Questions (OBs) Flashcards
1
Q
A patient with post-natal depression.
What is the most appropriate drug to manage this patient’s?
Bupropion
Fluoxetine
Mirtazapine
Olanzapine
Paroxetine
A
Paroxetine
postpartum sadness - PS - paroxetine and sertraline
2
Q
How do you reverse MgS overdose? [1]
A
Calcium gluconate
3
Q
Termination of pregnancy:
- how is mifepristone and misoprostol each delivered? [2]
A
Oral mifepristone
Vaginal misoprostol
4
Q
List 3 possible causes of second trimester miscarriages [3]
A
septate or bicornuate uterus, cervical incompetence, and antiphospholipid syndrome or systemic lupus erythematosus
5
Q
First ti
A
6
Q
A 32-year-old female has been referred to the infertility clinic with her partner. They have been trying to conceive for almost one year now, having regular unprotected intercourse. Initial investigations, including thyroid function tests and mid-luteal phase progesterone and prolactin, are normal. Semen analysis is also normal. No sexually transmitted infections were detected on testing. The patient reports regular periods and a history of endometriosis.
What is the next most appropriate investigation? [1]
A
Laparoscopy and dye is the most appropriate next step of investigation in this scenario. NICE guidelines recommend this procedure to investigate tubal patency in women with known co-morbidities, such as previous ectopic pregnancy, a history of pelvic inflammatory disease and endometriosis
- It involves explorative laparoscopy, allowing direct visualisation of the pelvis, which is superior to the hysterosalpingogram because assessment and treatment can occur in one setting
7
Q
A baby is born with improper skull formation. Which is the most likely to have caused this if taken in throughout the pregnancy?
Amlodipine
Hydrochlorothiazide
Atenolol
Lisinopril
Nifedipine
A
A baby is born with improper skull formation. Which is the most likely to have caused this if taken in throughout the pregnancy?
Lisinopril causes hypocalvaria (incomplete formation of the skull bones)
8
Q
A 32-year-old woman, at 34 weeks of pregnancy, is prescribed an antihypertensive medication for the management of gestational hypertension. After two weeks, she presents for a routine ultrasound, where oligohydramnios is detected. She reports no prior history of any conditions that would typically lead to a decrease in amniotic fluid levels.
Question:
Which of the following medications is most likely to cause oligohydramnios in this pregnant woman?
Amlodipine
Hydrochlorothiazide
Atenolol
Lisinopril
Nifedipine
A
According to the NICE guidelines for the management of hypertension in pregnancy, ACE inhibitors(Option C) are contraindicated during pregnancy because they can cause significant harm to the fetus, including oligohydramnios. ACE inhibitors can lead to a reduction in renal perfusion, which in turn reduces fetal urine output, a major contributor to amniotic fluid production.
9
Q
An anomaly scan at 20 weeks shows this image.
Which drug is likely to have caused this presentation?
Phenytoin
Amlodopine
Sodium Valproate
Lithium
Linisopril
A
An anomaly scan at 20 weeks shows this image.
Which drug is likely to have caused this presentation?
Sodium Valproate
- image shows a NTD; caused by sodium valproate
10
Q
An anomaly scan at 20 weeks shows this image.
Which drug is likely to have caused this presentation?
Phenytoin
Amlodopine
Sodium Valproate
Lithium
Linisopril
A
Lithium - Epstein abnormality
11
Q
A
12
Q
A
13
Q
The following are all different types of ovarian cancers. Which can secrete oestrogen and therefore cause endometrial hyperplasia?
Granulosa cell tumour
Endometrioid
Theca cell tumours
Sertoli-Leydig cell tumour
Clear cell
A
The following are all different types of ovarian cancers. Which can secrete oestrogen and therefore cause endometrial hyperplasia?
Granulosa cell tumour
Endometrioid
Theca cell tumours
Sertoli-Leydig cell tumour
Clear cell
14
Q
A 28-year-old woman presents with a 10-week history of amenorrhea followed by intermittent, heavy vaginal bleeding. She reports severe nausea and vomiting, which has worsened over the past two weeks. On further questioning, she mentions abdominal discomfort and a sensation of fullness. A home pregnancy test performed four weeks ago was strongly positive.
Which is the most likely cyst that a person with this condition will present with?
Follicular Cyst
Corpus Luteum Cyst
Theca-Lutein Cyst
Endometrioma
Dermoid Cyst
A
A 28-year-old woman presents with a 10-week history of amenorrhea followed by intermittent, heavy vaginal bleeding. She reports severe nausea and vomiting, which has worsened over the past two weeks. On further questioning, she mentions abdominal discomfort and a sensation of fullness. A home pregnancy test performed four weeks ago was strongly positive.
Which is the most likely cyst that a person with this condition will present with?
