vasodilate to allow for the lower pressure in the right sided circulation after birth. The occlusion of the umbilical vessels lowers venous return (B), the expansion of the lungs with air lowers the pulmonary circulatory pressure. These act to change the pressure differential across the foramen ovale, closing it (C). The right ventricle increases it's output due to lower resistance (A)

Answer 65

B. Tone, colour, respiratory effort, heart rate and reflex irritability Tone and colour are in all the answers, we just need to decide which are the other three measurements. One easy way is that with some time spent on neonates you will know that blood pressure isn't measured in newborns... Even without that knowledge onlt two of these chices (E and B) refer, correctly, to heart rate, the others all say pulse. and of these two, (E) makes no effort to check respiratory effort. (B) is our answer.

Answer 66

D. Rapid fluid resuscitation, uterine massage, oxytocin infusion and vaginal assessmentIt is important here to recognise that this is a primary post-partum haemorrhage. All of the options listed are recognised steps in the management of primary PPH, but only (D) is the first line. In the first instance a priamry PPH should be managed by fluid resuscitation, uterine massage and oxytocin. IV ergometrine (A) and bimanual compression (B) are second line steps if initial steps have failed to control the bleeding. A balloon catheter (C) and intramyometrial uterotonic agents (E) are only used if other interventions have failed. The other help in answering this question is that only option (D) includes a vaginal assesment, always a sensible thing to do in the first instance in a PV bleed!

Answer 67

C. Sheehan’s syndrome The inability to lactate (in a motivated mother) coupled with the lack of periods points towards hypopituatarism as there appears to be a deficit in prolactin **_and_** FSH/LH. This is clearly not a hyperpituitarism (D) Depression (E) doesn't seem evident here and it doesn't explain the continued abscence of periods. (A) and (B) are not in line with this case. Sheehan's is an ischemia of the pituatary that can occur after a significant bleed in pregnancy, which causes a loss of perfusion to the hyperplastic pituitary.

Answer 68

C. Toxoplasma gondii CMV (A) is very common and appears as a mild flu like illness, complications for the fetus include; visual and hearing loss, microcephaly and long-term neurodevelopmental disability. Babies will not have hydrocephalus though, making this the wrong answer. HIV (B) should have been screened for, but it could present as a flu-like illness in seroconversion. Once again, the symptoms in the infant do not correlate with HIV. Strep (D) would not cause the hydocephalus Listeria (E) is classically linked with unpasturised cheese and pate, it causes misscarridge, stillbirth and early delivery. The correct answer here is Toxoplasmosis (C), classically associated with undercooked meat and cat faeces. Initial maternal infection is mild but it causes sever sequele in the infant.

Answer 69

C. Human papilloma virus (HPV) you should know this!

Answer 70

C. Imperforate hymen primary amenorrhoea is a failure to start periods, it can be due to a structural abnormality or a problem with the hypothalamic-pituitary axis (HPA). This girl's normal external genitalia and breast development indicate that the HPA is funtioning correctly. This rules out (E), (B), and (A) Anorexia (D) would cause a lack of secondary development if it started before puberty or secondary amenorrhoea, neither is the case here. In this case the problem is that the hymen has failed to seperate at the time of menarche and this has led to a build up of menstrual blod in the pelvis/abdomen. This is known as a haematocolpos and is what is seen in this case as a bulging red disc.

Answer 71

D. Hydatidiform mole The pathological findings here are consistent with a hydatidiform mole. This is part of specrum of benign trophoblastic tumours found in pregnancy. The usual presentation is of unusual or heavy bleeding after the 6th week of pregnancy with a pregnancy that is larger than dates suggest. Pre-eclampsia, thyrotoxicosis and hyperemesis Gravidarum are common also. bhCG assesment clinically will reveal a massively raised leve, and the ultrasound will show a 'snowstorm' appearance. If the bhCG levels don't fall during serial measurement then further action is needed. Choriocarcinoma (A) is an agressive and malignant form of trophoblastic disease, it has histological findings of closely related syccytiotrophoblasts and cytotrophoblasts, there will also be syncytiotrophoblasts with abnormal nuclei and high eosiniphil counts. (B) would not show histology related to pregnancy. This can't be a complete miscarriage (E) as the woman is undergoing a ERPC. Uterine dysgerminomas (C) are distinct germ cell tumours which will have lobular cells with fibrous stromal cells and lymphocytic invasion.

