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Flashcards in Obstetrics and Gynaecology Deck (139):
1

A nervous 42-year-old woman presents herself to your antenatal clinic very worried that she has missed the right time to have her combined test for Down's syndrome screening. She is now 17 weeks pregnant, and is very concerned about her age. You counsel her about the appropriate alternative, the quadruple test and arrange to have this done. What assays make up the quadruple test?

a) AFP, PAPP-A, inhibin B, and beta hCG
b) Unconjugated oestradiol, hCG, AFP, and inhibin A
c) Beta hCG, PAPP-A, nuchal translucency, and inhibin A
d) AFP, inhibin B, beta hCG, and oestradiol
e) Unconjugated oestradiol, PAPP-A, beta hCG, and inhibin A

B

10-13 weeks:
Nuchal translucency
PAPP-A
beta-hCG

14-20 weeks:
Unconjugated oestradiol
Total hCG
AFP
Inhibin A

Integrated test uses the combined test and the quadruple test.

2

A 33-year-old nulliparous woman is 29 weeks pregnant. She was referred to the rapid access breast clinic for investigation of a solitary breast lump. Sadly, a biopsy of this lump revealed a carcinoma. After much counselling from the oncologists and her obstetricians a decision is reached on her further treatment. What option below may be available to her?

a) Tamoxifen
b) Computed tomography (CT) of the abdomen-pelvis
c) Radiography
d) Chemotherapy
e) Bone isotope scan to look for metastases in order to stage the disease

D

Chemotherapy is teratogenic in the first trimester but safer in the mid and third trimesters. Birth should be 2-3wks after most recent session to allow bone marrow regeneration.

Tamoxifen is teratogenic in pregnancy and breastfeeding.

Radiotherapy is contraindicated in pregnancy unless life-saving.

CT and bone isotope scans wouldn't be clinically useful enough to warrant the dose of radiation.

3

A 38-year-old woman with type 2 diabetes attends the maternal medicine clinic. She has a body mass index (BMI) of 48 and is currently controlling her sugars with insulin. You have a long discussion about her weight. What should not be routinely offered to this woman?

a) Post-natal thromboprophylaxis
b) Vitamin C 10mg once a day
c) Regular screening for pre-eclampsia
d) Referral to an obstetric anaesthetist
e) An active third stage of labour as increased risk of postpartum haemorrhage

B

Obesity is a risk factor for maternal death, failed regional anaesthesia, and postpartum haemorrhage.

In pregnant women with a BMI >30kg/m^2:
Offer mechanical and pharmaceutical thromboprophylaxis
Offer screening for diabetes
Give Vitamin D 10mg once a day
Offer an antenatal anaesthetic review
Actively managed the third stage of labour with syntometrine and controlled cord traction.

4

A nulliparous woman is seen at the antenatal clinic 27 weeks into her first pregnancy. Routine screening with a 75g oral glucose tolerance test for gestational diabetes mellitus (GDM) is performed. Which of the following would confirm a diagnosis of GDM?

a) Fasting plasma venous glucose of greater than 5.0μmol/L.
b) 2-hour plasma venous glucose of greater than 7.8μmol/L.
c) Random plasma venous glucose of greater than 4.8μmol/L.
d) 2-hour plasma venous glucose of greater than 7.0μmol/L.
e) 2-hour plasma venous glucose of less than 7.8μmol/L.

B

2-5% pregnancies in the UK are complicated by diabetes, and 85% are GDM.

Risk factors include:
High BMI
Previous macrocosmic baby
Previous GDM
Family history of diabetes
Ethnicity

A 75g OGTT is offered to at risk women, and a 2-hour plasma venous glucose of greater than 7.8μmol/L confirms GDM.

5

A 29-year-old woman is seen at her booking visit and has blood taken for screening. Which of these is the most appropriate set of booking tests?

a) Hepatitis C, HIV, syphilis, and toxoplasmosis
b) Rubella, hepatitis B, hepatitis C, and syphilis
c) Syphilis, rubella, hepatitis B, and HIV
d) HIV, CMV, rubella, and hepatitis B
e) HIV, syphilis, rubella, and group B Streptococcus

C

CMV, toxoplasmosis, and hepatitis C are not cost effective to screen for.

6

A 34-year-old woman attends antenatal clinic for a routine ultrasound scan. Abnormalities of placentation are detected and an MRI scan is organised by the foetal medicine consultant. The MRI report shows: 'The placenta is in the lower anterior uterine wall with evidence of invasion to the posterior wall of the bladder'. What is the most likely diagnosis?

a) Placenta accreta
b) Placenta percreta
c) Placenta increta
d) Placenta praevia
e) Ectopic pregnancy

B

Placenta accreta is firm adhesion of the placenta to the uterine wall without extending through the full myometrium.
Placenta increta extends through the full myometrium.
Placenta percreta extends through and beyond the myometrium, e.g. into the bladder.
Risk factors of the above include uterine scar tissue, for example after uterine cavity surgery.

Placenta praevia attaches to the uterine wall close to the cervical opening.

7

A 30-year-old nulliparous woman is 29 weeks pregnant. She presented to hospital with a history of a minor, unprovoked painless vaginal bleed of about a teaspoonful. Her anomaly scan at 20 weeks showed a low-lying placenta. Her foetus is moving well and CTG is reassuring. What is the most appropriate management.

a) Allow home since the bleed is small
b) Admit and give steroids
c) Admit, IV access, observe bleed-free for 48h before discharge
d) Admit, IV access, Group and Save and administer steroids if bleeds more.
e) Group and Save, FBC, and allow home; review in clinic in a week

D

Antenatal bleeding is common. The most dangerous reasons are placental abruption and placenta praevia.

Abruptions tend to be painful, and this woman has placenta praevia.

Small bleeds can precede larger bleeds so she should be admitted. Steroids tend to be given only if haemodynamically unstable. There is no need to observe for 48h due to the risk of VTE and nosocomial infections.

8

A 28-year-old pregnant woman attends accident and emergency with a history of clear vaginal loss. She is 18 weeks pregnant and so far has had no problems. Her past medical history includes a large cone biopsy of the cervix and she is allergic to penicillin. She is worried because the fluid continues to come and there is now some blood. On examination it is apparent that her membranes have ruptured. What is the most appropriate initial management.

a) Discharge, USS the next day
b) Offer her a termination as it is not possible for this pregnancy to continue
c) Admit, infection markers, USS, and steroids
d) USS, infection markers, and observation
e) Discharge and explain that she will probably miscarry at home

D

Rupture of membranes this early almost always ends in miscarriage, and large cone biopsy of the cervix is a risk factor for second trimester miscarriage.

She should be admitted, observed, and investigated for infections. The biggest concern is risk of ascending infection, chorioamnionitis, and sepsis from PROM.

In the case of sepsis, induction is required, but as the gestation is under <24wks, steroids for foetal lung maturity are not indicated. She may spontaneously miscarry, or get to 24wks, when steroids and premature delivery may be considered.

PPROM management involves a 10d course of Abx prophylaxis against chorioamnionitis and steroids to aid lung maturation before the 34th week, delivering between 34 and 36 weeks.

9

A 37-year-old woman in her fourth ongoing pregnancy presents to the labour ward at 34 weeks' gestation complaining of a sharp pain in her chest, worse on inspiration. An ABG shows: pH 7.51, PO2 8.0kPa, PCO2 4.61kPa, BE 0.9. What is the most appropriate investigation?

a) CTPA
b) MRI
c) D-dimer
d) V/Q scintigraphy
e) USS

D

She likely has a PE, so needs urgent definitive diagnosis. CTPA or V/Q scans will provide this. V/Q scans have a lower radiation dose so are preferred.

10

A 32-year-old woman in her second pregnancy presents at 36 weeks gestation with a history of a passing gush of blood stained fluid from the vagina an hour ago, followed by a constant trickle since. The admitting obstetrician reviews her history and weekly antenatal ultrasound scans have shown a placenta praevia. She has a firm, posterior cervix, and has not been experiencing any contractions. What is the most appropriate management?

a) Induction of labour with a synthetic oxytocin drip
b) Cervical ripening with prostaglandins followed by a synthetic oxytocin drip
c) Digital examination to assess the position of the foetus
d) Monitor for 24 hours and manage as for preterm pre-labour rupture of membranes
e) Caesarean delivery

E

This is PPROM with placenta praevia, so vaginal delivery is not an option. Digital examinations are contraindicated with antepartum haemorrhage.

Option D involves a 10d course of Abx prophylaxis against chorioamnionitis and steroids to aid lung maturation before the 34th week, delivering between 34 and 36 weeks. As this woman is 36 weeks pregnant, delivery must be expedited with a caesarean section.

11

Maternal physiology changes throughout the pregnancy to cope with the additional demands of carrying a foetus. Which of the following changes best represents a normal pregnancy?

a) Stroke volume increases by 10% by the start of the third trimester
b) Plasma volume increases disproportionately to the change in red cell mass creating a relative anaemia
c) Plasma levels of fibrinogen fall, reaching a trough in the mid-trimester
d) Systemic arterial pressure rises to 10mmHg above the baseline by term
e) Aortocaval compression reduces venous return to the heart, in turn increasing pulmonary and arterial pressure

B

Stroke volume increases from the first trimester to over 30% higher by the third trimester.

Plasma fibrinogen, and factors VII, X, and XII, increase throughout pregnancy.

Systemic and pulmonary arterial pressures do not alter.

Aortocaval compression does occur, but does not affect pulmonary circulation.

12

A 30-year-old woman attends the antenatal clinic asking to be sterilised at the time of her elective caesarean. She is 34 weeks into her second pregnancy having had her first child 2 years ago via an emergency caesarean section. She is not sure that she wants any more children. Further more, she does not wish to try for a vaginal birth. She has tried the contraceptive pill in the past but does not like the side effects. You talk to her about other options, including the sterilisation she is requesting. What is the best management option for this woman?

a) Mirena coil
b) Sterilisation at the time of her caesarean section
c) T380 coil
d) Implanon
e) Vasectomy

C

As she is 'not sure that she wants any more children', sterilisation is not the best option.

She doesn't like the side effects of hormonal contraception, so Mirena coil and Implanon are not applicable.

Vasectomy requires her partner to make a decision, and is also not applicable in this situation.

13

A 41-year-old multipara attends the antenatal clinic at 36 weeks gestation complaining of lower abdominal cramps and fatigue when mobilising. Clinical examination is unremarkable save for a grade 1 pan systolic murmur, loudest over the fourth intercostal space in the midaxillary line. What is the most appropriate management?

a) Urgent outpatient echocardiogram and referral to a maternal-foetal medicine consultant
b) Reassurance and a 38-week antenatal clinic follow-up
c) Admission and work-up for cardiomyopathy
d) Post-natal referral to a cardiologist
e) Admission to the labour ward for induction of labour

B

The described murmur is mild tricuspid regurgitation, which is physiological in pregnancy.

Lower abdominal cramps and fatigue are also common symptoms in pregnancy.

14

A 32-year-old HIV positive woman who booked for antenatal care at 28 weeks gestation arrives on the delivery suite at 37 weeks with painful regular contractions and a cervix dilated to 4cm. Ultrasonography confirms a breech singleton pregnancy with a reactive foetal heart rate.

a) Await onset of labour, avoid operative delivery, wash the baby at delivery
b) Induce labour with synthetic prostaglandins
c) Await onset of labour, but have a low threshold for expediting vaginal delivery using forceps
d) Await onset of labour, avoid operative delivery, administer steroids to the infant immediately after birth
e) Caesarean delivery, wash the baby at delivery

E

As this lady is not in established labour, and has a breech singleton pregnancy, a caesarean delivery has the best foetal outcome.

In HIV positive women, washing of the baby after delivery can reduce risk of vertical transmission, but does not change the choice for caesarean section delivery.

15

A 41-year-old multiparous woman attends A&E at 32 weeks gestation complaining of sudden onset shortness of breath. A CTPA demonstrates a large saddle embolus. What is the most appropriate treatment regimen?

a) Load with warfarin to achieve a target INR of 3.0
b) Load with warfarin to achieve a target INR of 2.5
c) Load with warfarin to achieve a target INR of 20
d) 80mg enoxaparin twice daily
e) 7.5mg fondaparinux once daily

D

Warfarin is teratogenic in all trimesters but in different ways depending on gestational age.

Enoxaparin and fondaparinux are both indicated in PE treatment, but efficacy and safety of fondaparinux in pregnancy is not supported by evidence, whereas enoxaparin is.

16

A 21-year-old woman attends the labour ward with per vaginal bleeding of 100mL. She is 32 weeks pregnant and has had one normal delivery in the past. An important history to note is that of an antepartum haemorrhage in her last pregnancy, and she smokes 10 cigarettes a day. Her 20-week anomaly ultrasound revealed a posterior fundal placenta. She admits she and her partner had intercourse last night and is concerned by terrible abdominal pains. What is the most likely diagnosis?

a) Vasa praevia
b) Placenta praevia
c) Placenta accreta
d) Placental abruption
e) Cervical ectropion

D
Painful antenatal haemorrhage is a worrying symptom of placental abruption. Abruption is life threatening to mother and child.

Placenta accreta is firm adhesion of the placenta to the uterine wall without extending through the full myometrium. Placenta increta extends through the full myometrium. Placenta percreta extends through and beyond the myometrium. Risk is increased in intrauterine scarring.

Placenta praevia attaches to the uterine wall close to the cervical opening, and is characteristically a painless bleed.

Vasa praevia is a rare painless bleed on ROM, associated with sudden foetal compromise and often intrauterine death.

Cervical ectropion is a normal phenomonen and causes painless vaginal bleeding.

17

At a booking visit, a first time mother is told that she is rhesus negative. Which of these answers is the most appropriate advice for the mother?

a) It is important to have anti-D as it will make sure your baby does not develop antibodies
b) If you have any bleeding before 12 weeks be sure to get an injection of anti-D
c) Anti-D will stop your body creating antibodies to your baby's blood that may help protect the health of your next child
d) If your partner is rhesus negative you do not need to have anti-D
e) You need one injection that will cover your pregnancy even if you have episodes of vaginal bleeding

C

Foeto-maternal transfer of blood in Rh- mothers of Rh+ babies causes maternal sensitisation with production of anti-D antibodies.
Subsequent Rh+ babies' RBCs will be attacked by the maternal anti-D antibodies, causing haemolytic anaemia.

1500IU of anti-D is given at 28wks, with further doses in the case of sensitising events such as vaginal bleeding, abdominal trauma, or ECV.

Rh- fathers would indicate a Rh- baby, but as many 1 in 10 partners are not the real fathers, so it can't be assumed.