Theca-Lutein Cyst
- Caused by overstimulation of hCG during pregnancy
- stimulates growth in follicular theca cells
15
Q
A 32-year-old woman is incidentally found to have a 7.5 cm simple ovarian cyst during an abdominal ultrasound for nonspecific pelvic pain. She is asymptomatic and has no significant medical history. According to NICE guidelines, what is the most appropriate next step in management?
A) Repeat ultrasound in 4–6 weeks
B) Refer for an urgent gynecological evaluation
C) Arrange a follow-up ultrasound in 6 months
D) Perform tumor marker testing and refer for surgical evaluation
E) Discharge the patient with no further follow-up
A
B) Refer for an urgent gynecological evaluation
- Explanation: NICE guidelines recommend referral to a gynecologist for cysts larger than 7 cm due to an increased risk of malignancy or complications like torsion or rupture. While tumor marker testing (e.g., CA-125) and monitoring might also be part of the assessment, immediate referral is the critical next step.
16
Q
Name an absolute contraindication for external cephalic version? [1]
A
Antepartum haemorrhage within the last 7 days of the procedure
17
Q
A patient undergoes forceps delivery.
Prior to attempting an instrumental delivery, the registrar performs a nerve block to provide regional analgesia.
Which nerve is blocked in this circumstance? [1]
A
To perform a pudendal nerve block, Lidocaine is injected 1–2cm medially, and below the right and left ischial spines transvaginally with a specially designed pudendal needle
* This provides effective regional anaesthesia to the perineum, including the external genitalia and external anal sphincter
18
Q
Describe the difference between a footling, frank and complete breech [3]
A
Footling breech
- where one or both legs are fully extended towards the pelvic inlet, with the foot or feet being the presenting part
Frank breech:
- where the legs are fully extended up to the shoulders and the presenting part is the buttocks
Complete breech
- is where the hips and knees are both flexed and the presenting part is the buttocks
19
Q
An ultrasonography of a 25 year old female at 24 weeks gestation reveals twin pregnancy. Both foetuses are female and it appears to be a diamniotic, monochorionic twin pregnancy. Twin A appears much smaller than Twin B.
Name a concern for Twin B [1] and Twin A [1]
A
The recipient twin would develop hypervolemia as a result of receiving transfusion from the donor twin (which would develop oligohydramnios and growth retardation)
20
Q
A patient presents with reports of a 6 month history of amenorrhoea.
They have had previous uterine surgery (e.g. dilatation and curettage). They still recieve cyclical pain.
What is the most likely dx? [1]
A
21
Q
Which palsy is most likely to occur in birth? [1]
How does it present? [2]
Which nerve roots are affected? [1]
A
Erb’s palsy
- It is the most common injury seen in traumatic births, commonly affecting the brachial plexus.
- waiters tip hand: internal rotation of forearm and wrist and finger flexion
- C5-C6
22
Q
A patient presents with congenital rubella syndrome.
What would you measure to confirm this diagnosis? state how this varies with age
A
Under 6 months:
- IgM
6-12 months:
- IgG and IgM
- This is because IgM, although may persist up to 12 months of age, is negative in 50% of patients after 6 months
23
Q
Describe why may give a PPI prior to C section? [1]
A
Pregnant women are physiologically at increased risk of gastric reflux compared to the normal population
Give a PPI before Caesarean section to reduce maternal gastric volume and acidity. This reduces the risk of aspiration of gastric contents during surgery and subsequent aspiration pneumonitis
24
Q
A patient presents with ?neonatal sepsis.
What is the most likely cause [1] and treatment [1]
A
Group B Streptococcus (GBS)
- Intravenous benzylpenicillin is a first-line antibiotic
25
**[]** is a patented mixture of inhaled nitrous oxide and oxygen (1:1). It is the most popular form of analgesia for mild labour pain
**Entonox** is a patented mixture of inhaled nitrous oxide and oxygen (1:1). It is the most popular form of analgesia for mild labour pain
26
**[]** is considered the first-line management for polycystic ovary syndrome (PCOS) due to their ability to suppress luteinizing hormone secretion and ovarian androgen production.
**COCP** is considered the first-line management for polycystic ovary syndrome (PCOS) due to their ability to suppress luteinizing hormone secretion and ovarian androgen production.
27
A 30-year-old woman with a past medical history of endometriosis presents with worsening symptoms despite taking regular ibuprofen and paracetamol. She is not planning to have children.
**What is the most appropriate next step? [1]**
**Prescribe the combined oral contraceptive pill**
- Laparoscopic excision of endometriosis implants is a minimally invasive surgical option for treating endometriosis. It is often recommended for women who wish to preserve their fertility. However hormonal therapy such as the combined contraceptive pill would be the most appropriate next step.
28
New-onset hypertension prior to 20 weeks’ gestation is most commonly due to [1]
New-onset hypertension prior to 20 weeks’ gestation is most commonly due to **gestational trophoblastic disease**.