Answer 72

E. Twice weekly 0.1 per cent estriol cream and insertion of shelf pessary This woman has a bladder prolapse that is causing symptoms so treatment is needed. Unfortunately her age and severe aortic stenosis leave her unfit for surgery, this leaves just options (E) and (D). Frankly option (D) is a bit ridiculous in an 89 year-old

Answer 73

B. Weight loss and pelvic physiotherapy with the woman's BMI given as 35 in the question, weight loss is always going to be the sensisble first step. Fesoterodine (A) and Solifenacin (D) reduce bladder activity to help with urge incontinence. It's not clear but it's likely this is stress incontinence. (C) and (E) are both god surgical choices but in the first case (B) is definitely the choice here.

Answer 74

C. Human papilloma virus type 6 HPV a6 and 18 (A) and (B) are associated with CIN not warts HSV (D) causes a different infection entirely, papulovesicular morpholog is the clasical description. Epidermophyton floccosum (E) is a fungal infection that presents as tinea cruris. HPV 6 (C) and 11 are asscoiated with genital warts.

Answer 75

A. Marsupialization The history strongly suggests a Bartholin's abscess, the bartholin's glands lie in the labia minora at the 8 and 4 o'clock positions and are normally non-palpable. If the ducts become blocked then a situation as in this case can develop. The treatment is to remove the top of the abcess and suture the edges down, it will then shrink down as it drains and this prevents recurrence. This is marsupilization (A). antibiotics (B) would be insufficient at this late stage, additionally this regime is for PID. This isn't a sebaceous cyst (C) And this is also not thrush (D) No specialist assesment is needed here (E), you would refer if there was concerns that this mght be malignant.

Answer 76

D. There is an increase in the risk of ovarian cancer The COCP is associated with a decresed risk of cancer overall (A) and a specific decrease in risk of bowel and rectal cancer (C) As this woman is under 25 there is no need for a smear test (E), the small increased risk of cervical cancer (B) with long term use is mitigated by the screening program that starts at 25. The use of a COCP is actually associated with a reduction in the risk of ovarian cancer (D)

Answer 77

D. Clomiphene Given the low chances of sucess of IVF in this age group any of options (A,B,C, and E) would be appropriate. In fact (E) might offer the best chance of sucess as the donor eggs may well be of better quality. Clomiphene is a selective oestrogen receptor modulator and would be used to induce ovulation. In this case the woman is already ovulating so it is unecessary.

Answer 78

B. Oxybutynin Diagnosis of an overactive bladder is made clinically, urodynamic studies can confirm but this is an invasive step. In is usually appropriate to trial a medical therapy such as the options here. Oxybutynin (B), as an immediate release, is the first line treatment for overactive bladder. Alkl the other options are second line treatments. It is improtant to counsel this patient on anti-muscarinic side effects - dry mouth, constipation, and urinary retention.

Answer 79

C. Decreased risk of ectopic pregnancies There are many risks associated with IVF conception, (C) is incorrect as there is actually an increased risk of ectopics in IVF. The use of a donor egg is associated with a 7-fold increase in PIH (E) but the mechanism is unknown.

Answer 80

B. Gaining consent from her mother This one is relatively straightforward as long as you don't overlook the relevant fact that she is 16 years old. As she is 16 she is pressumed Gillick competent and so can consent to any procedure offered without need to involve a parent (B). All the other options are required components of a well managed STOP.