18

A 42-year-old para 4 with a dichorionic-diamniotic twin pregnancy at 31 weeks gestation presents to hospital with a painful per vaginal bleed of 400mL. The bleeding seems to be slowing. She is cardiovascularly stable, although having abdominal pains every 10 minutes. There is still a small active bleed on speculum and the cervix appears closed. Both foetuses have reactive CTGs. She has had no problems antenatally, and her 28-week ultrasound revealed both placentas to be well away from the cervix. What is your preferred management plan?

a) Admit to antenatal ward, ABC, IV access, Group and Save, CTG, steroids, consider expediting delivery
b) Reassure and ask to come back to clinic next week if there are any problems
c) Admit for observation, IV access
d) Admit to labour ward, ABC, IV access, FBC, cross-match 4 units of blood, CTG, steroids, consider expediting delivery
e) As bleeding settled and placenta not low, offer admission but arrange follow-up if refused

D

Painful vaginal bleeding is in keeping with placental abruption, which is a very serious complication.
Admission, ABC, IV access, Group and Save, and CTG should be done to monitor and prepare. 4U of blood should be cross-matched as there is a high risk of blood transfusion required. Steroids should be given to aid foetal lung maturation, and admission should be to the labour ward in order to prepare for emergency delivery.

19

You are the FY1 covering the antenatal ward. A 27-year-old nulliparous woman who is 36 weeks and 5 days pregnant has been admitted to your ward with suspected pre-eclampsia. The emergency buzzer goes off in her room. You are the first to attend and find your patient flat on the bed having a generalised seizure - what do you do?

a) Call for help, ABC, nasopharyngeal airway, IV access, and wait for fit to stop
b) Call for help, ABC, protect her airway, prepare for grade 1 caesarean section
c) Call for help, ABC, left lateral tilt, wait for seizure to end, listen to foetus
d) Call for help, ABC, left lateral tilt, protect airway, prepare magnesium
e) Call for help, ABC, protect airway, prepare magnesium, check blood pressure

D

This is an eclamptic fit, which is a life-threatening situation.

The left lateral position should be assumed and her airway protected. Additional airway insertion and obtaining IV access is dangerous in an actively fitting woman. Magnesium sulphate is a cerebral membrane stabiliser and must be given ASAP.

The mother, and not the foetus, must be the primary concern, so checking foetal heart before stabilising and monitoring the mother is incorrect.

20

A 38-year old woman in her first pregnancy is 36 weeks pregnant. She presents to the labour ward feeling dizzy with a mild headache and flashing lights. Her past medical history includes SLE, renal stones, and malaria. Her BP is 158/99 mmHg with 2+ protein in her urine. Her platelets are 55X10^9/L, Hb 10.1 g/dL, bilirubin 62 62 μmol/L, ALT 359 IU/L, urea 2.3mmol/L and creatinine 64 μmol/L. What is the most likely diagnosis?

a) TTP
b) HELLP syndrome
c) ITP
d) SLE
e) HIV

B

TTP is microangiopathic haemolytic anaemia, thrombocytopenia, fever, neurological involvement, and renal impairment.

HELLP is pre-eclampsia with haemolysis, elevated LFTs, and low platelets.

ITP is a diagnosis of exclusion.

SLE and HIV can both cause thrombocytopenia, but are unlikely compared to HELLP.

21

A 19-year-old woman in her first pregnancy presents to the GUM clinic with an outbreak of primary herpes simplex infection on her labia. She is 33 weeks pregnant. What is the best advice regarding her herpes?

a) Aciclovir from 36 weeks until delivery
b) Caesarean section should be performed if she labours within the next 8 weeks
c) Reassure as the infection will pass and pose no further concern
d) If she labours within 6 weeks, a caesarean should be recommended
e) Aciclovir for 10 days and an elective caesarean at 39 weeks

D

Primary herpes during pregnancy may risk vertical transmission. If the infection is within 6 weeks of the due date, or labour is within 6 weeks, caesarean section is recommended. If refused, IV acyclovir during labour and close postnatal monitoring is used.

22

A 33-year old woman presents to hospital with a 2-day history of itching on the soles of her feet and the plasma of her hands. Her pregnancy has been straightforward and she has good foetal movements. LFTs reveal an ALT of 64 IU/L and bile acids of 30 μmol/L. You suspect that she might have developed obstetric cholestasis. Which of the following bits of advice is true.

a) She could have intermittent monitoring in labour
b) US and CTG surveillance help prevent stillbirth
c) Poor outcomes can be predicted by bile acid levels
d) UDCA helps prevent stillbirth
e) Meconium stained liquor is more common in labour

E

Obstetric cholestasis is pruritus and deranged LFTs. LFTs should thence be monitored weekly.

The main concern is stillbirth, which cannot be predicted. Preterm labour and meconium stained liquor is more likely. Continuous CTG should be done throughout labour.

UDCA is not licensed but helps itching with no apparent side effects, though it doesn't help prevent stillbirth.

23

A 24-year-old woman who is 32 weeks pregnant presents to the labour ward with a terrible headache that has not improved despite analgesia. It started 2 days ago and came on suddenly. She has stayed in bed as it hurts to be in sunlight and she vomited twice this morning. Her past medical history includes a macroprolactinoma (which has been removed) and occasional migraines. She is haemodynamically stable with no focal neurology or papilloedema. You arrange for her to have an emergency head CT, which adds no further information to aid your diagnosis. There are red cells on lumbar puncture, but no organisms are isolated. What is the most likely diagnosis?

a) Migraine
b) Viral meningitis
c) Cerebral vein thrombosis
d) Subarachnoid haemorrhage
e) Idiopathic intracranial hypertension

A

Migraines are most common, particularly in pregnancy, and presents with these symptoms. All the other causes present with the above symptoms, too.

Viral meningitis would also give fever, and neck stiffness.

CVTs classically presents postpartum. 2/3 also have neural deficits.

SAH often has papilloedema, and focal neurology.

IIH is associated with papilloedema in young obese women. It is raised ICP with no hydrocephalus or SOLs.

24

A 19-year-old woman in her first pregnancy is admitted to the labour ward with a 4-hour history of lower abdominal pain - she is 22 weeks pregnant. She has not had any vaginal bleeding but describes a possible history of rupture of her membranes. Her past medical history includes and appendicectomy and a large cone biopsy of her cervix. On examination she has palpable lower abdominal tenderness, her cervix is 2cm dilated, she has an offensive vaginal discharge and her temperature is 38.9C. Her WCC is 19.0x10^9/L and her CRP is 188 mg/L. There are no signs of cardiovascular compromise. How would you manage this woman?

a) Insert a cervical suture
b) 12 mg betamethasone, atosiban for tocolysis and antibiotics
c) Head down, bed rest, antibiotics, and await events
d) Antibiotics and induce labour
e) Caesarean section

D

This woman is septic, with PROM, offensive vaginal discharge, abdominal pain, fever, and past history of cone biopsy.

She must be treated with antibiotics and, sadly, induction of labour.

Cervical sutures and tocolysis are contraindicated in infection.

The foetus is not viable, so steroids are not indicated.

25

A 24-year-old multiparous woman is 23 weeks pregnant. She has not had chicken pox before. She goes to 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 acyclovir.
b) Test for varicella antibodies and give VZIG within the first 24h
c) Test for varicella antibodies and give acyclovir 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

D

Pregnant women are at higher risk of complications from chicken pox, and foetal varicella syndrome is a risk before 28 weeks gestation.

Varicella antibodies should be tested for, and VZIG given within 10 days if her antibody screen is negative.

Acyclovir is only used to treat chicken pox within 24 hours of the rash appearing, so is not necessary yet.

26

A 32-year-old woman in her third pregnancy is 37 weeks pregnant and has an extended breech baby on ultrasound. After discussion in the antenatal clinic, which of the following is not an absolute contraindication to an external cephalic version?

a) Multiple pregnancy
b) Major uterine abnormality
c) Antepartum haemorrhage within 7 days
d) Rupture of membranes
e) Small for gestational age with abnormal Doppler scan

E

3-4% of babies are breech at term. ECV is offered from 36wks in nullips, and 37wks in multips. Success ranges from 30-80%.

Relative CIs:
Small for gestational age with abnormal Doppler scan
Pre-eclampsia
Scarred uterus
Oligohydramnios

Absolute CIs (little or no room to turn foetus, or risk of abruption):
Multiple pregnancy
Major uterine abnormalities
Antepartum haemorrhage
ROM

27

A 24-year-old type 1 diabetic woman has just had her first baby delivered by caesarean section at 35 weeks due to foetal macrosomia and poor blood sugar control. The operation is straightforward with no complications. She has an insulin sliding scale running when you review her on the ward 12 hours postoperatively. She has begun to eat and drink. How would you manage her insulin requirements?

a) Continue the sliding scale for 24 hours
b) Change her back to her pre-pregnancy insulin and stop the sliding scale
c) Halve the dose of insulin with each meal for the next 48 hours
d) Stop the insulin now that baby is delivered
e) Sliding scale for 48 hours to prevent hyperglycaemia

B

As soon as the mother is eating and drinking again (usually around 6h after operation), pre-pregnancy insulin can be started, and the sliding scale can be stopped.

28

A 19-year-old woman is referred to your pre-conception clinic. She has SLE and wants to fall pregnant. She is currently not on any treatment and has no symptoms. As part of your general counselling you should talk about the risks associated with pregnancy. Which of the following is not a particular risk to a woman with SLE?

a) Foetal growth restriction
b) Diabetes mellitus
c) Pre-eclampsia
d) Stillbirth
e) Preterm delivery

B

Pregnancy increases the likelihood of a flare of SLE by 40-60%.

Risks include:
Spontaneous miscarriage
Foetal death
Pre-eclampsia
Preterm delivery
Foetal growth restriction

29

A 44-year-old woman who is 18 weeks pregnant presents to your clinic with a 2-day history of a viral illness. She is extremely anxious and is in floods of tears. She recently had some soft cheese in a restaurant and after an internet search she is convinced she has a particular infection. What infection is she concerned about?

a) Toxoplasmosis
b) Cytomegalovirus
c) Listeria monocytogenes
d) Hepatitis E
e) Parvovirus B19

C

Listeriosis is a food-borne infection often by unpasteurised cheese and pate. It can cause mid-trimester loss, early meconium, and preterm labour.

30

A 26-year-old woman is 37 weeks pregnant and consults you about a rash that started on her abdomen and has now spread all over her body. Interestingly, her umbilicus is spared. The rash is very itchy and nothing is helping. The rash is her first problem in this pregnancy. Of interest, her mother has pemphigoid and her sister has psoriasis. What is the most likely cause of her rash?

a) Pemphigoid gestationis
b) Pruritic urticarial papules and plaques of pregnancy (PUPP)
c) Impetigo herpetiformis
d) Prurigo gestationis
e) Contact dermatitis

B

PUPP starts in stretch marks on the abdomen, spreads over the body with periumbilical sparing. It starts at 34wks and disappears after birth.

Pemphigoid gestationis is blistering of the umbilicus spreading over the body.

Impetigo herpetiformis is a blistering condition with fever that can cause maternal and foetal death.

Prurigo gestationis is a rash of the trunk and upper limbs with abdominal sparing.

31

Which of the following drugs is not absolutely contraindicated in pregnancy?

a) Acitretin
b) Fluconazole
c) Mebendazole
d) Sodium valproate
e) Methotrexate

D

Sodium valproate can cause congenital malformations, but if it is the best form of epilepsy control it should be used.

Acitretin and methotrexate are teratogenic. Mebendazole is toxic in animal studies. Fluconazole causes congenital abnormalities.

32

A 42-year-old woman is in her first pregnancy. She conceived with IVF, and has had a straightforward pregnancy so far. At 25 weeks gestation she is seen in clinic with a BP of 142/94 mmHg and protein + in her urine. A protein creatinine ratio (PCR) comes back as 19. She says that her BP is often up at the doctor's. With the information you have to hand what is the most likely diagnosis?

a) Pre-eclampsia
b) White coat hypertension
c) Essential hypertension
d) Conn's syndrome
e) Pregnancy-induced hypertension

E
Pregnancy induced hypertension is higher risk here as she's a 42 year old primip with IVF.

Normally, BP in pregnancy falls to a trough from weeks 22 to 24, and then rises throughout pregnancy.

Pre-eclampsia is a raised BP with proteinuria (PCR >30).

33

A 24-year-old woman attends the antenatal clinic. She has had a GTT which is abnormal. A diagnosis of GDM is made. The primary purpose of this appointment is to explain to her what GDM means to her and her baby. You explain to her that sugar control is important and there are specific glucose ranges that she should try to adhere to. Which of the following would be correct advice for this woman?

a) Pre-meal blood sugar <7.1 μmol/L
b) Post-meal 1-hour sugar <11.1 μmol/L
c) Post-meal 1-hour sugar <7.8 μmol/L
d) Post-meal 2-hour blood sugar <7.8 μmol/L
e) Pre-meal blood sugar <7.8 μmol/L

C

In pregnancy, pre-meal blood sugars should be below 5.5μmol/L, and 1-hour post-meal should be below 7.8μmol/L. Outside of pregnancy, 2-hour post-meal measurements are used.

The risks of diabetes in pregnancy include:
Neonatal hypoglycaemia
Pre-eclampsia
Pre-term labour
Polyhydramnios
Macrosomia
Shoulder dystocia

34

A 24-year-old woman in her first pregnancy has a significantly raised GTT at 28 weeks gestation: 4.6 μmol/L fasting; 12.1 μmol/L at one hour; 9.1 μmol/L at 2 hours. She is given the diagnosis of GDM. You are asked to counsel her about the effects of gestational diabetes on pregnancy. Which of the following is not an additional effect of having GDM.

a) Shoulder dystocia with a macrocosmic foetus
b) Stillbirth
c) Neonatal hypoglycaemia
d) 10% chance of developing type 2 diabetes over the next 10 years
e) Pre-eclampsia

D

The risks of diabetes in pregnancy include:
Neonatal hypoglycaemia
Pre-eclampsia
Pre-term labour
Polyhydramnios
Macrosomia
Shoulder dystocia

Women with GDM also have a 35-60% chance of developing type 2 diabetes over the next 10 - 15 years.

Delivery is recommended after 38 weeks unless glycemic control is very poor.

35

A 24-year-old woman who is HIV positive is in her first pregnancy. She is 39 weeks pregnant and is seen by you in the antenatal clinic. She has just transferred to your care, with no other previous antenatal care. She reports that her pregnancy has been uncomplicated. Her CD4 count is 180/mm^3 and her viral load is 5500 copies/mL. She has come to find out what advice you have for her delivery.

a) SVD
b) Induction of labour to prevent CD4 decreasing
c) Caesarean section
d) Start HAART and await for labour to start
e) Start HAART, amniotomy, and HAART for baby when born

C

A low CD4 count and high viral load means she's at risk of AIDS and of vertical transmission. HIV positive mothers should be started on HAART if necessary throughout the pregnancy and onwards, or alternatively antiretroviral treatment from 20 to 28 weeks to prevent transmission.