29
What are oral abx specifically trying to prevent in asymptomatic bacteriuria in pregnancy? [2]
Oral antibiotics are recommended in cases of asymptomatic bacteriuria to prevent progression to **pyelonephritis** and **increased risk of preterm labour**
30
Ultrasound of fetus reveals a pericardial effusion, pleural effusion and possible ascites of the foetus
What is the most likely diagnosis seen on the ultrasound?
Beta-thalassaemia minor
Hydrops foetalis
Potter syndrome
Alpha-thalassaemia minor
Tetralogy of Fallot
**Hydrops foetalis**
* as the ultrasound shows foetal oedema, which must be seen in at least two compartments for a diagnosis. This was likely to be missed due to the lack of attendance to appointments, as well as prophylaxis medication such as anti-D injections.
31
Why are newborns susceptible to vitamin K deficiency bleeding? [1]
Vitamin K is poorly transferred through the placenta and has low concentrations in breastmilk, making newborns susceptible to vitamin K deficiency bleeding. Therefore, they are administered a vitamin K injection shortly after birth.
32
Which type of tears can be repaired by a suitably experienced midwife? [1]
Which type of tears need to be repaired in an operating theatre? [1]
**Second degree tears** require suturing, and this can be performed on the ward by a **suitably experienced midwife or clinician.**
**Third and forth degree tears** always require **surgical repair in an operating theatre environment** by a suitably **experienced clinician**
33
In **pre-labour rupture of membranes** at term, [1] is crucial for confirming the diagnosis.
In pre-labour rupture of membranes at term, a **sterile speculum examination** is crucial for confirming the diagnosis, assessing the risk of infection, and evaluating fetal position and cord prolapse.
34
Women with dichorionic twin pregnancies should be offered elective birth from **[]**
Women with **dichorionic twin pregnancies** should be offered elective birth from **37 weeks 0 days**
35
A patient presents with PV early in pregnancy.
When you perform a bHCG test - it comes back at 200, 000iu.
What is the patient at risk of developing from this condition? [2]
**Pulmonary metastasis and thyroid dysfunction**
- The lungs are among the first sites of metastatic disease. Gestational trophoblastic disease is also strongly associated with thyroid dysfunction.
36
Preterm labour, preterm birth, and premature rupture of membranes (PROM) are conditions related to early onset of labour and delivery before **[]** weeks of gestation
Preterm labour, preterm birth, and premature rupture of membranes (PROM) are conditions related to early onset of labour and delivery **before 37 weeks of gestation**
37
Which test can be used to screen for pre-term delivery after the onset of pre-term labour? [1]
The **foetal fibronectin test (fFN test)** is a screening test used to assess the risk of preterm delivery after the onset of pre-term labour. A negative fFN test indicates a low risk of delivery occurring within the next 7-14 days.
38
Women with uncomplicated monochorionic twin pregnancies should be offered elective birth from **[]**
Women with uncomplicated monochorionic twin pregnancies should be offered elective birth from **36 weeks 0 days**, after a course of antenatal corticosteroids has been advised
39
Why should you not apply fundal pressure if shoulder dystocia is suspected? [2]
may lead to **uterine** **rupture** and discourage maternal pushing as this **may exacerbate shoulder impaction**
40
tender palpable adnexal mass, low-grade fever is highly suggestive of **[]**
tender palpable adnexal mass, low-grade fever is highly suggestive of **ovarian torsion**
41
What are the serious complications of amniotic fluid embolisms? [2]
disseminated intravascular coagulation (DIC) and maternal cardiac arrest.
42
43
The **[]** manoeuvre should be considered if McRoberts and suprapubic pressure has failed.
Describe this [1]
The **wood screw (Rubin) manoeuvre** should be considered if McRoberts and suprapubic pressure has failed.
- **anterior shoulder** is pushed towards the **foetal** **chest** and the **posterior shoulder** is pushed towards the **foetal back.**
## Footnote
NB: this is an internal rotational manoeuvre
44
Describe the process of McRobert's manoeuvre [3]
* **Hyperflexion** and **abduction** of the mother's **legs** tightly to the **abdomen**
* This may be accompanied with applied **suprapubic pressure**
* **Routine** **traction** (as applied during normal delivery) in an **axial direction** should be applied to assess whether the shoulders have been released.
45
A 35 year old primiparous woman presents to the maternity unit in a small community hospital with regular painful uterine contractions occurring every 20 minutes and lasting for 60 seconds each. She is currently 34 weeks pregnant and suffers from gestational hypertension. A vaginal examination reveals that the cervix is 3cm dilated. Her membranes rupture during the digital examination.