Answer 81

D. Hypothalamic hypogonadism in this scenario we see reduced levels of FSH and LH, so much so that her ovaries are not producing oestradiol. But tellingly because the LH and FSH are low it means that the negative feedback loop has not worked, there is a hypothalamic issue here (D) Her BMI is just below normal so not pathological (E) Prolactin is also normal (C) TSH is high normal so not significant (B) She likely fulfils the oligo/anovulation criteria of PCOS (A) but there is no information on the hyperandrogenism or polycystic ovaries critera.

Answer 82

E. 25 per cent Sickle cell anaemia is an autosomal dominant condition, so the gender of teh offspring and the family history is largely irrelevant. The fact that both parents are carriers puts the risk at 25% of the offspring being afected by the disease (E). There is a 50% chance of the offspring being sickle cell trait though.

Answer 83

A. Herpes simplex virus (HSV) Human papilloma virus is associated with cervical cancer but not HSV (A) Smoking is a risk factor for pretty much anything (B) Any immunocompromise increses the chance of a CIN developing into a malignant type, HIV is an example of this (C) COCP (D) and multiparity (E) are both linked factors because of the risky behaviour associated with it.

Answer 84

C. Instillation of methylene blue into the urinary bladder and speculum This is an appropriate first line investigation that can be carried out in the clinic. By passing the dye into the bladder the woman can be examined to determine where the dye is emerging. EUA and cystoscopy (A) would be an appropriate second line investigation. Urodynamics (E) wouldn't help identify stress incontinence, equally imaging (B and D) won't help to visualise the structures in question with any accuracy.

Answer 85

B. A copper intrauterine device (IUD) should be inserted with prior screening for sexually transmitted infections (STIs) Option (A) would not be apropriate as an emergency contraception and she is on an enzyme inducer. (E) is incorrect advice, she may well be at risk. Realistically she could be offered the copper coil (B), which is effective up to 5 days after the UPSI, the progesterone antagonist ulipristal (D) also effective up to 5 days after UPSI, and Levonorgestrel (C) effective up to 72 hours after the UPSI. The fact that she is on an enzyme inducer reduces thr efficacy of levonorgestrel making it uncertain to be effective. The fact that she is worried about pregnancy and her young age makes the copper coil an advisable option here (B)

Answer 86

B. Mirena coil The mention of heavy menstruation and the specified normal uterine structure indicates what line of management the question is trying to direct you towards. The mirena will reduce the severity of her periods and may stop them completely, she is to be warned that there may be up to 6 months of spotting. You can't reccomend a vasectomy (D) to this patient without consulting the partner. A total abdominal hysterectomy (E) is a seriously over the top move for a basically healthy woman. Also the abdominal approach for this is bizzare. Laproscopic sterilisation (C) is a good choice but only if she is sure that she doesn't want children. the fact that she has just started a new relationship would caution against this option. The COCP (A) is a good choice also, but it wouldn't have the added benefit of reducing the severity of her periods.

Answer 87

D. Asherman’s syndrome PCOS (A) is charecterised by biochemical or physical evidence of hyperandrogenism and an ultrasound scan showing 12 or more follicles in the ovary. There is no evidence of this in this case. Her prolactin is high, but normal, this makes a prolactinoma (B) unlikey. Her normal BMI and normal LH and FSH go against anorexia (E) Sheehan's (C) in a pituatary failure caused by a post-partumn ischemia/bleed in the pituitary. THere is nothing in the case suggestive that she has just given birth or any sign of hormonal irregularities. This leaves the likely diagnosis of Asherman's syndrome (D) a rare complication after uterin surgical procedures where uterine scar tissue forms adhesions. In light of her two previos STOPs this needs to be investigated by hysteroscopy.