Viral loads of below 50 copies/mL allow a normal delivery, avoiding prolonged and artificial ROM.

This is a high risk pregnancy, and should be delivered by caesarean section to reduce the risk of vertical transmission.

36

A 24-year-old woman attends A&E 4 weeks after a positive urinary pregnancy test. She has had 3 days of painless vaginal bleeding and is passing clots. Over the past 2 days, the bleeding has settled. An ultrasound scan shows an empty uterus. What is the correct diagnosis?

a) Threatened abortion
b) Missed miscarriage
c) Septic abortion
d) Complete abortion
e) Incomplete miscarriage

D

Abortion and miscarriage historically mean the same thing. Now, the word abortion tends to be avoided, differentiating by using miscarriage and termination.

Threatened abortion is vaginal bleeding before viability (as opposed to antepartum haemorrhage, which is vaginal bleeding after 24 weeks).

Missed miscarriage is the loss of pregnancy without passed products of conception of bleeding.

Septic abortion is loss of an early pregnancy complicated by infection of a retained conceptus.

Complete abortion is loss of pregnancy with expulsion of products of conception.

Incomplete miscarriage is loss of an early pregnancy with bleeding but not total expulsion of products of conception.

37

A 51-year-old woman in her 12th week of an assisted-conception triplet pregnancy presents to A&E with severe nausea and vomiting. She has mild lower abdominal and back pains. Urine dipstick shows blood -ve, protein -ve, ketones ++++, glucose +. What is the most appropriate management plan?

a) IV crystalloids and doxycycline, urgent USS
b) Discharge with 1 week's ciprofloxacin
c) Referral to the medics for investigation of viral gastroenteritis
d) IV crystalloids, oral antiemetics
e) Referral to the surgeons for investifation of appendicitis

D

This is hyperemesis gravidarum. HG affects 2% of pregnancies and causes dehydration. Risk is increased in multiple pregnancies.

The mild abdominal and back pain are normal symptoms of pregnancy.

38

A 19-year-old woman is referred to your early pregnancy unit as she is having some vaginal bleeding. This is her first pregnancy, she has regular menses and the date of her last menstrual period suggests she is 8 weeks gestation today. She is well apart from her bleeding and is naturally concerned. A transvaginal ultrasound reveals an intrauterine gestational sac of 18mm with a yolk sac. What is the most likely explanation of these findings?

a) A viable intrauterine pregnancy
b) A pseudosac
c) A blighted ovum
d) A pregnancy of uncertain viability
e) An anembryonic pregnancy

D

Abdominal pain and vaginal bleeding in early pregnancy have a 20% miscarriage rate.

This woman is having a threatened miscarriage. There is no foetal pole or foetal pulsation so it isn't clear if it is viable. The scan should be repeated in 10-14d.

Blighted ovum and an embryonic pregnancies are the same, but yolk sac would not be present. If anembryonic pregnancies are suspected, two scans must be done 10-14d apart to confirm.

Pseudosacs are found in 10-20% of ectopic pregnancies, and are decimal reactions with no yolk sac.

39

A 31-year-old woman is seen in the TOP clinic requesting a termination. She is 5 weeks pregnant in her first pregnancy. She is otherwise well but does have some lower abdominal pain on the right hand side. On examination her abdomen is soft and non-tender. An ultrasound reveals a small sac in the uterus which might be a pseudosac. What would be your next management step?

a) Urgent referral to hospital to rule out ectopic pregnancy
b) Rescan in 10d time
c) Blood test for beta hCG now and in 48 hours time
d) Arrange for her to come in for a medical termination
e) Arrange a surgical termination of pregnancy

C

Pregnancy must be confirmed before TOP is offered.

A pseudosac is a decimal reaction to an ectopic pregnancy. It's unclear that this is a pseudosac, and she is stable and well, so (with safety netting with symptoms of ectopics) she can be managed as an outpatient.

A beta hCG would be required with a repeat in 48h. A 67% rise would suggest that the sac was a viable pregnancy, and a USS in 10-14d would confirm. A TOP could then be arranged. A rise lower than that should be seen in hospital for assessment.

40

A 28-year-old woman with a history of pelvic inflammatory disease is 6 weeks into her third pregnancy. She previously had two terminations. She presents with lower abdominal pain and per vaginal bleeding. Her beta hCG is 1650 mIU/mL, progesterone 11nmol/L. An USS reveals a small mass in her left fallopian tube with no intrauterine pregnancy seen. There is no free fluid in the pouch of Douglas. She is diagnosed with an ectopic pregnancy and is clinically stable but scared of surgery. How would you manage this case?

a) Laparoscopic salpingectomy
b) Methotrexate
c) Laparotomy and salpingectomy
d) Laparoscopic salpingotomy
e) Beta hCG in 48h

B

Methotrexate is given IM if the ectopic is small, with no foetal pulse, no clinical compromise, and no free fluid in the pouch of Douglas.

Surgery has a potential risk of decreasing future fertility.

Risk factors for ectopic:
Previous tubal surgery
Intrauterine use
Pelvic infection
IVF

Risk of ectopic:
Rupture
Intra-abdominal bleed
Acute collapse
Death

Tubal miscarriage can avoid ectopic rupture, which is detected by a fall in beta hCG.

41

A 24-year-old woman attends her GP complaining of deep dyspareunia and post-coital bleeding. She has cramps lower abdominal pain. Of note, she has been treated in the past for gonorrhoea on more than one occasion. On speculum examination there is no visible discharge, but the cervix bleeds easily on contact. What is the most appropriate management?

a) IM cefotaxime, oral doxycycline and metronidazole
b) 1g oral metronidazole stat
c) Urgent referral to the gynaecology clinic
d) Referral to a sexual health clinic
e) Admission to hospital under the gynaecologists

C

An easily bleeding cervix, deep dyspareunia, post-coital bleeding, and a history of STIs raises suspicion of cervical cancer. At 24, she is unlikely to have had previous cervical smears.

The presentation may be STIs or pelvic inflammatory disease, but urgent referral is required nonetheless. Treatment for PID (IM cefotaxime, oral doxycycline and metronidazole) may also be started in tandem with these investigations.

42

A 16-year-old girl attends A&E complaining of mild vaginal spotting. Her serum beta hCG is 4016 mIU/mL. She is complaining of severe left iliac fossa pain and stabbing sensations in her shoulder tip. What is the most appropriate definitive investigation?

a) Diagnostic laparoscopy
b) Serial serum beta hCG measurement
c) CT abdomen and pelvis
d) Clinical assessment with speculum and digital vaginal examination
e) Transvaginal USS

E

This describes potential ectopic pregnancy.

CT should be avoided due to radiation dose to the foetus, with teratogenicity of radiation highest in the first trimester.

Clinical assessment, and serial beta hCG measurements are the routine initial investigations, but are not definitive.

Transvaginal USS would provide the highest chance of a definitive diagnosis, followed by confirmation via diagnostic and therapeutic laparoscopy. Beta hCG of above 1000mIU/mL usually gives a visible pregnancy on TVUSS, and certainly above 1500mIU/mL.

Diagnostic laparoscopy would not be appropriate without US imaging.

43

An 18-year-old woman presents to A&E having fainted at work. She is complaining of pain in the lower abdomen. A serum beta hCG performed in the emergency department is 3020 mIU/mL. The on-call gynaecologist performs transvaginal USS in the resuscitation area which shows free fluid in the pouch of Douglas and no visible intrauterine pregnancy. Her pulse is 120bpm and BP 90/45 mmHg. What is the most likely diagnosis?

a) Rupture ovarian cyst
b) Cervical ectopic pregnancy
c) Ruptured tubal pregnancy
d) Perforated appendix
e) Ovarian torsion

C

Lower abdominal pain, positive pregnancy test, and haemodynamic instability suggest an ectopic pregnancy.

The haemodynamic instability suggests it wouldn't be a ruptured cyst or ovarian torsion. Both have sudden onset pain, and ruptured cyst pain often subsides with simple analgesia, whereas ovarian torsion does not.

At this level of beta hCG, a cervical ectopic pregnancy would be visible on TVUSS. Therefore, a ruptured tubal pregnancy is likely, and is a surgical emergency.

44

A 50-year-old woman comes to your clinic with a 2-year history of no periods. Her GP has confirmed that her LH and FSH levels are menopausal. Her night sweats and hot flushes are unbearable and are preventing her from going to work. She would like to start HRT, but is very worried about the side effects. Which of the following is incorrect?

a) There is evidence that HRT prevents coronary heart disease
b) There is a small increase in the risk of strokes
c) There is an increased risk of breast cancer
d) There is an increase in the risk of ovarian cancer
e) There is an increase in the rate of VTE

A

Starting HRT 10 years post-menopause actually increases the risk of heart disease.

The rest are true, as is increased risk of endometrial cancer in oestrogen-only HRT.

45

A 24-year old woman who is 9 weeks pregnant is brought to A and E by ambulance with left iliac fossa pain and a small vaginal bleed. An abdominal USS performed at the bedside demonstrates a corneal pregnancy and free fluid in the pelvis. Her observations are: pulse 119bpm, BP 74/40 mmHg, RR 24/minute. What is the most appropriate definitive management?

a) Transvaginal USS
b) Serum beta hCG estimation
c) Diagnostic laparoscopy
d) Admission to the gynaecology ward and fluid resuscitation
e) Urine pregnancy test

C

Lower abdominal pain, positive pregnancy test, and haemodynamic instability suggest an ectopic pregnancy. This is confirmed by USS.

TVUSS, serum beta hCG, and urine pregnancy tests would be unlikely to give more information.

This is a surgical emergency, so admission to a ward would not be appropriate, and diagnostic laparoscopy would be the correct option.

46

A 26-year old woman presents to A and E with left-sided lower abdominal pain and a single episode of vaginal spotting the day before. A urinary beta hCG is positive, and her last period was 6 weeks ago. A transvaginal USS shows two gestational sacs. What is the most likely diagnosis?

a) Ruptured theca lutein cyst
b) Appendicitis
c) Diverticulitis
d) Complete miscarriage
e) UTI

A

Functional ovarian cysts are common in women of childbearing age. One type is a theca lutein cyst which is composed of luteinised follicular cells, triggered by high levels of beta hCG (e.g. in multiple pregnancy).

This woman is pregnant with twins, and has developed a cyst as a result, that has ruptured.

47

A 59-year-old woman attends the gynaecology clinic complaining of worsening pain during penetrative sexual intercourse. She went through the menopause 9 years before, with very few problems, and did not require HRT. She has been with the same partner for 4 years since the death of her husband with whom she had four children. What is the most likely diagnosis?

a) Ovarian malignancy
b) Chlamydia trachomatis infection
c) Discoid lupus erythematous
d) Atrophic vaginitis
e) Bacterial vaginosis

D

Post-menopause, vaginal lining atrophies progressively as oestrogen levels decrease.

It is important to exclude STIs, acute intrapelvic conditions, and cervical pathology.

48

A 19-year-old woman is referred to A and E with a fluctuant lower right abdominal pain which started over the course of the morning, associated with vomiting. There is rebound tenderness on examination. She is afebrile. Serum beta hCG is negative. An ultrasound shows free fluid in the peritoneal cavity but no other pathology to account for the pain. White cells are 14x10^9/L and the CRP is 184 mg/L. What is the most likely diagnosis?

a) Acute appendicitis
b) Early ectopic pregnancy
c) Pelvic inflammatory disease
d) Tubo-ovarian abscess
e) Ovarian torsion

A

The location of the pain, the rebound tenderness, and high CRP suggest acute appendicitis.

Ectopic pregnancies would give a positive serum beta hCG.

PID and tube-ovarian abscess would cause fever and high white cell count.

Ovarian torsion tends to be constant pain rather than fluctuating.

49

A 39-year-old woman is seen in the gynaecology clinic having been diagnosed with polycystic ovarian syndrome (PCOS). She has lots of questions in particular about the associated long-tern risks. Which of the following is not a risk of PCOS?

a) Endometrial hyperplasia
b) Sleep apnoea
c) Diabetes
d) Breast cancer
e) Acne

D

PCOS is diagnosed by two of:
Oligo/amennhorea
Polycystic ovarise
Clinical/biochemical signs of hyperandrogenism

All but breast cancer are long term risks of PCOS. Diet, weight control, and exercise are key to prevent these risks.

50

A 54-year-old menopausal woman comes to your clinic desperate for HRT as her vasomotor symptoms are very troubling. Her next door neighbour recently developed a DVT while on HRT. She is concerned about the risks of VTE and wants your advice. Which of the following would you not advise?

a) The risk of VTE is highest in the first year of taking HRT
b) She should have a thrombophilia screen prior to starting HRT
c) There is no evidence of a continuing VTE risk after stopping HRT
d) Personal history of VTE is a contraindication to oral HRT
e) If she develops any VTE while on HRT it should be stopped immediately

B

It is not routine to offer thrombophilia screens before starting HRT, but it might be sensible if there was a family history of VTE.

51

A 34-year-old woman with long-standing menorrhagia attends A and E having fainted at home. She is on the third day of her period, which has been unusually heavy this month. She insists she cannot be pregnant as she has not had sexual intercourse for a year. She is haemodynamically stable. A point-of-care test venous FBC in the emergency department shows:

Hb 5.2g/dL
WCC 8.9x10^9/L
Hct 0.41% L
MCV 80 fL

What should the initial management be?

a) Establish large-bore venous access, commence fluid resuscitation and cross-match four units of packed red cells
b) Call for senior help, establish large-bore venous access and prepare the patient for urgent laparotomy
c) Call for senior help, establish large-bore venous access and give group O Rh negative blood
d) Establish large-bore venous access and begin transfusing group-specific blood as soon as it is available
e) Await the result of a beta hCG test before deciding further management

A

This is significant normocytic anaemia as a result of blood loss from menorrhagia. Fluid resuscitation is needed.

Rapid decompensation may occur, despite her current haemodynamic stability. As she is currently stable, though, the risks of giving non-cross-matched blood are not justified.

A laparotomy is not indicated yet as menorrhagia is the supposed cause, and this would not aid diagnosis.