What is the next most appropriate step in her management? [2]
Give **maternal dexamethasone**, transfer to nearest hospital with a **neonatal unit**
46
How do you monitor patients with severe pre-eclampsia? [3]
Patients with severe pre-eclampsia should have **blood tests three times per week to anticipate if a patient is developing HELLP syndrome**, a complication of pre-eclampsia involving haemolysis, elevated liver enzymes and low platelets
- **U&E, FBC, transaminases and bilirubin three times per week**
47
How do you dx [1] and tx [1] premature ovarian insufficiency?
women **under** the age of **40** who have symptoms of **menopause** (eg. period cessation) **alongside two FSH measurements of >25 IU/l.** The most appropriate management is **hormone-replacement therapy.**
48
Which medication given in pregnancy is most likely to have caused this presentation
Phenytoin
Valproate
Lamotrigine
Levetiracetam
Carbamazepine
Which medication given in pregnancy is most likely to have caused this presentation
**Phenytoin**
Valproate
Lamotrigine
Levetiracetam
Carbamazepine
49
A 31-year-old female is admitted to the Labour Suite, two weeks post-due date, for the induction of labour. She is assessed using the Bishop’s scoring system and is noted to have a score of 5.
Which treatment should be administered to this patient?
Vaginal PGE2, then reassess 6 h later
Artificial rupture of membranes
Membrane sweep
Anti-progesterone, then reassess 4 h later
Artificial rupture of membranes + Syntocinon®
#15885
A 31-year-old female is admitted to the Labour Suite, two weeks post-due date, for the induction of labour. She is assessed using the Bishop’s scoring system and is noted to have a score of 5.
Which treatment should be administered to this patient?
**Vaginal PGE2, then reassess 6 h later**
Artificial rupture of membranes
Membrane sweep
Anti-progesterone, then reassess 4 h later
Artificial rupture of membranes + Syntocinon®
#15885
50
A 32-year-old primagravida discovers from her booking blood tests that she has contracted hepatitis B. She is both HbsAg and HbeAg positive at the time of delivery.
**What is the best management for the foetus?** [2]
**HBV IgG** and **HBV vaccination** within **24 hours of delivery**
51
A 32-year-old female presented a diary with evidence of cyclical symptoms in the second half of her menstrual cycle, consisting of abdominal bloating, mood swings and aggression ongoing for five months. During these episodes, she becomes withdrawn, requires time off work and does not attend social engagements. She is worried because her relationship is suffering as a result of this. Examination and basic blood profile are unremarkable. She is diagnosed with severe pre-menstrual syndrome.
Which of the following is the most appropriate management option for this patient?
Bilateral salpingo-oophorectomy
Fluoxetine
Cognitive behavioural therapy (CBT)
Combined oral contraceptive pill (COCP)
Referral to a specialist clinic
52
How would a patient present if they have MgS toxicity? [3]
Symptoms of magnesium sulfate toxicity include **loss of deep tendon reflexes, respiratory depression, and cardiac arrest.** Loss of deep tendon reflexes is the first sign of magnesium toxicity.
53
How would you differentiate between threatened and inevitable miscarriage? [2]
**Inevitable miscarriage**
* **heavy** **bleeding** with **clots and PAIN**
* **cervical os** is **open**
**Threatened miscarriage**:
* **PAINLESS** **vaginal** **bleeding** occurring **before 24 weeks**, but typically occurs at **6 - 9 weeks**
* the bleeding is often **less than menstruation**
* **cervical os is closed**
* complicates up to **25% of all pregnancies**
54
How do you treat MgS toxicity? [1]
**Calcium gluconate**
55
What is the classic triad of vasa praevia? [3]
The classic triad of vasa praevia is **rupture of membranes followed by painless vaginal bleeding and fetal bradycardia.**
## Footnote
**NB**:
**VASA PRAEVIA** = foetal distress in stem (Bradycardic etc), probably some mention of ROM
**PLACENTA PRAEVIA** = baby fine usually, just painless PV bleed
56
Patient presents with palpitations, tremors, sweating, and diarrhoea.
They have given birth 10 days ago.
How do you manage them? [1]
The **thyrotoxicosis** phase of postpartum thyroiditis is generally managed with **propranolol** **alone**
57
Which antibodies would you find in post-partum thyroiditis? [1]
**Thyroid peroxidase antibodies** are found in 90% of patients
58
Pregnant women (26 weeks), presents with PV bleeding. She is Rh -ve.
How do you treat with regards to her Rh status and why? [2]
**One dose of Anti-D immunoglobulin followed by a Kleihauer test**
- Antepartum haemorrhage is associated with fetomaternal haemorrhage (FMH) and therefore an **increased risk of Rhesus sensitisation** and **Rhesus disease of the newborn in subsequent pregnancies**
- A **Kleihauer test is a test for FMH** which detects **fetal** **cells** in the **maternal circulation** and, if present, **estimates the volume of FMH** to allow **calculation of additional anti-D immunoglobulin.**
59
Which of the following is a potentially sensitising event in pregnancy and requires administration of anti-D in a RhD-negative woman?