Answer 88

B. Day 1–3 FSH and LH, mid-luteal progesterone, semen analysis A laproscope (E) is never going to be a first line investigation for subfertility Day 14 FSH and LH (A) would not be helpful as there will be a LH surge at the time of ovulation. In addition a hysterosalpingogram is rather invasive as a first line investigation. Random hormone levels (D) are a pointless as the stage in the cycle needs to be known. This leaves us options (B) and (C). of the two (B) is the option of choice as the mid-follicular progesterone levels will always be low. After carrying out a mid-luteal progesterone, a level greater than 30 nmol/L would lead you to determine that the woman was indeed ovulating.

Answer 89

C. 40 per cent have normal motility male factor subfertility is indicated in 25-40% of subfertile couples, Criteria for normal ejaculate are as follows; Sperm Count should be over 15million per ml (A) Volume should be between 1.5-6ml (B) 50% normal motility (C) Over 4% have normal morphology (D) pH should be between 7.2 and 8.0 (E) It can be seen from these criteria that the abnormal measurement here is the motility of the sperm, answer (C).

Answer 90

C. Haemodilution OHSS is caused by overstimulatin of the ovaries during IVF, it occurs in a mild form in 33% of all IVF cycles, and as a severe form in 3-8%. It presents as abdominal pain and swelling, and vomiting. Ovarian torsion, appendicitis and ectopic pregnancy should be excluded There is the finding of haemoconcentration with hypoproteinaemia and ascites (E), which may lead to pleural effusion (A). This is why option (C) is incorrect. This haemoconcentration is why there is an increased risk of DVT (B) Severe OHSS cuases large third space losses which leads to reduced renal perfusion and oligouria (D)

Answer 91

B. Turner’s syndrome Lack of secondary sexual characteristics, short stature and a widened (or webbed) neck are clasic features of Turner's syndrome (B). AIS (A) would present as primary amenorrhoea but without the syndromic features here CAH (C) would present with virilisation of the female genitallia and hyperandrogenism. Kallmann's (D) could fit here, there is a reduction in gnRH leading to hypogonadism, delayed puberty and a lack of secondary characteristics. Rokitansky's (E) is mullerian agenesis, the girl would be 46xx with normal ovaries and so normal secondary characteristics. THere would, however, be agenesis of the uterus, fallopian tubes or proximal vagina.

Answer 92

D. Trichomonas Trichomonas (D) is a sexualy transmitted infection, which BV is not, it also classically presents with a frothy, foul, green, discharge. Bacterial vaginosis is a disturbance in the usual bacterial make up of the vagina and is accompianed by a fishy white discharge. aside from Trichomonas, all of the others are bacteria involved in BV.

Answer 93

C. Arrange colposcopy at the gynaecology clinic I have edited the question to include reference to a HPV co-infection, this makes it work as a question. Answer (C) is correct as per the NICE guidelines Feb 2015 (copied below) ***Ensure the woman has received an explanation as to what an abnormal result means and what further tests or treatment she may need.*** *Patient information may be found online.* ***Women with _borderline or mild_ (low-grade) dyskaryosis — the laboratory will test the cervical cytology sample for human papillomavirus (HPV):*** *If HPV is found the woman will be referred for colposcopy (within 8 weeks). If HPV is not found the woman will be returned to the routine screening programme (every 3-5 years depending on her age).* ***Women with _moderate or high-grade_ dyskaryosis will be referred for colposcopy within 4 weeks. Women with suspected invasive cancer or glandular neoplasia will be referred for colposcpy within 2 weeks.***

Answer 94

A. Pubic arch, ischial tuberosities and the coccyx The pectineal line is a groove that runs along the pelvis and isn't a vorder of the outlet. This makes (D) and (B) incorrect. The sacrum forms the pelvin inlet not the outlet, so (C) and (E) are wrong. The outlet can be seen in the attached illustration.