52

A 66-year-old post-menopausal woman is referred to you urgently by her GP. She had been complaining of some lower abdominal pain. An USS arranged by the GP shows a 4cm simple left ovarian cyst. A CA 125 comes back as 29 U/mL (normal 0-35 U/mL). What is the most appropriate management?

a) Referral to a specialist cancer unit
b) Laparoscopic ovarian cystectomy
c) Laparotomy and oophorectomy
d) Conservative management
e) Total laparoscopic hysterectomy and bilateral salpingo-oophorectomy

D

If the risk of malignancy index (RMI), calculated using CA125, USS, and menopausal status, is low, then the cyst can be managed conservatively.

Concerning findings:
Bilateral cysts
Multioculated cysts
Solid components
Ascites
Metastases
Large (>5cm)
High CA125
Symptomatic

Conservative management involves 4 monthly scans and CA125 levels for 1 year.

53

A 79-year-old woman attends your clinic with some vaginal bleeding. Her last period was 16 years ago. She has had two children, both via caesarean section, has a normal smear history, and is currently sexually active. On examination, the vagina appears mildly atrophic with some raw areas near the cervix. What is the most important next step in her management?

a) Vagifem nightly for 2 weeks and then twice a week after that
b) Triple vaginal swabs for STIs
c) Pelvic ultrasonography
d) HRT to help the vaginal raw areas
e) Smear test

C

Post-menopausal bleeding requires an USS to exclude cervical or endometrial cancer.

Vagifem and vaginal swabs may well be indicated, but an USS to ensure endometrial thickness is less than 4mm should be performed first.

54

At laparoscopy, a 21-year-old woman is found to have severe endometriosis. There are multiple adhesions and both ovaries are adherent to the pelvic side wall. The sigmoid colon is adherent to a large rectovaginal nodule. The nodule is excised and the bowel and ovaries freed. Which of the following medications would be appropriate to help treat her endometriosis?

a) Danazol
b) Triptorelin
c) Microgynon 30
d) Tranexamic acid
e) Medroxyprogesterone acetate

B

Triptorelin is a GNRH agonist which creates a temporary menopause for up to 6m. In this case, it gives the best chance of clearance, if followed by a secondary laparoscopy.

Danazol is anti-oestrogenic and anti-progestognenic. It is used for 3-6m.

Microgynon 30 is a combined oral contraceptive pill.

Tranexamic acid is an antifibrinolytic.

Medroxyprogesterone acetate is a progestogen.

55

A 54-year-old woman comes to your clinic complaining of hot flushes and night sweats that are unbearable. Her last menstrual period was 14 months ago. She has had a levonorgestrel releasing intrauterine system (Mirena) in situ for 2 years as treatment for extremely heavy periods. What treatment would you consider for her symptoms?

a) Elleste Solo
b) Elleste Duet
c) Vagifem
d) Oestrogen implants
e) Evorel

A

Oestrogens help vasomotor symptoms and atrophic vaginitis. Women with a uterus should also take progestogens to reduce the incidence of endometrial cancer with oestrogen replacement. In this case, the Mirena coil provides progestogens so oestrogen therapy (Elleste Solo, containing estradiol) is appropriate.

Elleste Duet contains estradiol and norethisterone, and Evorel is the same combination.

Oestrogen implants do help, but often lead to rapid recurrence of symptoms if levels fall.

56

A 19-year-old biochemistry student is seen in your clinic worried about her hormone levels. She has been told by her GP that her progesterone is low. You enter into a long discussion about the effects of progesterone on the body. Progesterone:

a) Enhances endometrial receptivity
b) Stimulates endometrial growth
c) Increases uterine growth
d) Increases fat deposition
e) Increases bone resorption

A

Progesterone enhances endometrial receptivity, increase RR, increase sodium excretion, reduce bowel motility, and increase body temperature.

The other effects mentioned are all of oestrogens.

57

A 41-year-old mother of two presents to the GP with long-standing heavy menstrual bleeding which has become worse over the past year. She is otherwise well and has no significant medical history. She requests treatment to alleviate the impact of her heavy bleeding on her social life. Pelvic examination reveals a normal sized uterus. What is the most appropriate first line treatment?

a) Levonorgestrel-releasing intrauterine system
b) Tranexamic acid
c) Mefenamic acid
d) Tranexamic acid and mefenamic acid combined
e) Vaginal hysterectomy

A

Mirena coils are the first line treatment for heavy menstrual bleeding, followed by tranexamic acid. Hysterectomy is a last line treatment.

58

A 42-year-old woman is seen in the gynaecology clinic. She has been suffering from severe premenstrual symptoms all her life. They have now significantly after her relationship and her husband is filing for divorce. She comes to your clinic in tears regarding the future of her children. She demands a hysterectomy and bilateral salpingoophrectomy. After taking her history you talk about other less radical treatments. Which management option is inappropriate?

a) Antidepressants
b) Vitamin C
c) Exercise
d) Cognitive behavioural therapy
e) Yasmin - combined oral contraceptive pill

B

Premenstrual syndrome is distressing physical, behavioural, and psychological symptoms occurring in the luteal phase of each menstrual cycle with no underlying organic or psychiatric disease.

PMS is treated with SSRIs, vitamin B6, improved diet and exercise, CBT, or combined oral contraceptive pills.

59

A 22-year-old woman is seen in A and E with lower abdominal pain and some vaginal discharge. She has had PID once in the past and was treated for it. She is otherwise well. Her temperature is 36.9C, pulse 90, BP 105/66 mmHg. She is passing good volumes of urine. On clinical examination, she has diffuse lower abdominal tenderness. There are no signs of peritoneum on examining her abdomen. On vaginal examination she had adnexal tenderness and an offensive discharge. Her CRP is 28 mg/L and her white blood count is 12.2x10^9/L. Her pregnancy test is negative. She reviewed by your senior and is diagnosed with PID. What would be an appropriate antibiotic regime?
a) IV ceftriaxone and IV doxycycline
b) IV ofloxacin and IV metronidazole
c) IM ceftriaxone, oral doxycycline, and oral metronidazole
d) IV clindamycin and gentamicin
e) Oral azithromycin and benzylpenicillin

C

PID symptoms:

Bilateral adnexal tenderness, abnormal vaginal discharge, fever over 38C, vaginal bleeding, deep dyspareunia, and cervical motion tenderness. Inflammatory markers may also be present.

Option C is the first line regime, but if the woman had severe disease (peritonism, fever, systemic infection, or a tubo-ovarian abscess), then any of the IV regimes would be appropriate.

60

A 24-year-old woman in her first pregnancy has no significant medical history, and is 40 weeks and 2 days pregnant. She has been contracting for 4 days, and is not coping with the pain. She has been given IM pethidine. On examination she is found to be 4cm dilated (foetus in the occipital-posterior position) having been the same 4 hours previously. What analgesia would you recommend?

a) Remifentanil
b) Pethidine
c) Diamorphine
d) Epidural injection
e) Entonox

D

This is a very long latent phase of labour (it usually only lasts 24h). The occipital-posterior position is associated with slower labours. Thus, an epidural will help most, and she will likely require augmentation as well.

Remifentanil is an infusion given if spinal or epidural analgesia is contraindicated.

Entonox is a good adjunct, but is unlikely to help her through the remainder of labour.

61

A 36-year-old woman is 41 weeks pregnant and is established in spontaneous labour. She is contracting three times every 10 minutes and has ruptured her membranes. She is draining significant meconium stained liquor. Her cervix is 7cm dilated. Her midwife has started continuous electronic foetal monitoring using a cardiotocograph (CTG). The baseline rate has been 155, with variability of 2 beats per minute, for the past 60 minutes. There are no accelerations and no decelerations. What is the most appropriate management?

a) Pathological CTG - needs delivery
b) Suspicious CTG - needs delivery after foetal blood sampling (FBS)
c) Suspicious CTG - change maternal position, intravenous fluids and reassess in 20 minutes
d) Suspicious CTG - perform foetal blood sampling and deliver if abnormal
e) Normal CTG - do nothing

D

CTG has four features, and each can be reassuring, non-reassuring, or pathological. One non-reassuring feature is suspicious. Two non-reassuring or one pathological feature is pathological. As CTGs have a high false positive rate, pathological CTGs should be followed by a FBS to check how the foetus is coping with labour.

Baseline
R: 110-160
NR: 161-180 or 100-109
P: >180, <100

Variability
R: >5bpm
NR: <5bpm for 40-90m
P: <5bpm for >90m

Accelerations
R: present
NR: absent accelerations are of uncertain significance
P: atypical variable decelerations with >50% of contractions for >30m; or late decelerations for >30m

Decelerations
R: none
NR: typical variable decelerations with >50% of contractions for >90m; or single prolonged deceleration for <3m
P: single prolonged deceleration for >3m

62

A 19-year-old woman is giving birth to her first baby. She has been pushing for an hour and the foetal head has been on the perineum for 6 minutes. There seems to be a restriction due to resistance of her tissues. Her midwife carries out a right mediolateral episiotomy. Which of the following structures should not be cut with the episiotomy?

a) Bulbospongiosus
b) Superficial transverse perineii (STP)
c) Vaginal mucosa
d) Perineal membrane
e) Ischiocavernosus

E

Ischiocavernosus reaches from the crus of the clitoris to the ischial tuberosity, so should not be cut in a correctly performed episiotomy. The other muscles all run in the line of an episiotomy.

63

A 25-year-old woman in her first pregnancy has a pathological CTG. Her cervix is 5cm dilated. Which of the following wouldn't increase the risk to the foetus if the doctor performed a foetal blood sample?

a) HIV
b) HPV
c) Maternal immune thrombocytopenia
d) Factor IX deficiency
e) Hepatitis C

B

As CTGs have a high false positive rate, pathological CTGs should be followed by a FBS to check how the foetus is coping with labour.

FBS increases the risk of vertical transmission of blood-borne viruses like HIV and hepatitis C. FBS should also be avoided in maternal clotting disorders as there is a chance the foetus is also affected. HPV would not increase risk to the foetus on FBS.

64

A multiparous woman is admitted to the labour ward with regular painful contractions. On examination she is 9cm dilated with intact membranes and is coping well with labour pains. Forty minutes later her membranes rupture while she is being examined and you see the umbilical cord hanging from her vagina. You inform the woman what has happened. She is now fully dilated, the foetal position is direct occipitoanterior, and the presenting part is below the ischial spines. What do you do next?

a) Gain IV access, call for help, and stop the woman pushing
b) Perform a grade 1 emergency caesarean section
c) Call for help, perform an episiotomy and commence pushing
d) Call for help and prepare for an instrumental delivery
e) Elevate the presenting part by inserting a vaginal pack

D

This is cord prolapse, and obstetric emergency. The cord is at risk of being obstructed or going into spasm, starving the foetus of oxygen.
Delivery must be expedited, with help from a full obstetric team, preferably immediately in theatre. If the cervix is not fully dilated, a grade 1 caesarean section is indicated, but in this case an instrumental vaginal delivery would be faster due to her multiparity and foetal position.

65

A 34-year-old para 0 has been admitted for a post-dates induction of labour at 42 weeks. She has received 4mg prostaglandin vaginally. After 72 hours her cervix is 5cm dilated. Four hours later she is still 5cm dilated. On abdominal examination the foetus appears to be a normal size. The foetal head position is left occipital-transverse, and the station is -1. There is no moulding but a mild caput. She is contracting two times in every 10 minutes and has an epidural in situ. You are asked to review and make a management plan. What would be the most appropriate plan?

a) Re-examine in 4 hours provided the baby is not distressed
b) Discuss the situation with the patient and offer her a caesarean section
c) Start an oxytocin infusion and intermittent monitoring and reassess in 4 hours
d) Insert another 1mg prostaglandin as she is not contracting and reassess in 2 hours
e) Start an oxytocin infusion, commence continuous monitoring and reassess within an appropriate time span

E

This is a delay in the first stage of labour. Broadly, active labour commences at 3cm dilation, so she is in active labour.

Upon assessing power, passage, and passenger, it appears that she is not progressing due to suboptimal contraction frequency.

Augmentation is required using oxytocin, which requires continuous foetal monitoring, because of the risk of hyperstimulation.

66

A mother comes to labour ward who is low risk, in labour at term. The unit is short staffed and there are not enough midwives to provide intermittent auscultation of the foetal heart. You decide to start continuous electronic monitoring (CTG). She is an epidemiologist and asks you about the CTG and how it will help her labour and prevent her baby suffering harm. Which of the following would you tell her? Continuous monitoring has a:

a) High sensitivity and low specificity
b) High sensitivity and high specificity
c) Low sensitivity and low specificity
d) Low sensitivity and high specificity
e) High sensitivity and high positive predictive value

A

CTGs have high sensitivity, low specificity, and high false-positive rates.

67

A 29-year-old woman comes to the labour ward complaining that her baby has not been moving for 72 hours. She is 36 weeks pregnant. Otherwise her pregnancy has been complicated with gestational diabetes for which she is taking insulin. On examination you fail to pick up the foetal heart. You confirm the diagnosis of an intrauterine death. The scan shows no liquor and the baby is transverse. After a long discussion you explain that she unfortunately needs to deliver her baby. What is the best way for her to deliver her baby?

a) Induction with oral mifepristone and oral misoprostol
b) Induction with oral mifepristone and vaginal misoprostol
c) Induction with oral misoprostol
d) Induction with vaginal dinoprostone
e) Caesarean section

E

Usually, intrauterine death inductions require mifepristone and misoprostol to start contractions. However, the lack of liquor and transverse position mean the baby will not deliver vaginally (inducing a transverse baby increases the risk of uterine rupture) and require caesarean delivery.

68

A 24-year-old woman with gestational diabetes has been progressing normally through an uncomplicated labour. The midwife delivers the head but it retracts and does not descend any further. What should the midwife do next?

a) Pull the emergency bell and place the woman in McRobert's position
b) Place the woman on all fours and instruct her not to push
c) Pull the emergency bell and commence rotational manoeuvres for shoulder dystocia
d) Pull the emergency cord and ask your helper to apply fundal pressure
e) Pull the emergency bell and prepare for emergency caesarean delivery

A

Shoulder dystocia is an obstetric emergency heralded by the 'turtle neck' sign described here.

The woman is put in the McRobert's position, which is usually effective, before attempting other manoeuvres such as all fours, internal rotation, and suprapubic pressure.

If all fails, Zavanelli's manoeuvre and caesarean delivery is attempted.

69

A 29-year-old multiparous woman is in established labour contracting strongly. She is 4cm dilated and had been having regular painful contractions for 6 hours before they stopped abruptly, heralded by a sudden onset of severe, continuous lower abdominal pain. The foetal heart trace is difficult to identify, and the tocometer does not register a signal. What is the most appropriate management?

a) Foetal assessment with a formal USS
b) FBS
c) Immediate trial of delivery in theatre, with resuscitation facilities on standby
d) Immediate caesarean delivery
e) Expedite delivery with synthetic oxytocin infusion

D

This is likely to be a uterine rupture. A 'crash' caesarean delivery and subsequent repair is requiured to save the life of the baby and mother, who is at risk of haemorrhage shock. If a repair is not possible, hysterectomy is necessary.