Previously non-sensitised 11 week pregnant woman with first episode of painless vaginal bleeding
Previously non-sensitised 16 weeks pregnant woman undergoing amniocentesis
Previously sensitised 8 week pregnant woman with an ectopic pregnancy
Previously non-sensitised woman after delivery of a RhD-negative baby
Previously sensitised woman after delivery of a RhD-positive baby
**Previously non-sensitised 16 weeks pregnant woman undergoing amniocentesis**
60
When do you discontinue Mg treatment for eclampsia? [1]
Magnesium treatment should continue for **24 hours after delivery** or **after last seizure**
61
Which of the following immunoglobulins is responsible for attacking a Rhesus-positive foetus from a Rhesus-negative mother?
IgA
IgM
IgE
IgD
IgG
62
At what gestation should anti-D be administered?
12 weeks
18 and 28 weeks
32 and 37 weeks
28 and 34 weeks
20 weeks
**28 and 34 weeks**
63
A 37-year-old woman presents for review. She is 26 weeks pregnant and has had no problems with her pregnancy to date. Blood pressure is 144/92 mmHg, a rise from her booking reading of 110/80 mmHg. Urine dipstick reveals the following:
Protein negative
Leucocytes negative
Blood negative
What is the most appropriate description of her condition?
Moderate pre-eclampsia
Mild pre-eclampsia
Gestational hypertension
Normal physiological change in blood pressure
Pre-existing hypertension
**Gestational hypertension**
- The correct answer is gestational hypertension. This is because the patient has a significant increase in blood pressure (≥140/90 mmHg) after 20 weeks of gestation **without any proteinuria** or other **systemic features**. According to UK guidelines, gestational hypertension is diagnosed when there is new-onset hypertension during pregnancy without any proteinuria or other features suggestive of pre-eclampsia.
64
**[]** and an **[]** is the **preferred method** of induction of labour if the **Bishop score is > 6**
**Amniotomy** and an **intravenous oxytocin infusion** is the preferred method of induction of labour if the **Bishop score is > 6**
- **NB** if the Bishop score is **≤ 6**
**vaginal prostaglandins or oral misoprostol**
mechanical methods such as a **balloon catheter** can be considered if the woman is at higher risk of hyperstimulation or has had a previous caesarean
## Footnote
a score of **< 5** indicates that labour is unlikely to start without induction
a score of** ≥ 8** indicates that the cervix is ripe, or 'favourable' - there is a high chance of spontaneous labour, or response to interventions made to induce labour
65
Mneumonic for which drugs shouldnt be used when breastfeeding? [+]
**LAMBAST** mothers ceen taking:
**L**ithium
**A**miodarone
**M**TX
**B**enzos
**A**spirin
**S**ulfonamides
**T**etracyclines
**C**arbimazole, **ci**pro, **c**hloramphenicol
66
If a previous pregnancy has had neonate sepsis, e.g. due to Group B Strep (GBS), how do you prevent this in a future pregnancy? [1]
Which drug is given for GBS prophylaxis? [1]
**Maternal intravenous antibiotic prophylaxis during labour** should be offered to women with a previous baby with early- or late-onset GBS disease
- **benzylpenicillin** is the **antibiotic of choice for GBS prophylaxis**
67
In which cases would GBS Intrapartum Antibiotic Prophylaxis be given? [5]
* **A positive GBS screening** culture at **35-37** weeks gestation.
* A **previous** **infant** with **GBS** disease.
* **GBS** **bacteriuria** during the **current pregnancy.**
* **Unknown** **GBS** status and risk factors such as **preterm labour (< 37 weeks)** or **prolonged rupture of membranes ( > 18 hours).**
* women with a **pyrexia** during labour (**>38ºC**)
68
What is the current position of the fetal vertex shown in this image?
Left occiput posterior
Occiput anterior
Right occiput posterior
Left occiput anterior
Right occiput anterior
baby's OCCIPUT is pointing to the mother's LEFT thigh and the occiput against the mother's spine/back (POSTERIOR)
69
Explain what happens when maternal anti-D antibodies cross the placenta? [2]
**Haemolytic disease of the newborn occurs**:
- when a **Rhesus negative** woman becomes **pregnant** with a **Rhesus** **positive** **foetus**.
- This is usually not a problem during the first pregnancy.
- However, during **subsequent** **pregnancies**, the **maternal anti-D antibodies** can **cross** the **placenta** and lead to **haemolysis** of **foetal red blood cells.**
- Anti-D is given during pregnancy to neutralise maternal anti-D antibodies and reduce the risk of haemolytic disease of the newborn.
70
A patient has pre-exisiting hypertension prior to becoming pregnant.