Answer 95

E. Transfuse four units of cross-matched packed red cells and return to theatre for further laparoscopy a dropping haemoglobin post-operatively is strongly suggestive of an ongoing bleed. The umbilical swelling, pain and anaemic symptoms add weight to this. (A), (B), and (C) are essentialy conservative approaches and completely inapropriate here. I don't even know what (D) would solve, this is clearly not a bowel obstruction. It's got to be (E)

Answer 96

B. Ultrasound of the abdomen and pelvis Given the histoy of abdominal bloating and a raised CA125 ovarian cancer is to be investigated here. A pipelle biopsy (A) is used in endometrial cancer. CT abdo/pelvis (C) is an assesment carried out for staging purposes if a diagnosis of ovarian malignancy is made. At this stage we are not ready to refer (D) as we still need to carry out an assesment, which would be an ultrasound scan (B)

Answer 97

E. Mixed metabolic alkalosis and respiratory alkalosis From the history of frequent vomiting we know that this woman is likely to have a metabolic alkolosis. We straight away see that her pH is severely alkolotic. But the next abnormality is a low CO2, which doesn't fit with a pure metabolic alkolosis (A). We see a hypokalemia also, this represent's the metabolic component at work here and confirms our first thoughts from the history. She is losing anions in th eform of K+ and H+ in the vomitus. We can confidently say this is a mixed alkolosis (E) The respiratory alkolosis is likely due to tachypnea, due to the pneumonia.

Answer 98

C. Laparoscopic hysterectomy Telling you that this woman has never had surgery does tell you that the question author is thinking of a laproscopic approach. In this case she has a mild prolapse already, hasn't got adhesions die to surgery, and has an early stage endometrial cancer. The recovery will be speedier. Of the other answers; A Wetheim's (A) is an option for cervical cancer. It removes the uterus and upper third of the vagina, which is not indicated here. A total abdominal (B) would be appropriate if there was involvement of the ovaries also. A subtotal hysterectomy (D) would preserve the cervix, this would not be appropriate for a curative operation for endometrial cancer. Posterior exenteration (E) is a Wetheim's and a bowel resection, it's not indicated in early stage endometrial cancer.

Answer 99

C. Stage IIIA FIGO staging generally follows a similar pattern acroos different cancers. In the case of endometrial cancer; * Ia - confined to the uterus with less than half the myometrium invaded * Ib - greater than half the myometrium invaded * II - beyond the myometrium but not past the basement layer of the uterus * IIIa - adnexal or serosal involvement * IIIb - vaginal / parametrial involvement * IIIc1 - pelvic lymph nodes * IIIC2 - Para-aortic lymph nodes +- pelvic nodes * IVa - Bladder or bowel * IVb - distant mets

Answer 100

C. Staging laparotomy and optimal cytoreduction Staging of ovarian cancer is primarily surgical (C), imaging doesn't replace histological analysis. This is the preffered option in any patient fit for surgery, regardless of how advanced the disease. Offering palliation in a fit patient is innapropriate (D) unless by patient choice. Removing the aortic lymph nodes (B) has little evidence for improving survival and carries a large risk. Concominant radiotherapy to a differnt organ (A) at the same time as radical surgery is a significant risk. Total Exenteration (E) is the removal of the bladder, rectum and reproductive organs. It is ususally used for vulval, rectal, uterine, and vaginal cancers without distant spread. It is not appropriate here.

Answer 101

B. Carcinoma of the ovary The vaginal bleeding, bloating, and the poor appetite are allarming signs for an advanced gyne malignancy. The high protein content of the ascities points towards malignant or inflammatory processes., rather than CCF (A) or Cirhosis (D). Meigs' syndrome (C) is a pleural effussion, classically on the right, associated with a benign ovarian fibroma. It is a very rare syndrome and doesn't explain the red flag symptoms here. Of the two malignancies here, cervical cancer (E) tends to present earlier and this level of systemic involvement is less likely. Ovarian cancer (B) is more classically associated with massive abdominal distension.

Answer 102

C. Admit, resuscitate and prepare her for immediate transfer to theatre So this is a grim question... Anyway... The severe, and symptomatic, anaemia indicates this woman has lost a significant amount of blood. She is also actively bleeding, discharging her at this stage (A or B) would be extremely negligent. You need to asses the damage to the genital area, she connot tolerate this so needs an examination under anesthesia (C) If she cannot tolerate an examination, packing will be impossible (E) And option (D) does nothing to rectify the active bleeding.