70

A 23-year-old woman is in her first labour. Her cervix is 6cm dilated and she is in distress. She is asking for an epidural. Before you call the anaesthetist you check her history. Which of the following would be an absolute contraindication fro an epidural?

a) Previous spinal surgery
b) Hypotension
c) Mitral stenosis
d) Multiple sclerosis
e) Aortic stenosis

B

Absolute contraindications:
Patient refusal
Allergies to anaesthetic agents
Systemic infection
Skin infection over epidural site
Bleeding disorders
Platelet count <80,000/mL
Uncontrolled hypotension

Relative contraindications:
HOCM
Aortic stenosis
Mitral stenosis

71

A 38-year-old nulliparous woman has had an uncomplicated pregnancy. She has laboured very quickly and is 10cm dilated. The foetal heart falls to 60 for 4 minutes. She is pushing effectively and the head is 1cm below the ischial spines. You prepare for forceps delivery in the room. She has had no analgesia so you quickly insert a pudendal nerve block and deliver the baby 3 minutes later in good condition. Which of the following is not a branch of the pudendal nerve?

a) Inferior anal nerve
b) Perineal nerve
c) Dorsal nerve of the clitoris
d) Posterior labial nerve
e) Genital branch of the genitofemoral nerve

E

72

The obstetric team is alerted to a blue-light trauma call expected in A and E. A 28-year-old woman who is 37 weeks pregnant has been involved in a high-speed road traffic collision. On arrival, where the obstetric team is on standby, her Glasgow Coma Scale score is 5 and she has a tachycardia hypotension. What is the most appropriate management sequence?

a) Resuscitation according to ATLS guidelines and transfer to the labour ward
b) Transfer to the CT scanner in preparation for immediate trauma laparotomy
c) Resuscitation according to ATLS guidelines and foetal assessment with the patient in left lateral tilt
d) Resuscitation according to ATLS guidelines with immediate caesarean delivery
e) Resuscitation according to ATLS guidelines and corticosteroids for foetal lung maturation

C

Transfer of patients with unstable polytrauma, especially with haemorrhagic shock, is extremely dangerous, and should be avoided.

Steroids are only necessary in potential deliveries between 24 and 34 weeks gestation.

Caesarean section is not acceptable as the mother must be stabilised before looking at delivering the baby.

Instead, the left lateral tilt improves venous return and foetal assessment can contribute to the management plan.

73

A 24-year-old woman is seen after her normal vaginal birth. The midwife who delivered the baby is concerned that there is a third degree tear. The woman is taken to theatre to repair the external anal sphincter. Which of the following is not a risk factor for third degree tear?

a) Forceps delivery
b) Second stage of labour lasting over an hour
c) Shoulder dystocia
d) Ventouse delivery
e) Maternal age

E

Tears are very common in vaginal births. Risk is increased in instrumental delivery, second stage >1h, shoulder dystocia, primiparity, induction of labour, macrosomic baby, occipitoposterior position, and midline episiotomy.

Grade 1 tears involve the perineum and vaginal mucosa, but no muscles.

Grade 2 tears involve the muscles underneath and require stitching.

Grade 3 tears affect 1% of all vaginal births, and involve the anal sphincter. 3a tears involve <50% of the EAS. 3b tears involve >50% of the EAS. 3c tears involve the EAS and IAS.

Grade 4 tears through the anal sphincter and to tissue beneath it.

74

A 34-year-old woman is brought straight to intensive care from the obstetric theatre after an emergency caesarean section for foetal distress. The attending obstetrician remarks that she is showing haematological signs of DIC. Which blood profile is she most likely to have?

A B C D E
PT v v ^ ^ >
aPTT > > ^ ^ ^
BT ^ ^ ^ ^ ^
Plat. > ^ v ^ >
Bleed Y N Y N N

C

DIC is a consumptive coagulopathy, prolonging PT, aPTT, and BT. Platelets are consumed in clots, reducing the platelet count in the blood.

75

A 31-year-old undergoes a planned caesarean section for a breech presentation. After delivery of her healthy baby, there is difficulty in delivering the placenta, as it is adhered to the uterus. She has lost 5L of blood as a result of the placenta accreta. The placenta has been removed but she is still bleeding and is cardiovascularly unstable despite blood product replacement. What would be the best management to definitively arrest haemorrhage?

a) Syntocinon infusion
b) B-Lynch suture
c) Internal artery ligation
d) Hysterectomy
e) Intrauterine balloon

D

The management of primary post-partum haemorrhage is to help the uterus contract and compress any bleeding vessels.

Syntocinon infusions and B-Lynch sutures both cause uterine contraction.

Internal iliac artery ligation prevents blood flow through the uterine arteries.

Intrauterine balloon would also prevent bleeding.

However, this woman is extremely compromised, and a hysterectomy would be the only definitive treatment to arrest haemorrhage.

76

A 39-year-old woman is 6 days postpartum and has come back to hospital with shortness of breath. She is struggling to breath at rest has an RR of 28, pulse 115, BP 105/60 mmHg, temperature 37.4C. On examination she has an audible wheeze and cough. Investigations reveal a PO2 of 9.5kPa on ABG and a PCO2 3.7kPa, pH 7.36, BE -3.4. A CXR shows some upper lobe diversion and bilateral diffuse shadowing with an enlarged heart. Her Hb is 8.9g/dL, WBC 11.1x10^9/L, and CRP 21mg/L. What is the most likely cause of her symptoms?

a) LRTI
b) PE
c) Peri-partum cardiomyopathy
d) SIRS
e) Post-partum anaemia

C

Peri-partum cardiomyopathy is rare but has a mortality rate of 9-15%. It usually develops between the last month of pregnancy and the first five months postpartum. Risk factors include multiple pregnancies, HTN, and advanced maternal age. It causes SoB, tachycardia, tachypnoea, and signs of congestive cardiac failure.

In this case, the other differentials would not cause the x-ray findings of cardiomegaly or pulmonary oedema.

77

A 17-year-old girl is seen in A and E 14 days after an emergency caesarean delivery of a healthy infant, her first. Her neighbours became concerned and called the police. She had been seen prostrate in the garden chanting verses from the Bible and shouted at them accusing them of being spies when they asked if she was okay. They say her problem has worsened over the past fortnight. What is the most likely diagnosis?

a) Post-partum depression
b) Bipolar affective disorder
c) Puerperal psychosis
d) Schizophrenai
e) Acute confusional state (delirium)

C

Puerperal psychosis affects 1:1000 mothers, presenting in the first 2 weeks postpartum. Risk factors include C-sections, emergency delivery, and primips.

78

At birth, which of the following does not occur in the foetal circulation?

a) Right ventricular output increases
b) A decrease in venous return
c) Closure of the foramen ovale
d) Pulmonary artery vasoconstriction
e) Closure of the ductus arteriosus

D

After birth, the umbilical vessels are occluded. This reduces venous return to the right side of the heart, reducing the RAP, and closing the foramen ovale. Upon breathing, the pulmonary circulation pressure lowers and right ventricular output increases. The pulmonary artery vasodilates to develop this low-pressure system. Subsequent venous return to the left side of the heart increases pressure on the left side. Rising oxygenation levels then close the ductus arteriosus.

79

A woman on the labour ward has just had a normal birth. At birth there was a lot of meconium present. The newborn did not respond initially but did after subsequent resuscitation. The midwife records the Apgar score as 5. Which of the following best describes the categories an Apgar score is created from?

a) Tone, colour, nice, pulse, and BP
b) Tone, colour, respiratory effort, HR, and reflex irritability
c) Tone, colour, pulse, reflex irritability, and BP
d) Tone, colour, pulse, respiratory effort, and BP
e) Tone, colour, cry, BP, and HR

B

Apgar scores quickly assess newborns, and are recorded at 1, 5, and 10 minutes. Each category is scored from 0 to 2, with a score of 10 being the best possible score.

Activity (absent/flexed limbs/active)
Pulse (absent/<100bpm/>100bpm)
Grimace (floppy/minimal response/prompt response)
Appearance (blue, pale/pink with blue extremities/ pink)
Respiration (absent/slow, irregular/vigorous cry)

80

An 18-year-old woman has been successfully delivered of a healthy female infant by elective caesarean section for maternal request. Estimated blood loss was 1120mL. Forty minutes after return to the recovery area, she has a brisk vaginal bleed of around a litre. Her pulse rate is 120bpm and BP is 95/55mmHg. What should the immediate management process be?

a) Rapid fluid resuscitation, uterine massage, and IV ergometrine
b) Rapid fluid resuscitation, IV ergometrine, and bimanual compression of uterus
c) Rapid fluid resuscitation, insertion of an intrauterine balloon catheter device
d) Rapid fluid resuscitation, uterine massage, oxytocin infusion, and vaginal assessment
e) Rapid fluid resuscitation and administration of direct intramyometrial uterotonic agents

D

This woman has a primary postpartum haemorrhage. Initial management is rapid fluid resuscitation, uterine massage, and oxytocin infusion. Secondary measures may include IV ergometrine, and bimanual compression, then moving onto intrauterine balloons and intramyometrial uterotonics.

81

A 34-year-old woman develops a significant postpartum haemorrhage and hypotensive shock following vaginal delivery of a healthy infant at term. The labour was uncomplicated. She recovers well with volume replacement and oxytocin and returns to the post-natal ward. She is unable to breast feed on the ward and 2m later has neither started breastfeeding nor resumed her periods and is increasingly fatigued. What is the most likely diagnosis?

a) Addison's disease
b) SIADH
c) Sheehan's syndrome
d) Panhyperpituitarism
e) Post-partum depression

C

Inability to lactate in a well-motivated mother is concerning.

The anterior pituitary is hyperplastic during pregnancy, and responds acutely to falls in BP, as in postpartum haemorrhage. Significant hypovolaemia can cause necrosis or infarction of the anterior pituitary. This is called Sheehan's syndrome. It presents with absence of lactation and periods, fatigue, and sometimes diabetes insipidus. SIADH can be a complication of long term Sheehan's syndrome, but is not the diagnosis.

82

A 30-year-old French woman delivers a live female infant by spontaneous vaginal delivery at term. In the eleventh week of pregnancy she developed a flu-like illness which resolved spontaneously a week later. Her newborn child has severe hydrocephalus and chorioretinitis. Four days after birth, she develops severe convulsions and efforts to revive her are unsuccessful. Which pathogen is most likely to be responsible?

a) CMV
b) HIV
c) Toxoplasma gondii
d) Group B Streptococcus
e) Listeria monocytogenes

C

Toxoplasma gondii is contracted from undercooked meat and cat faeces. It can cause chorioretinitis, macro- or microcephaly, convulsions and long-term neurodevelopment delay. Initial infection is often mild, and not noticed.

60% of the population have had a prior infection of CMV, and 40-50% of foetuses become infected if contracted during pregnancy .Complications include visual loss, hearing loss, microcephaly, and long-term neurodevelopment disability.

HIV is screened for, and routine antenatal care should detect at-risk mothers.

Group B Streptococcus is present in the genital tract of 25% of women, but doesn't cause hydrocephalus.

Listeria is present in unpasteurised cheese and pate. It can cause miscarriage, stillbirth, or preterm delivery.

83

A 32-year-old woman has a routine cervical smear at her GP practice. The result returns as severe dyskaryosis. Following colposcopy and cervical biopsy, formal histological examination reveals cervical intraepithelial neoplasia 3 (CIN 3). Which of the following pathogens is most likely to have caused this disease?

a) Candida albicans
b) HIV
c) HPV
d) HSV
e) Treponema pallidum

C

HPV 16 and 18 are the most oncogenic, and are responsible for 70% of all cervical cancer cases.

Candida albicans causes thrush.

HIV-positive woman are at high risk of contracting HPV, and thus are at more risk of intraepithelial neoplasias, but HIV is not causative.

HSV causes oral cold sores and genital herpes.

Treponema pallidum causes syphilis.

84

A 15-year-old girl attends the paediatric gynaecology clinic with primary amenorrhoea and features of secondary breast development. She has intermittent abdominal bloating and is extremely worried that she is 'not like other girls'. On speculum examination of the vagina, which is normal externally, a bulging red disc is seen 3cm proximal to the introitus. What is the most likely diagnosis?

a) Turner's syndrome
b) Congenital adrenal hyperplasia
c) Imperforate hymen
d) Anorexia nervosa
e) Delayed puberty

C

Menstruation requires structurally normal anatomy, and a properly functioning HPA. This girl has a functioning HPA, as shown by her secondary breast development.

On speculum, she exhibits haematocolpos, which is a build up of menstrual blood behind an intact hymen. This would also explain her intermittent bloating.

85

A 19-year-old woman undergoes surgical evacuation of the retained products of conception (ERPC). Histological examination of the sample shows genetically abnormal placenta with a mixture of large and small villi with scalloped outlines, trophoblastic hyperplasia. What is the most likely diagnosis?

a) Choriocarcinoma
b) Degenerated uterine leimyoma
c) Uterine dysgerminoma
d) Hydatidiform mole
e) Complete miscarriage

D

Hydatidiform moles are a spectrum of pathological pregnancies.

Risk is increased by extremes of age, previous molar pregnancies, and race.

Women present with unusual or heavy bleeding past the sixth week of pregnancy, with a large for dates pregnancy. Pre-eclampsia, thyrotoxicosis, and hyperemesis gravidarum are common in molar pregnancy.

Beta hCG is often far higher than expected in normal early pregnancies, and USS may show a 'snowstorm appearance'.

86

An 89-year-old woman attends the gynaecology clinic with a long history of a dragging sensation in the vagina. Apart from severe aortic stenosis, she has no significant medical history. She leaks fluid when she sneezes or coughs. On examination with a Sims' speculum in the left lateral position, a grade 1 uterine prolapse is seen, with an additional cystocoele. What is the most appropriate management?

a) Vaginal hysterectomy with anterior colporrhapy (cystocoele repair)
b) Vaginal hysterectomy alone
c) Tension-free vaginal tape (TVT)
d) Weight loss and pelvic floor exercises
e) Twice weekly 0.1% estriol cream and insertion of shelf pessary

E

This is symptomatic uterine and bladder prolapse. Surgical treatment is appropriate in significant, symptomatic prolapse, as here. However, this woman is a poor surgical candidate due to her aortic stenosis and age, so surgery is inappropriate. Again, a woman of this age is unlikely to benefit from pelvic floor exercises, so the best option is E.