How do you reduce the risk of pre-eclampsia? [1]
A woman at moderate or high risk of pre-eclampsia should take **aspirin 75-150mg daily from 12 weeks** **gestation until the birth**
71
A patient is having twins. There is a risk of TTTS.
When during the pregnancy is this most likely to occur? [1]
How do you detect this? [1]
**TTTS** usually occurs in **early or mid-pregnancy,** thus **ultrasound examinations performed between 16 and 24 weeks** focus on detecting this condition
- After 24 weeks the main purpose of ultrasound examinations is to **detect fetal growth restriction.**
72
Why is a cervical membrane sweep the first step in inducing labour? [1]
A cervical membrane sweep **increases the likelihood of spontaneous labour** initiating as it **causes release of prostaglandins**
73
Which treatment for asymptomatic bacteruria can be given in the first [1] and third [1] trimester of pregnancy?
**Nitrofurantoin** is usually a good choice for the **treatment** of urinary tract infections (UTIs) in the **first** / second. **Avoid** in **third** trimester as risk of **neonatal haemolysis**
- **N**itrofurantoin - use for **n**ew babies
**Cefalexin** is an **appropriate choice unless** contraindicated by allergies or previous urine culture sensitivities.
74
What dose of vit. D should you give throughout pregnancy? [1]
Correct. The recommended daily dose of vitamin D for pregnant women is **10 micrograms**, which is equivalent to 0.01 milligrams. This helps maintain bone health for both the mother and developing baby.
75
Describe the process of the Rubin manoeuvre [1]
When is it indicated? [1]
**The Rubin manoeuvre** is an **internal** **intervention** used to help r**elieve shoulder dystocia**.
- It involves **applying pressure behind the anterior shoulder** to **rotate** the **shoulders** into the **oblique diameter** and facilitate **delivery**.
- This manoeuvre is performed **after external manoeuvres have failed.**
76
Describe the process going on in this image [1]
77
You should think chorioamnionitis in women with **[]** with a triad of **maternal** [2], and **fetal** [1]
You should think chorioamnionitis in women with **preterm-PROM** with a **triad of maternal pyrexia, maternal tachycardia, and fetal tachycardia**
78
What is the last maneuver used to birth babies stuck with shoulder dystocia? [1]
**Gaskin maneuver**, which utilizes downward traction on the head to allow the posterior shoulder to descend and be delivered.
## Footnote
Unsure if actually used
79
Which of the following statements regarding TTTS is true?
The recipient twin is more likely to survive to birth
There is currently no treatment available
The recipient twin is at risk of developing foetal hydrops
The donor twin is not at risk of developing heart failure
One of the foetuses usually develop normally
The recipient twin is at risk of **developing fluid overload** and as a consequence, **foetal hydrops and heart failure**
80
In TTTS, which pathologies are the donor and recipient twins at risk of suffering? [2]
Describe the pathophysiology of TTTS [4]
**Donor twin:**
- **high output cardiac failure** as a result of **severe anaemia**
**Recipient twin**
- can suffer from **fluid overload due to excess blood volume.**
**Pathophysiology**:
**Stage 1:**
- unequal blood flow between twins sharing a placenta results in **recipient** **twin** having too much amniotic fluid (**polyhydramnios**), and **donor twin** with little or no amniotic fluid (**oligohydramnios**)
**Stage 2:**
- Donor's twin bladder doesn't fill or empty because blood is diverted to kidneys, brain and heart.
**Stage 3:**
**Stage 4:**
- **hydrops** (massive fluid retention) develops - which is **indicative** of **heart failure** in the **recipient twin**, whilst the donor is suffering from **HF**
81
G1 PO, aged 30.
**When is the earliest time she can be offered ECV for a breeched baby?**
**When would this change? [1]**
Immediately
39 weeks
37 weeks
36 weeks
38 weeks
**36 weeks**
- If the lady was **multiparous** **ECV** would be offered from **37 weeks.**
82
Placental abruption is characterised by **constant pain,** **shock** out of keeping with the **visible** loss, **[description x2] uterus**
Placental abruption is characterised by constant pain, shock out of keeping with the visible loss, **tender and tense uterus**
83
Chickenpox exposure in pregnancy - if not immune give... if they're at what stage in their pregnancy? [2]
Chickenpox exposure in pregnancy - if not immune give either **oral antivirals**
- Women who develop chickenpox during pregnancy should be treated with **oral aciclovir 800mg 5 times a day for 7 days** if **>20 weeks pregnant.**
84
**Vaginal PGE2 or oral misoprostol** is the preferred method of induction of labour if the Bishop score is ≤ 6
**[]** or **[]** is the preferred method of induction of labour if the **Bishop score is ≤ 6**
85
Name 5 short term complications of delivery
Sepsis
PPH
Perineal Tears
Sheehans syndrome
Baby blues
86
What is the difference between a tear and an episiotomy? [1]
An **episiotomy** is a **cut** made by a healthcare professional into the perineum and vaginal wall to make more space for the baby to be born.