Answer 103

C. Steroid cover with 50 mg hydrocortisone intravenously at induction of anaesthesia and 50 mg 8-hourly for 3 days Patients taking more than 10mg of steroids a day for more than 3 months will almost certainly have a blunted Hypothalamic-pituitary access. This means that they cannot ount an appropriate physiological increase in corticosteroid levels after surgery. They will require supportive steroid therapy. Option (C) is the standard regime for major gyne surgery, any single dose of steroid (A or B) is not going to be sufficient cover until she is eating and drinking again and can resume oral steroids. option (D) represents a covering treatment against asthma attacks and would not be routinely used. Finally, any patient with well controlled asthma will not need a respiratory review (E)

Answer 104

A. Internal pudendal artery which itself arises from the internal iliac B. Inferior gluteal artery - Supplies the buttock and posterior thigh C. Uterine artery - Supplies the uterus D. Obturator artery - Supplies the medial compartment of the thigh E. Inferior vesical artery - supplies the lower part of thebladder

Answer 105

A. Perineal nerve The perineal nerve is a branch of the pudendal nerve, it provides sensory enervation to parts of the labia and perineum. Compromise of the pudendal nerve (C) would cause much more severe deficits. The Peroneal nerve (B) also known as the common fibular nerve, supplies the anterior and lateral aspects of the lower leg. The remaining two answers are also branches of the pudendal nerve. The Dorsal nerve of clitoris (D) supplies part of the clitoris, shock horror... The inferior anal nerve (E) supplies the anal skin and external anal sphincter.

Answer 106

B. Anaemia This woman's history of ischemic heart disease means that this level of anaemia (B) is causing a degree of sub-optimal perfusion of the cardiac muscle. This is causing the cheast pain, but isn't actually infarcting (A). The norml troponic and normal ECG confirm ths is not a MI. This woman is on thromboprophylaxis, this makes a PE an unlikely diagnosis (C) Without fever and so rapidly after the operation sepsis (E) is unlikely. The patient dosen't report any SOB or cough, combined with teh parid onset after surgery this makes Atelectasis (D) very unlikely.

Answer 107

A. Aggressive fluid resuscitation, alert the operating surgeon and prepare for a return to theatre This level of systemic shock in a fit, young patient is seriously alarming. It needs to be assumed to be a haemorrhage until proven otherwise. Although the idea of establishing large-bore IV access is always a good idea in a patient such as this, neither a ABG (D) or a fluid challenge (E) are definitive steps in this woman's management. This woman needs decisive life saving resuscitation and potentialy another surgery, options (B) and (C) are simply not enough for a potentially exsanguinating patient. Fluid resuscitation needs to be aggressive and she needs to be back in theatre where the team can decide on next steps (A). In a case such as this you should always tell the origional surgeon that thier patient is showing signs of a significant post-operative bleed.

Answer 108

C. Rectouterine pouch (Pouch of Douglas) The pouch of Douglas (C) is the deepest extent of the peritoneal cavity, if you don't remember this anatomical fact, just remember that this is the site that free fluid inevitibly ends up. It lies between the posterior uterus and the rectum. The Vesicouterine pouch (A), unsurprisingly, lies between the bladder and anterior uterus. Paravesical fossa (B) are either side of the peritoneal covered bladder. Pararectal fossa (D) is similarly either side of teh uper rectum The Rectovesical pouch (E) doesn't exist in the female pelvis as this is where the uterus lies.