87

A 46-year-old woman presents to your clinic with a 6-year history of incontinence. She has had four children by vaginal deliveries, has a BMI of 35 kg/m^2, and suffers from hayfever. Initial examination reveals a very small cystocoele. A mid-stream urine culture is negative and urodynamic studies show a weakened urethral sphincter. What is the most appropriate first line management?

a) Fesoterodine 4mg daily
b) Weight loss and pelvic physiotherapy
c) Tension-free vaginal tape
d) Solifenacin 5mg daily and pelvic physiotherapy
e) Anterior repair and insertion of a transobturator tape

B

This is stress incontinence. She has many risk factors for this, including multiple vaginal deliveries and a high BMI. Conservative options are attempted first, before a TVT or TOT could be used.

There are no urge symptoms, so fesoterodine and solifenacin are not appropriate.

88

A 16-year-old girl attends the gynaecology clinic complaining of vaginal itching and lumpy labia. On examination, the area is covered with vulval warts. Which is the causative pathogen for vulval warts?

a) HPV 16
b) HPV 18
c) HPV 6
d) HSV
e) Epidermophyton floccosum

C

HPV 6 and 11 are associated with vulval warts, whereas types 16 and 18 are associated with cervical cancer.

HSV tends to cause papulovesicular rashes rather than warts. Epidermophyton floccosum is responsible for athlete's foot, but can manifest in the groin.

89

A 25-year-old woman attends accident and emergency with an exquisitely sore, large swelling of her vagina which steadily got much bigger. On examination, there is a soft fluctuant mass on the right labia minora which is very tender. What is the most appropriate management?

a) Marsupialisation
b) Oral ofloxacin and metronidazole
c) Sebaceous cystectomy
d) Local 2% clotrimazole (Canestan)
e) Referral to a vulval clinic

A

This describes a Bartholin's abscess. Bartholin's glands are found commonly at 4- and 8-o'clock inn the labia minora. Treatment of blocked ducts, as in this case, is marsupialisation, leaving a permanent opening to prevent recurrence.

Abx may be appropriate post-operatively, or in very small abscesses, but not here.

90

An 18-year-old woman attends clinic seeking contraceptive advice. She is currently using condoms only and is keen to start taking the combined oral contraceptive pill. Her sister used to take it, but told her there were lots of problems with it. Her aunt has bowel cancer and she has no other past medical history. Appropriate counselling should cover all of the following except:

a) There is an overall 12% risk in reduction of cancers
b) There is a small increase in cervical cancer with prolonged use (>8y)
c) There is a reduction in the risk of bowel cancer
d) There is an increase in the risk of ovarian cancer
e) There is no need for a cervical smear prior to starting the pill

D

The combination oral contraceptive pill increases risk of:
Cervical cancer with prolonged use (mitigated with regular screening)

Decreases risk of:
Bowel and rectal cancer
Overall cancers
Ovarian cancer

91

A 49-year-old woman presents to a private clinic expressing her desire to become pregnant. She has no past medical history. Initial investigations show that she still has ovarian function, is ovulating, and is having regular periods. A pelvic USS shows no structural abnormality and a hysterosalpingography demonstrates patent Fallopian tubes. Analysis of her partner's semen is normal. Which would not be an appropriate first line management option?

a) IVF
b) Intracytoplasmic sperm implantation
c) Intrauterine insemination
d) Clomiphene
e) Egg donation IVF

D

Clomiphene is a selective oestrogen receptor modulator which increases the production of gonadotropins to induce ovulation. As this woman is ovulating, it would not be useful here. Any of the other options would be appropriate first-line treatments.

92

A 42-year-old woman presents to the urogynaecology clinic with a 3-year history or urge incontinence. She has features of an overactive bladder and is desperate to start treatment for her problem as it is affecting her quality of life. She opts for medical treatment. What is the most appropriate first line pharmacological therapeutic?

a) Darifenacin
b) Oxybutynin
c) Fesoterodine
d) Solifenacin
e) Oxybutynin dermal patch

B

First-line treatment is immediate release oxybutynin. The other options are second-line treatments.

All antimuscarinics can cause dry mouth, constipation, and urinary retention. If medication does not work, surgical approaches such as sacral nerve stimulation or Botox injections may be appropriate.

93

A 41-year-old woman is about to undergo her first cycle of IVF. As part of the consultation, she is counselled about the maternal and foetal risks involved with IVF-conceived pregnancies. All of the following occur in such pregnancies except:

a) Increased risk of low birth weight
b) Increased risk of foetal congenital abnormalities
c) Decreased risk of ectopic pregnancies
d) Increased risk of small for gestational age foetuses in singleton pregnancies
e) Increased risk of maternal pregnancy-induced hypertension

C

IVF gives an increased risk of:
Ectopic pregnancies
LBW
Foetal congenital abnormalities
Small for gestational age in singletons
Maternal pregnancy-induced hypertension
Multiple pregnancies

94

A 16-year-old presents to the termination of pregnancy service 6 weeks into her second pregnancy requesting surgical termination. What is not required as part of her work-up for the procedure?

a) Antibiotic prophylaxis for Chlamydia
b) Gaining consent from her mother
c) Contraception discussion
d) Explaining the risks of STOP
e) Explaining that the risk of uterine perforation is 1/300

B

If this patient is Gillick competent, consent from her mother is not required. All other options should be performed.

95

A 35-year-old woman is seen in the assisted conception unit. She has been trying to conceive for 4 years. In this period she has been having regular intercourse. Her periods have been irregular and recently she has had no periods at all. Her BMI is 19.5 kg/m^2, she has had an appendicectomy, and is otherwise well. Her biochemistry comes back as follows: LH 0.5 IU/L, FSH 1.0 IU/L, prolactin 490 mIU/L, T4 12, TSH 4.2 mIU/L, oestradiol 60 pmol/L. What is the most likely cause of her subfertility?

a) PCOS
b) Hypothyroidism
c) Microprolactinoma
d) Hypothalamic hypogonadism
e) Anorexia

D

This woman has low LH and FSH, and the negative feedback loop is not activated: FSH production is not increased despite low oestradiol. This can be attributed to hypothalamic hypogonadism.

96

A 19-year-old comes to you for some pre-conception advice. Some members of her family and her partner's family have a sickle cell anaemia. She reveals that her sister and his sister are both affected. Tests have shown that they are both carriers. What is the chance that, if their child was a boy, he would have sickle cell anaemia?

a) 50%
b) 67%
c) 100%
d) 33%
e) 25%

E

Sickle-cell anaemia is an autosomal recessive condition, so the chance is 25% of having an affected child.

97

An 18-year-old girl is seen in the colposcopy clinic after having had persistent post-coital bleeding. She has been sexually active since the age of 14 and has no past medical history. She is studying for her A-levels and has been doing a lot of reading. She is concerned that she might have cervical cancer. Which of the following is not a risk factor for cervical cancer?

a) HSV
b) Smoking
c) HIV
d) Use of the oral contraceptive pill
e) Multiparity

A

Most cervical cancers are associated with HPV.

Smoking is an independent risk factor, as is immunosuppression (as in HIV). There's also an association with multiparty and the oral contraceptive pill.

98

A 49-year-old comes to the urogynaecology clinic with a history of leaking urine for the last year. There are associated stress symptoms and some urge symptoms. Interestingly she says that it seems to come from inside the vagina as well. She had a hysterectomy last year for endometrial cancer and had quite a prolonged recovery. She has a BMI of 30 kg/m^2, does not smoke, and is otherwise fit and well. You are suspicious that she might have a vesicovaginal fistula secondary to her operation. What is the most appropriate first line investigation?

a) Exammination under anaesthesia and cystoscopy
b) Pelvic MRI
c) Instillation of methylene blue into the urinary bladder and speculum examination
d) Pelvic CT
e) Urodynamic study

C

The most common global cause of vesico-vaginal fistulae is obstructed labour. In developed countries, however, it is pelvic surgery.

The first-line investigation is catheterisation and injection of methylene blue, with subsequent speculum examination.

Second-line investigations involve EUA and cystoscopy.

Urodynamics and imaging are not useful as they're unlikely to be detected on x-ray.

99

A 16-year-old girl presents to your surgery with a history of unprotected sexual intercourse (UPSI) 70 hours ago. Her last menstrual period was 8 days ago. Her only past medical history of note is that of epilepsy which is well controlled by carbamazepine. She is worried about becoming pregnant, does not want her mother to find out, and is in a hurry to get home before suspicions are raised. Which of the following options are available to her?

a) Take the combined oral contraceptive pill continuously for the next month
b) A copper IUD should be inserted with prior screening for STIs
c) Levonorgestrel 1.5mg should be given as she is within 72 hours of UPSI
d) Reassure and tell her to come back when she has made her mind up as ulipristal can be taken up to 7 days after UPSI
e) Reassure her that she is in the safe part of her cycle and she should try and use condoms in the future

B

During this conversation, you should counsel about all options of emergency contraception, and the risks associated with UPSI, including future contraception advice.

Emergency contraception is levonorgestrel 1.5mg within 72h, ulipristal within 5d, or copper coil within 5d.

As she is taking carbamazepine, an enzyme-inducer, levonorgestrel may be ineffective. Therefore, copper coil would be the best option for her.

100

A 40-year-old woman comes to your clinic alone wanting an effective form of contraception. She has two children from a previous marriage and has recently started a new relationship. She says that she does not want any further children. She has regular heavy periods, no menopausal symptoms, and she is otherwise well with no past medical history. A recent USS showed a normal sized uterus and pipelle biopsy revealed normal secretory endometrial tissue. What is the most appropriate form of contraception?

a) Combined oral contraceptive pill with <30 ug of oestrogen
b) Mirena coil
c) Laparoscopic sterilisation
d) Vasectomy
e) Total abdominal hysterectomy

B

The Mirena coil is a good option as she has heavy periods and a normal endometrium.

The combined oral contraceptive pill is also a good choice, but the Mirena is more effective and may help her periods.

Laparoscopic sterilisation is only used if she is sure she wants no more children, and often not first-line.

Vasectomy requires talking with the partner.

TAH is not indicated for contraceptive purposes in an otherwise healthy woman.

101

In a busy gynaecology clinic you are assessing a 22-year-old woman who has not had a period for 18 months. She is not pregnant, and previously had regular periods. She has had two surgical terminations of pregnancies, an underactive thyroid gland, and an appendicectomy. Clinical examination is unremarkable with a BMI of 20 kg/m^2. Biochemical investigations reveal a T4 of 17 pmol/L, TSH 4.6 uIU/L, prolactin 570 mU/L, testosterone 42 ng/dL. LH and FSH are normal. Vaginal USS shows a normal sized uterus and the left ovary contains four cysts. Which of the answers listed below is the most likely cause?

a) PCOS
b) Prolactinoma
c) Sheehan's syndrome
d) Asherman's syndrome
e) Anorexia nervosa

D

This is Asherman's syndrome. Intrauterine scar tissue and adhesions form after instrumentation of the uterus (as with this lady's surgical history). A hysteroscopy could confirm.

PCOS is a multisystem disorder diagnosed by having two of:
Anovulation/oligo-ovulation
Biochemical or physical hyperandrogensism
USS showing 12+ ovarian follicles

Prolactin levels range from 100-850 mIU/L, so this is not abnormal, suggesting against prolactinoma.

Sheehan's syndrome is a postpartum complication in which large haemorrhage causes hypoperfusion of the pituitary causing ischaemia and necrosis.

Anorexia leads to hypothalamic hypogonadism, but this woman's BMI is normal.

102

A 26-year-old woman, otherwise fit and well, has been trying to conceive for over 2 years. On questioning, she has regular periods, and has been having regular intercourse. There are no abnormalities on clinical examination. What would be your first line investigations for her subfertility?

a) Day 14 FSH and LH, USS, HSG, semen analysis
b) Day 1-3 FSH and LH, mid-luteal progesterone, semen analysis
c) Day 1-3 FSH and LH, mid-follicular progesterone, semen analysis
d) Random LH, FSH, HSG, semen analysis
e) USS, laparoscopy, semen analysis

B

Causes of infertility can be divided into male factor, uterine factor, tubal factor, and ovarian factor.

Investigations should check each of these factors. First-line tests should be non-invasive: semen analysis for male factor; and days 1-3 FSH and LH with mid-luteal progesterone to test ovarian factor.

Second-line investigations involve HSG to look at tubal factors, and an USS to look at uterine factors.

If nothing is found, a laparoscopy would be performed to rule out endometriosis.

103

A 42-year-old man undergoes semen analysis as part of the investigation of subfertility with his wife. What result would most likely contribute to their subfertility?

a) Sperm count 30 million/mL
b) Volume 2.5mL
c) 40% have normal motility
d) 5% normal morphology
e) pH 7.4

C

Male factor is responsible for 25% to 40% of sub fertility cases. Semen analysis measures volume (1.5-6mL), count (15 million per mL), mobility (>50%), pH (7.2-8.0), and morphology (>4%).

104

A 46-year-old woman in her fifth IVF cycle is admitted to the emergency department 4 days after egg collection. She is complaining of a swollen abdomen and shortness of breath. She is reviewed and a diagnosis of ovarian hyperstimulation syndrome (OHSS) is made. Which of the following is not a clinical feature or complication of OHSS?

a) Hydrothorax
b) DVT
c) Haemodilution
d) Oliguria
e) Marked ascites

C

33% of IVF cycles lead to mild OHSS, and 3-8% to severe OHSS. It presents with abdominal pain and distension, and vomiting.

Blood becomes haemoconcentrated, with hypoproteinaemia. Ascites will occur which can lead to pleural effusion. Haemoconcentration increases the risk of DVT. Severe OHSS can decrease kidney perfusion, with intravascular volume drawn into third spaces, causing oliguria.

105

A 17-year-old girl comes to clinic with her mother as she has not started having periods yet and they are worried. On examination, she is of short stature, with a slightly widened neck and has no secondary sexual characteristics. There is no obvious abnormality of the external genitalia. What is the most likely diagnosis from this limited information?

a) Androgen insensitivity syndrome
b) Turner's syndrome
c) Congenital adrenal hyperplasia
d) Kallmann's syndrome
e) Rokitansky's syndrome

B

This is Turner's syndrome (XO), which often presents as primary amenorrhea, short stature, and neck webbing. It causes gonadal dysgenesis and sterility.

AIS is unlikely in a female, as carriers are unaffected and fertile men with AIS are very uncommon.

CAH is autosomal recessive and causes hyperandrogegism and virilisation of female genitalia.

Kallmann's syndrome is decreases GNRH leading to hypogonadism, delayed puberty, and lack of secondary sexual characteristics, so is possible, but doesn't explain the neck webbing.