**Episiotomies** are done with your **consent**.
- They are only done if your baby needs to be born quickly, often if you are having an instrumental (forceps or vacuum assisted) birth, or if you are at risk of a serious perineal tear.
**Tears** **happen** spontaneously as the baby stretches the vagina and the perineum during birth.
87
How much blood loss occurs in vaginal [1] and C-section [1] PPH?
Vaginal > 500ml
C-section > 1000ml
88
What are the differences in primary and secondary causes of PPH?
89
After a perineal tear - what clinic would a patient be booked into for their follow up care? [1]
**OASI clinic**
- obstetric anal sphincter injury
90
What two key presentations would make you think a patient is suffering from Sheehan's syndrome? [2]
**amenorrhea** and **difficulty to lactate** (w/ a Hx of PPH)
91
Which are T/F? [5]
**A: True**
**B: True** - may be prolonged by anaemia as worsens fatigue and excerbates mood swings
**C** - **false**
**D - false**
**E - false**
92
Which are T/F? [5]
**A: True**
**B: False** - some medications need tapering
**C** - **true**
**D - false**
**E - false** - if patient needs inpatient treatment for mental health and have baby - usually cared for in mother / baby unit
93
SBA
**D**
## Footnote
**NB**: A - more than 80% develop their first pys. disease post-partum
94
* Dx: **PE**
* Investigations: **CXR** - prove to radiologist that have excluded other pathologies; **CTPA** or **V/Q**
* Tx: **LMWH**
95
E
96
**C**
97
**A**
98
**E** - most common cause
99
When is vitamin K indicated in a newborn? [1]
What does it prevent? [1]
**After every birth**
- prevents **haemorrhagic disease of the newborn** / **Vitamin K deficiency bleeding (VKDB**) is now the preferred term for haemorrhagic disease of the newborn (HDN).
- Vitamin K is required for the production of clotting factors **II, VII, IX and X.**
100
The bleeding in classic **VKDB** most often presents as bleeding from where? [4]
* **Gastrointestinal** bleeding.
* Bleeding from the **skin** and **mucous** **membranes** - eg, the **nose** and **gums**.
* **Prolonged** **bleeding** following **circumcision**.
* **Bleeding** from the **umbilical stump**.
101
Describe the presentation of red degeneration of fibroid [2]
Describe the pathophysiology [1]
**TOM TIP**: Look out for the **pregnant** **woman** with a **history** of **fibroids** presenting with **severe abdominal pain** and a **low-grade feve**r in your exams. The diagnosis is likely to be red degeneration.
- Uterine contractions would come and go, these pains are more constant
**Red degeneration** may occur as the **fibroid** rapidly **enlarges** during **pregnancy**, **outgrowing its blood supply** and becoming **ischaemic**. It may also occur **due to kinking in the blood vessels** as the uterus changes shape and expands during pregnancy.
102
What is the most common type of fibroid degeneration? [1]
Desribe how you would differentiate this from other types? [1]
**Hyaline degeneration**
- involves the replacement of fibroid tissue with hyaline tissue; leading to the accumulation of homogenous, glassy, eosinophilic material.
103
Describe what is meant by cervical cerclage [1]
When is it indicated? [2]
A **cervical** **cerclage** is a treatment that involves **temporarily sewing the cervix closed with stitches.**
- Cervical cerclage is offered to women with a **cervical length less than 25mm** on vaginal ultrasound between **16 and 24 weeks gestation**, who have had a **previous premature birth or cervical trauma** (e.g. colposcopy and cone biopsy).
- “**Rescue**” **cervical cerclage** may also be offered **between 16 and 27 + 6 weeks** when there is **cervical** **dilatation** **without** **rupture** of **membranes**, to **prevent** **progression** and **premature** **delivery**.
104
Describe how you diagnose SROM [3]
**Maternal Hx**
**Speculum exam** - if no amniotic fluid observed then perform IGFBP-1 and PAMG-1 tests
**PAMG-1 Test:**
* **Basis**: PAMG-1 is a protein primarily found in amniotic fluid, present in extremely low concentrations in other body fluids.
* **Result in SROM:** Positive if amniotic fluid is detected in the vaginal fluid.
**IGFBP-1 Test:**
* Basis: IGFBP-1 is a protein produced by the decidua (the uterine lining during pregnancy) and is present in high concentrations in amniotic fluid.
* **Result in SROM**: Positive if amniotic fluid is present in vaginal secretions.
105
How do you treat PPROM? [3]
An **antibiotic** (preferably **erythromycin**) should be **given for 10 days** or **until the woman is in established labour** (whichever is sooner) following the **diagnosis of PPROM**, and **corticosteroids** and **magnesium** **sulfate**, considered or offered.