Answer 109

D. 720 The RMI uses several factors in it's calculation; * number of pathological ultrasound features (out of 5) * CA 125 score * Menopause status (score 3 for post-menopausal, 0 otherwise) Ultrasound features are; 1. Bilateral cysts 2. multiloculated cysts 3. Cysts with solid components 4. ascites 5. metastases Thus RMI = (U/S score) x (CA 125) x 3 (if postmenopausal) in this case; 2x120x3 = 720 This means she has a 75% chance of cancer, she should be reffered for investigation and work-up

Answer 110

C. Triple swabs for pelvic infection In a 21 year old patient with new onset inter-menstrual bleeding, pelvic infection needs to be investigated with a triple swab (C) She has yet to start the national smear test programme so a smear culd be offered (B) but it isn't the first investigation required. The biosy options (A and E) are rather extreme choices where there is no strong evidence of malignancy, especially in a very young woman. If the first line investigations didn't provide answers,t ehn an ultrasound scan (D)looking at endometrial thickness would be warranted. Only if this was abnormal would you choose to do a pipelle biopsy (E) of the endometrium.

Answer 111

C. Septic shock We can think about (B), (A) and (C) as a spectrum of conditions. SIRS (B) is when the body mounts a continuing systemic inflammatory response to a pathological insult. It is charecterised by a temprature of \<36c or \>38c, HR \>90bpm, tachypnoe \>20 minutes, or white cells \<4 or \>12. The patient meets these initial criteria. If, however, there is evidence of a pthogen then SIRS is classed as sepsis (A). If that sepsis leads to haemodynamic compromise and shock (as we see here with the use of vasopressors), then it is termed septic Shock (C). This is our answer in this scenario. Scepticaemia (D) is simply the isolation of a pthogen from the bloodstream Adult respiratory distress syndrome (E), is caused by insult to the lungs leading to impaired gas exchange. There are also systemic effects in this condition, but it is not the scenarion before us.

Answer 112

A. The ureter passes through the mesometrium and posterior to the uterine artery on its course to the urinary bladder The ureters run down the lateral pelvic side walls, along the anterior border of the greater sciatic notch and under the peritoneum. Medial to the obturator nerve, the ureter lies anterior to the internal iliac artery. It enters the pelvis crossing over the iliac vessels at the level of the bifurcation. The ureter passes underneath the uterine artery about 15 mm lateral to the supravaginal cervix (remember ‘water under the bridge’) before coursing towards the urinary bladder.

Answer 113

D. Ultrasound of the pelvis Although post-menopausal bleeding can be a symptom of ovarian, endometrial and cervical caner, in this case it is more likely to be as a result of her stopping HRT. We shouldn't rely on this assumption though and should investigate. A Hysteroscopy (B) and a pipelle biopsy (A) are both invasive procedures, they are not warrented before the first line investigation of an ultrasound scan to check the endometrial thickness (D) Her smear tests are up to date (C), so this is unecessary. Finally a CT abdo pelvis (E) is a staging tool rather than a diagnostic tool. It's not first line.

Answer 114

C. Endometrial glands with stromal cells The pelvic examination findings are consistent with endometriosis, particularly of note is the description of tiny brown nodules covering the majority of the pelvic structures. It follows that any histology of the excised nodules will show endometrial architecture (C). A krukenberg tumour (A) is a metastatic tumour of the ovary from a gastric primary. Vacuolated clear cells (B) are seen in clear cell adenocarcinoma Both (E) and (D) are suggestive of fibroids.

Answer 115

D. Superior epigastric artery -unfortunately another badly written question- During port insertion any structure, deep or superficial is at risk of damage. Extreme care must be taken. The superior epigastric artery (D) runs paralell to the mid line and anastomeses with the superficial epigastric artery (A) near the umbilicus. It can be seem that the superficial is at risk as it arises from the Femoral and travels to the umbilicus, the superior is nowhere near the site of lateral port insertion. . The two nerves here (C and E) both arises from L1 and are at risk of damage. Option (B) origionally said External iliac vein, this becomes the common iliac at the inguinal ligamnet so is nowhere near the site of port insertion.

Obstetrics and Gynaecology Flashcards

(139 cards)