Rokitansky's syndrome is Mullerian agenesis, so will have normal ovaries and secondary sexual development, but without fallopian tube or uterine development.

106

A 22-year-old woman presents to the GUM clinic with an offensive smelling discharge. She is sexually active and is in a monogamous relationship. She describes no pain or soreness, just an offensive smelling discharge. After examination and taking swabs for the second time, she is diagnosed with bacterial vaginosis. Which of the following organisms is not likely to be the cause?

a) Gardnerella
b) Mobiluncus
c) Bacteroides
d) Trichomonas
e) Mycoplasma

D

Bacterial vaginosis is not sexually transmitted, but is more common in those who are sexually active. It's an imbalance of naturally occurring vaginal flora. It leads to a fishy smell and white offensive discharge. Clue cells and loss of vaginal acidity are seen. All except Trichomonas here can cause it. Trichomonas is an STI caused by a protozoon leading to a green discharge.

107

A 28-year-old woman attends her GP clinic for routine cervical screening. Liquid-based cytology (LBC) shows mild dyskaryosis. A repeat sample shows mild dyskaryosis. What is the most appropriate management?

a) Repeat the LBC smear in 6m
b) Repeat the LBC smear in 3m
c) Arrange colposcopy at the gynaecology clinic
d) Knife cone biopsy of the cervix
e) Large loop excision of the transformation zone

C

Cervical screening in the UK is every 3 years from 25yo to 50yo, after which is reduces to every 5 years, ending at 65yo.
Mildly abnormal or borderline smears prompt a repeat screen within 3 months. 2 findings of mild dyskaryosis, 3 borderline results, or 1 finding of severe dyskaryosis prompts referral to colposcopy. If histological findings are present, the patient may be referred to knife cone biopsy or large loop excision.

108

When assessing the foetal presenting part in labour it is important to know the anatomy of the pelvis. What are the bony landmarks of the pelvic outlet?

a) Pubic arch, ischial tuberosities, coccyx
b) Pectineal line, ischial spines, coccyx
c) Pubic symphysis, pubic rami, sacrum
d) Pectineal line, ischial tuberosities, coccyx
e) Pubic arch, ischial spines, sacrum

A

109

A 26-year-old undergoes potassium-titanyl-phosphate (KTP) laser laparoscopic excision of endometriosis. Her postoperative haemoglobin is 8.1 g/dL. Six hours postoperatively she complains of increased umbilical swelling, abdominal pain, and shortness of breath. She appears pale. A repeat FBC now shows she has a haemoglobin count of 6.5 g/dL. What are the most appropriate steps you should take next?

a) Transfuse one unit of cross-matched packed red cells and await events
b) Volume replacement with colloids and reassessment of haemoglobin level
c) D-dimer and CTPA
d) Insertion of a large-bore NG tube on free drainage
e) Transfuse four units of cross matched packed red cells and return to theatre for further laparoscopy

E

A post-operative patient with falling haemoglobin is treated as haemorrhage until proven otherwise. Resuscitation followed by reoperation is required. Resuscitation alone will not solve the source of the bleeding. PE or bowel obstruction is unlikely to be the cause of the SOB or abdominal distension respectively.

110

A 54-year-old woman presents to her GP with a 1-year history of bloating, early satiety, and occasional crampy pelvic pain. She was diagnosed a year ago with irritable bowel syndrome. A serum CA 125 is 62 IU/mL (normal range <36IU/mL). What is the most appropriate management?

a) Pelvic examination and Pipelle biopsy
b) USS abdomen and pelvis
c) CT abdomen and pelvis
d) Urgent referral to the gynaecology clinic under the 2-week rule for suspected cancers
e) Trial of mebeverine and lifestyle modification

B

Progressive bloating, fullness, early satiety, and abdominal or pelvic pain in a woman of this age should raise suspicions of ovarian cancer.

An urgent USS should be organised. The results of this, combined with the CA 125 levels, will give an indication as to risk of malignancy.

Pipelle biopsy is for endometrial abnormality, not ovarian. New IBS is rare at this age, and may well be an incorrect diagnosis, and mebeverine should not be given without further testing.

111

A 24-year-old woman is admitted to the gynaecology ward with a 4d history of severe hyperemesis gravidarum. She has been unable to tolerate food or fluid orally for 2 days. On the second day of admission she develops signs of a severe pneumonia. This is presumed to be a hospital-acquired infection. She deteriorates rapidly. An ABG shows:

pH 7.68
pO2 10.0kPa
PCO2 4.26kPa
HCO3 32mmol/L
K+ 1.9mmol/L
Lactate 1.2mmol/L

What is the most accurate description of the acid-base disorder?

a) Metabolic alkalosis
b) Respiratory alkalosis
c) Mixed respiratory alkalosis and metabolic acidosis
d) Respiratory alkalosis with inadequate respiratory compensation
e) Mixed metabolic alkalosis and respiratory alkalosis

E

The ABG shows profound alkalosis. A combination of raised HCO3 with low pCO2 suggests mixed acid-base disturbance, in which both are causing alkalosis.

Pure metabolic alkalosis would show a higher pCO2. Pure respiratory alkalosis would show a much lower HCO3. Respiratory alkalosis can never have adequate respiratory compensation, by definition.

112

A 61- year-old woman has recently been diagnosed with a stage 1a endometrial carcinoma. She has four children, she has mild utero-vaginal prolapse, and she's never been operated on. She needs to have surgery. You see her in clinic and talk about the different operations available to her. Which is the most appropriate operation?

a) Wertheim's hysterectomy
b) Total abdominal hysterectomy
c) Laparoscopic hysterectomy
d) Subtotal hysterectomy
e) Posterior exenteration

C

A laparoscopic hysterectomy is indicated because it has a much quicker recovery time than laparotomy, and this woman is multiparous, mildly prolapsed, early stage, with no previous operations.

A Wertheim's hysterectomy is an operation for cervical cancer, removing the uterus, upper third of the vagina, and all the parametrium. Subtotal hysterectomy may leave some malignant tissue. Pelvic exenteration is a Wertheim's hysterectomy with a bowel resection, used for significant recurrent cervical or upper vaginal cancers.

113

A 58-year-old woman presents to the clinic with post-menopausal bleeding. A pipelle biopsy confirms adenocarcinoma of the endometrium. Further imaging of the pelvis shows that there is spread of the tumour outside of the uterus into the left adnexa. There is no other spread. What is the most likely stage of the tumour?

a) Stage IA
b) Stage II
c) Stage IIIA
d) Stage IVA
e) Stage IIIC2

C

Staging for endometrial cancers is as follows, defined by FIGO. The stage is the highest the cancer falls under.

IA - tumour confined to the uterus with no or <50% myometrial invasion
IB - tumour confined to the uterus with >50% myometrial invasion
II - cervical stromal invasion, not beyond uterus
IIIA - serosal or adnexal invasion
IIIB - vaginal or parametrial involvement
IIIC1 - pelvic lymph node involvement
IIIC2 - para-aortic lymph node involvement
IVA - bladder or bowel mucosa invasion
IVB - distant metastases, including abdominal metastases or inguinal lymph nodes

114

A 65-year-old woman is referred by her GP to the gynaecology clinic with increasing bloating and a raised CA 125 level. A CT scan shows an irregular, enlarged left ovary and several well-circumscribed nodular lesions in the liver and on the omentum which are highly suspicious for metastatic ovarian cancer. What is the most appropriate treatment regimen?

a) Total hysterectomy, bilateral salpingo-oopherectomy, and omentectomy along with concomitant stereotactic radiotherapy of the liver lesions
b) Total hysterectomy, bilateral salpingo-oopherectomy, omentectomy, aortopelvic lymphadenectomy
c) Staging laparotomy and optimal cytoreduction
d) Palliative care
e) Total pelvic exenteration

C

A work-up of suspected cervical cancers is a CA 125 level, followed by a CT abdo pelvis. Histological proof must now be found before cancer can be properly diagnosed. A laparotomy with optimal 'de-bulking' surgery is indicated in an otherwise well woman.

Following from this, total hysterectomy, bilateral salpingo-oopherectomy, and omentectomy is often employed, but radiotherapy of another system during a radical surgery increases risk of poor outcome. Aortopelvic lymphadenectomy does not improve 5-year survival rate.

As well as surgical intervention, a platinum-based chemotherapeutic agent may be indicated.

115

A 62-year-old woman presents to A and E with shortness of breath. Examination reveals reduced breath sounds and a swollen, distended abdomen. CXR demonstrates a left-sided pleural effusion. On further questioning, the woman has and a poor appetite for the last 6 months and recently had some vaginal bleeding. An ultrasound revealed large quantities of ascites, which were drained. Analysis of the ascites shows a high protein content. What is the most likely diagnosis?

a) Congestive cardiac failure
b) Carcinoma of the ovary
c) Meigs' syndrome
d) Cirrhosis of the liver
e) Carcinoma of the cervix

B

All of the options can cause PE and ascites. However, the ascites is exudative, implying a malignant or inflammatory cause.

Ovarian cancer is most likely in this case, given the age of the patient and the late presentation. Cervical cancer would present earlier, and in younger women. Meigs' syndrome is a rare condition when a benign ovarian fibroma presents with pleural effusion, classically right-sided.

The ascites is not transudative, making it unlikely to be cirrhosis or CCF.

116

A 28-year-old woman attends A and E unable to walk because she is so faint. She has had heavy vaginal bleeding for 4 hours since she engaged in sexual intercourse with a new partner, which she described as 'rough and very painful'. She is still bleeding and cannot tolerate vaginal examination due to the pain. A point-of-care haemoglobin estimation is 6.4 g/dL, and she is haemodynamically unstable. What is the most appropriate management?

a) Discharge with oral iron supplementation and follow-up in the gynaecology clinic in 2 days
b) Discharge with oral iron supplementation and follow-up on the ward in 24 hours
c) Admit, resuscitate, and prepare her for immediate transfer to theatre
d) Admit to the gynaecology ward, cross-match four units of packed red cells and send a formal FBC
e) Admit to the gynaecology ward having packed the vagina

C

This patient is haemodynamically unstable, so must be admitted. If her vagina cannot be examined, it would be impossible to pack, and she should be examined under anaesthesia. A cross-match and FBC could be done in tandem with this, but her genital tract trauma must be seen to.

117

A 64-year-old woman with asthma is admitted to the ward prior to an electric vaginal hysterectomy for symptomatic uterine prolapse. Her medications include Seretide (fluticasone/salmeterol 500/50) four times daily and oral prednisolone 20mg twice daily. What is the most important peri-operative consideration?

a) Steroid cover with 50mg hydrocortisone intravenously at induction of anaesthesia
b) Steroid conver with 100mg hydrocortison intravenously at induction of anaesthesia
c) Steroid cover with 50mg hydrocortisone intravenously at induction of anaesthesia and 50mg 8-hourly for 3 days
d) Bronchodilator cover with intravenous salbutamol infusion postoperatively
e) Continue regular medications and postoperative review by respiratory physician

C

During surgery, gut function does not allow intake of oral medications, such as oral prednisolone. A patient on lower than 10mg of prednisolone per day have a normal HPA and do not need steroid cover. Those on more than 10mg/day for over 3 months require cover to prevent shock as a result of secondary corticosteroid insufficiency. The standard is to give 50mg hydrocortisone IV at induction, and 50mg 8-hourly after for 3 days, or until normal gut function resumes and oral prednisolone can be readministered.

118

A woman is undergoing surgery to enhance the cosmetic appearance of her labia. A bleeding vessel is encountered at the labia majora which cannot be controlled through pressure alone. The surgeon believes it to be a branch of the posterior labial artery. The posterior labial artery is a branch of which artery?

a) Internal pudendal artery
b) Inferior gluteal artery
c) Uterine artery
d) Obturator artery
e) Inferior vesical artery

A

The posterior labial artery is a branch of the internal pudendal artery, itself the terminal branch of the internal ilial artery.

The inferior gluteal, uterine, obturator, and inferior vesical arteries are all branches of the internal ilial artery.

119

Following surgery to place a tension-free transobturator tape for stress incontinence, a 54-year-old woman loses some sensation in part of her labia anterior to the anus. Damage has most likely been caused to which nerve?

a) Perineal nerve
b) Peroneal nerve
c) Pudendal nerve
d) Dorsal nerve of clitoris
e) Inferior anal nerve

A

120

A 54-year-old woman with a history of significant ischaemic heart disease undergoes vaginal hysterectomy for symptomatic uterine prolapse. She develops significant surgical site bleeding which is repaired at reoperation the same day. Her postoperative haemoglobin is 6.4g/dL. Later that same day she develops chest pain. Her observations, blood gas, and cardiac enzymes are within normal limits. An ECG shows sinus rhythm, without ST changes. She is charted for thromboprophylaxis. What is the most likely cause of the chest pain?

a) NSTEMI
b) Anaemia
c) PE
d) Atelectasis
e) Postoperative sepsis

B

The low haemoglobin level in a woman with ischaemic heart disease will cause chest pain due to lack of oxygen to the heart, despite the lack of presence of frank infarction.

PE is possible but unlikely due to her current thromboprophylaxis. NSTEMI is very unlikely with a normal ECG and cardiac enzymes. Atelectasis and postoperative sepsis tend to present later, usually after at least 48 hours.

121

A 46-year-old woman is returned to the ward from the recovery room following a routine vaginal hysterectomy for heavy periods and prolapse. The estimated blood loss at operation was 200mL. Two hours later the ward sister becomes concerned that her urine output is low and calls the doctor. Her observations show: pulse 115bpm, BP 90/62 mmHg, temperature 37.1 degrees C. What are the most appropriate next steps in her management?

a) Aggressive fluid resuscitation, alert the operating surgeon and prepare for a return to theater
b) Fluid challenge, haemoglobin estimation and ABG
c) Vaginal examination, haemoglobin estimation and ABG
d) Establish large-bore IV access, alert the operating surgeon and perform ABG
e) Establish large-bore IV access, alert the operating surgeon and perform a fluid challenge

A

A post-operative patient with falling haemoglobin is treated as haemorrhage until proven otherwise. Resuscitation followed by reoperation is required. Fluid challenge or ABG alone will not solve the source of the bleeding.

122

The peritoneal lining drapes over the pelvic viscera and forms part of the peritoneal cavity. Which is the most inferior extent of the peritoneal cavity?

a) Vesicouterine pouch
b) Paravesical fossa
c) Rectouterine pouch (Pouch of Douglas)
d) Pararectal fossa
e) Rectovesical pouch

C

123

A 74-year-old woman has an annual health check up with her private insurer. They arrange an USS that shows a cyst on her right ovary. It is multioculated and has solid components. She is post-menopausal and otherwise well. A doctor has sent for a CA 125 which comes back as 120 U/mL. What is her risk of malignancy index score (RMI)?

a) 120
b) 240
c) 60
d) 720
e) 480

D

The RMI is calculated using CA 125, cyst characteristics on USS, and menopause status. The score is calculated by adding up one point for each of bilateral cysts, multioculated cysts, cysts with solid components, ascites, and metastases. This is then multiplied by the CA 125, and by three if post menopausal. In this case: 2 x 120 x 3 = 720.

Chance of cancer:
RMI <50 = 3%
RMI 50 - 250 = 20%
RMI >250 = 75%

124

A 21-year-old comes to the clinic with a history of intermenstrual bleeding for the last 6 weeks. She has regular periods and does not experience post-coital bleeding. She is not on the OCP and has no other past medical history. What is the most appropriate first line investigation?

a) Hysteroscopy and biopsy
b) Cervical smear test
c) Triple swabs for pelvic infection
d) Ultrasound scan of the pelvis
e) Pipelle biopsy

C

If the swabs come back negative, a cervical smear test could be performed, and if that is negative, then an USS would be the second line investigation.

125

Two days after undergoing posterior exenteration for recurrence of cervical adenocarcinoma, a 53-year-old woman develops tachypnoea, tachycardia of 125bpm, and a fever of 39 degrees C. Blood cultures have grown MRSA. She requires intravenous vasopressors. What is the most appropriate diagnosis?

a) Sepsis
b) SIRS
c) Septic shock
d) Septicaemia
e) ARDS

C

SIRS is diagnosed when 2 of the following are present: temp <36 or >38; pulse <90bpm; tachypnoea >20/min; WCC <4 or >12 x 10^9/L.
Septicaemia is microbiological proof of a pathogen in the blood.
If there is SIRS with septicaemia, this is sepsis.
Sepsis combined with haemodynamic shock is septic shock.
ARDS is an insult to the lung parenchyma resulting from massive release of inflammatory mediators.

126

A 60-year-old woman is undergoing abdominal hysterectomy for a fibroid uterus. During suture ligation of the right uterine pedicle, iatrogenic injury to the uterus is confirmed. Which of the following statements is correct?

a) The ureter passes through the mesometrium and posterior to the uterine artery on its course to the urinary bladder
b) The ureter passes outside of the mesometrium and anterior to the uterine artery on its course to the urinary bladder
c) The ureter lies posterior to the internal iliac artery and lateral to the obturator nerve opposite the lower part of the greater sciatic notch
d) The ureter passes inferior to the cardinal ligament before coursing anteriorally to enter the urinary bladder
e) The ureter is not closely related to the uterine arteries

A

The ureters run down the lateral pelvic side walls, along the anterior border of the greater sciatic notch, and under the peritoneum. They lie medial to the obturator nerve, and anterior to the internal iliac artery. It enters the pelvis over the iliac vessels at the level of the bifurcation of the common iliac artery. It then passes underneath the uterine artery and then towards the uterine bladder. Iatrogenic injury is most common during ligation of the uterine artery pedicle.

127

A 57-year-old woman has been referred by her GP under the 2-week suspected cancer referral approach with vaginal bleeding. She has been post-menopausal for the last 4 years and she has been taking Elleste Duet to treat her vasomotor symptoms. Two weeks ago, after reading about the risks associated with HRT, she stopped taking any medication. This is the first unscheduled bleeding she has ever had. She had a normal smear 2 years ago and is otherwise well. What would be your first line investigation?

a) Pipelle biopsy
b) Hysteroscopy
c) Smear test
d) USS of the pelvis
e) CT abdomen and pelvis

D

Post-menopausal bleeding could be a sign of ovarian, endometrial, or cervical cancer. It is likely to be a result of ending HRT, but it must not be dismissed. The right choice is USS of the pelvis. If withdrawing from HRT, it would be expected to find a smooth endometrium with a thickness less than 4mm.

Her smears are up to date, and hysteroscopy or Pipelle biopsy is unnecessarily invasive. CT is only indicated if endometrial cancer is discovered on USS as a staging tool.

128

A 39-year-old woman attends the gynaecology clinic complaining of long-standing pelvic pain. Routine bimanual examination and abdominal ultrasonography do not detect any abnormality. At diagnostic laparoscopy, multiple tiny dark brown nodular lesions are noted covering the surface of the uterus, tubes, and left ovary, as well as in the Pouch of Douglas. Which finding is most likely from histological examination of the excised lesions?

a) Krukenberg tumour
b) Vacuolated clear cells
c) Endometrial glands with stromal cells
d) Multiple leiomyomata
e) Enucleated hyperplastic smooth muscle cells

C

These findings are in keeping with endometriosis. The histology will therefore show endometrial tissue: endometrial glands, with stromal cells.

Krukenberg tumours are metastatic neoplasms of the ovary from gastric primaries. Vacuolated clear cells are seen in clear cell adenocarcinoma. Multiple leiomyomata or smooth muscle cells are seen in fibroids.

129

A 21-year-old woman with dysmenorrhoea, dyspareunia, and dyschezia has been scheduled for a laparoscopy to investigate possible endometriosis. You are asking for her consent and you describe the risks of a laparoscopy, which include bleeding and damage to blood vessels, viscera, and nerves. Which of the following is not a risk when inserting a lateral port?

a) Superficial epigastric artery
b) External iliac vein
c) Iliohypogastric nerve
d) Superior epigastric artery
e) Ilioinguinal nerve

D

A lateral port is inserted in the lower quadrant of the abdomen. It is inserted while transilluminating to reveal the superficial epigastric artery (running from the femoral to the umbilicus). The four mentioned (A, B, C, and E) as well as the external iliac, and inferior epigastric arteries are at risk, as is the ilioinguinal nerve.

130

A 32-year-old woman with paranoid schizophrenia is admitted for antenatal assessment at 36 weeks gestation with twins. Her pregnancy is complicated by intrauterine growth restriction and impaired placental flow. She has no psychotic symptoms in this pregnancy. Her obstetricians recommend an early caesarean section and argue it is in the best interests of the mother and her babies and to prevent further foetal insult. She has repeatedly said that despite the significant risks, which she understands, she refuses caesarean delivery. What is the most appropriate action?

a) Detain under section 5 of the MHA and deliver by caesarean section
b) Detain under section 2 of the MHA and deliver by caesarean section
c) Determine that the patient lacks mental capacity and, acting in her best interests, delivery by caesarean section
d) Determine that the patient lacks mental capacity, and acting in her foetus' best interests, deliver by caesarean section
e) Encourage voluntary admission to the antenatal and repeatedly explain the benefits of caesarean delivery

E

The Mental Health Act only allows sectioning of people with active mental health issues, and only allows treatment of those mental health issues. As this patient understands the risks, she has mental capacity, and therefore can make her own decisions.

131

Which of the following would be incorrect advice to give a woman requesting a caesarean section for non-medical indications?

a) You are twice as likely to have a stillbirth in a subsequent pregnancy
b) The risk of damaging the bladder is one in 20
c) There is an increased risk of placenta praevia in future pregnancies
d) 1-2% babies suffer lacerations
e) The risk of infection is 6%

B

The risk of damage to the bladder is 1 in 1000. As well as those mentioned, there is also a risk of VTE in 4-16 in 10,000, significant haemorrhage in 5 in 100, the need for hysterectomy (8 in 1000) and death (1 in 12000).

132

A 24-year-old Jehovah's Witness is brought to A and E with a GCS of 3, BP 90/30 mmHg and pulse 100bpm. Her husband reports that her last menstrual period was 8 weeks ago and she complained this morning of lower abdominal pain and vaginal spotting. Ultrasonography suggests a ruptured ectopic pregnancy. As part of the resuscitative measures employed before emergency laparotomy, a transfusion of group O-negative blood is prepared. Her husband interrupts and says that as a Jehovah's Witness, she would absolutely refuse all blood products, even at risk of death, and has previously signed an advance directive stating this. What is the most appropriate option?

a) Avoid transfusion and volume-replace with colloids before emergency transfer to theatre
b) Avoid transfusion and use a Cell Saver auto-transfuser in theatre
c) Avoid transfusion and immediately transfer to theatre
d) Stabilise the woman in A and E before transfer to theatre
e) Transfuse the woman with O-negative blood and immediately transfer to theatre

E

The two issues here are of best interests and advance directives. In this case, the woman is unconscious, and therefore unable to consent herself. Without the advance directive physically present, it cannot be obeyed, and therefore you must act purely in best interests.

133

An unbooked 26-week pregnant woman sees you at the hospital to request a termination of pregnancy. She says that if she leaves here today without a termination she will try and do it herself by stabbing her abdomen. Your consultant arranges an urgent psychiatric review, which finds no grounds under which to detain this woman in regards to her mental health. Under these circumstances, if a termination was performed, which part of the Abortion Act would it fall under?

a) The continuance of the pregnancy would involve risk to the life of the pregnant woman greater than if the pregnancy were terminated
b) The termination is necessary to prevent grave permanent injury to the physical or mental health of the pregnant woman
c) The pregnancy has not exceeded its 24th week and continuance of the pregnancy would involve risk, greater than if the pregnancy were terminated, of injury to the physical or mental health of the pregnant woman
d) The pregnancy has not exceeded its 24th week and continuance of the pregnancy would involve risk, greater than if the pregnancy were terminated, of injury to the physical or mental health of any existing child(ren) of the family of the pregnant woman
e) There is a substantial risk that if the child were born it would suffer from such physical or mental abnormalities as to be seriously handicapped

B

Both A and B are possible answers, but B seems to be most appropriate in this scenario.

134

A 24-year-old woman in her first pregnancy presents to the labour ward in labour. She and her partner express an overwhelming desire to avoid a caesarean section. Her labour does not progress and after 9 hours her cervix is still only 3cm dilated. Unfortunately, the foetal heart slows to 60bpm and does not recover after 5 minutes. Your senior registrar explains the situation to the woman and recommends an immediate caesarean section. She refuses and her partner tells you to stop harassing them. You explain that their unborn child will die if this continues. What options do you have?

a) Caesarean section under GA under section 3 of the MHA
b) Caesarean section under GA under section 2 of the MHA
c) No action. Allow foetus to die
d) Caesarean section without MHA application
e) Caesarean section under GA under Section 5(2) of the MHa

C

The Mental Health Act only allows sectioning of people with active mental health issues, and only allows treatment of those mental health issues. As this patient understands the risks, she has mental capacity, and therefore can make her own decisions.

135

A 16-year-old Muslim woman attends A and E with her father. She complains of a 1-day history of left iliac fossa pain and mild vaginal spotting. A urinary beta hCG test is positive. As part of your assessment, the patient consents to a vaginal examination. She insists you do not tell her father that she is pregnant, and you consider her to be competent in her judgement. Her father becomes angry and says you must not perform a vaginal examination. How should you proceed?

a) Perform the examination with a chaperone present and tell the father that it is a routine examination in pregnancy
b) Perform the examination with a chaperone present and explain that parental consent is not necessary in this situation
c) Defer performing the examination and document the situation fully
d) Perform the examination with a chaperone present having assessed the girl's Gillick Competence
e) Perform the examination with a chaperone present having assessed the girl's Fraser Competence

B

Parental consent is not necessary in cases of 16 and 17 year olds, as long as they have mental capacity. Confidentiality must also be maintained, so A is incorrect. Gillick competence and Fraser guidelines are only applicable to under 16-year-olds.

136

A 32-year-old woman is rushed to A and E as the victim of a high speed vehicle collision. She is 35 weeks pregnant and unconscious. There is evidence of blunt abdominal trauma and she is showing signs of grade 3 hypovolaemic shock. The consultant obstetrician on call immediately attends the resus call and recommends immediate perimortem caesarean delivery in a resuscitative effort to improve the management of her shock. Her husband has been brought into resus by the police, and insists that she would refuse caesarean section under any circumstances. What is the most appropriate management?

a) Rapid fluid resuscitation until the situation regarding the patient's wishes becomes clear
b) Replacement of the lost circulating volume with blood products
c) Admit to the intensive care unit and begin infusing inotropes to restore the cardiac output
d) Immediate caesarean delivery
e) Resuscitation and transfer to the obstetric theatre for emergency caesarean delivery

D

The issue here is of best interests. In this case, the woman is unconscious, and therefore unable to consent herself. You must act purely in the woman's best interests, and therefore follow the consultant obstetrician's advice.

137

A 59-year-old woman has been admitted for a hysterectomy for endometrial cancer. She has not yet given her consent and the rest of the team is in theatre. You have performed a hysterectomy before so feel confident in taking her through what will happen and the risks involved. The GMC says that you should tailor your discussion to all of the options except which of the following?

a) Their needs, wishes, and priorities
b) Their level of knowledge about, and understanding of, their condition, prognosis, and the treatment options
c) The onset of their condition
d) The complexity of the treatment
e) The nature and level of risk associated with the investigation

C

There are five things to do when consenting for any procedure:
1) Assess the patient's understanding of their disease
2) Explain the nature of their condition (not onset) based on 1)
3) Discuss their needs, wishes, and priorities
4) Discuss the complexity of their treatment
5) Explain the risks associated with the treatment

138

"A quality improvement process that seeks to improve patient care and outcome through systematic review of care against explicit criteria and the implementation of change." This is an accepted definition of what?

a) Audit
b) Clinical governance
c) Clinical research
d) Clinical effectiveness
e) Integrated governance

A

Clinical governance is the framework through which NHS organisations are accountable for improving quality.

Clinical research is a process to answer a clinical question, based on scientific method.

Clinical effectiveness studies whether a particular intervention works, and whether it is useful, acceptable to the patient, and good value for money.

Integrated governance refers to the combination of clinical and corporate governance.

139

A 15-year-old girl attends the gynaecology clinic with her boyfriend, also 15, requesting the morning after pill 4 months after being circumcised during a family trip to Somalia. She understands you advice and the implications of her decision to engage in sexual activity, is using condoms regularly and refuses to inform her parents. What is the most appropriate management?

a) Decline to prescribe the morning after pill and refer the patient back to her GP
b) Decline to prescribe the morning after pill, and inform her parents that she is having underage sex
c) Prescribe the morning after pill, give contraceptive advice and recommend that the girl informs her parents
d) Prescribe the morning after pill, give contraceptive advice and immediately alert your consultant and the Safeguarding Children Team
e) Prescribe the morning after pill, give contraceptive advice, and inform her parents

D

The girl in this scenario is Gillick competent, so the morning after pill can be prescribed. Informing her parents would be a breach of confidentiality.

This girl has also been circumcised, which is a type of FGM. It should be reported, as it is a serious offence in the UK, contrary to the Female Genital Mutilation Act 2003.