106
What is meant by uterine retraction? [1]
the **state** of **uterine** **muscle** fibres **remaining** **shortened** **after** **contracting** during labour
107
What increases the chance of atony of uterus? [+]
**Overdistension of the Uterus:**
* Multiple Gestation: Twins or higher-order multiples.
* Polyhydramnios: Excessive amniotic fluid stretches the uterus.
* Macrosomia: Large fetal size leads to uterine overdistension.
* Prolonged Labor: Excessive uterine stretching during prolonged contractions.
**Exhaustion of Uterine Muscle (Myometrium)**:
* Prolonged Labor: Extended uterine contractions cause fatigue.
**Infection:**
* Chorioamnionitis: Infection during labor weakens the myometrium.
**Medications:**
* Magnesium Sulfate: Used for preeclampsia or eclampsia; relaxes smooth muscle and reduces uterine tone.
**Grand Multiparity:** Repeated pregnancies reduce uterine tone and elasticity.
108
Describe the difference for spinal, epidural and general anesthesia:
* onset
* duration
* consciousness
* pain relief
* risk to fetus
* complications
* indication
109
Describe the treatment algorithm for GD [3]
* if glucose targets are not met within 1-2 weeks try **altering diet and exercise**
* if glucose targets are not met within 1-2 weeks of **altering diet/exercise metformin**should be started
* if glucose targets are still not met **insulin** should be added to diet/exercise/metformin - **short acting insulin only**
110
The most common **explanation** for **short** **episodes** (< 40 minutes) of **decreased variability on CTG** is []
The most common explanation for short episodes (< 40 minutes) of decreased variability on CTG **is that the foetus is asleep**
111
If fetal movements have not yet been felt by **[]** **weeks**, referral should be made to a maternal fetal medicine unit
If fetal movements have not yet been felt by **24 weeks,** referral should be made to a maternal fetal medicine unit
112
Where exactly would you investigate in using a speculum exam to see if PPROM has occurred? [1]
**Careful** **speculum** **examination** to look for **pooling of amniotic fluid** in the **posterior vaginal vault** is the first-line investigation for preterm prelabour rupture of the membranes
113
Early scan to confirm dates occurs when? [1]
10 -13+6 weeks
114
A history of sudden collapse occurring soon after a rupture of membranes is suggestive of **[]**
A history of sudden collapse occurring soon after a rupture of membranes is suggestive of **amniotic fluid embolism**
115
How do you manage a patient with grade III/IV placentra praevia if picked up early on US? [1]
Women with **grade III/IV placenta praevia** should be offered an elective caesarean section at **37-38 weeks**
116
An ultrasound is indicated if lochia persists beyond **[] weeks**
An ultrasound is indicated if lochia persists beyond **6 weeks**
117
Explain the different stages of lochia changes and what you expect them to look like / last [3]
3 stages of lochia are **rubra, serosa and alba** (red, yellow, white).
- usually takes about **6 weeks to stop but can take 12 weeks**
- Lochia is heavy at first but gradually subsides to a lighter flow until it goes away
**Lochia rubra** is the first stage
* **Dark** or **bright** red blood.
* Lasts for **three to four days**.
* Flows like a **heavy** **period**.
* **Small** **clots** are normal.
* **Mild**, **period**-**like** **cramping**.
**Lochia serosa is the second stage of lochia.**
* **Pinkish** **brown** **discharge** that's **less** **bloody and more watery.**
* Lasts for **four to 12 days.**
* **Flow** is **moderate**.
* **Less** **clotting** or no clots
**Lochia alba is the last stage of lochia**.
* **Yellowish** white **discharge**.
* **Little** to **no** **blood**.
* **Light** **flow** or **spotting**.
* Lasts from about **12 days
to six weeks.**
* **No clots.**
118
What is the difference in induction of GD and previous DM labours? [2]
GDM are induced at term
Previous DM are induced at 38 weeks
119
When would you admit a pregnant patient due to their hypertension? [1]
Pregnant women with blood pressure **≥ 160/110 mmHg** are likely to be admitted and observed
120
Name 5 absolute contraindications for the induction of labour [5]
Cephalopelvic disproportion
Major placenta praevia
Vasa praevia
Cord prolapse
Transverse lie
Active primary genital herpes
Previous classical Caesarean section
121
What is the difference between a membrane sweep and amniotomy? [1]
An **amniotomy** is where the membranes are **ruptured** **artificially** using an instrument called an **amnihook**.
**Membrane sweep** is performed by **inserting** a **gloved** **finger** through **cervix** and **rotating** it against the **fetal membranes**, aiming to **separate** the **chorionic** **membrane** from the **decidua**
122
When is insulin indicated as the first line tx for GD? [1]
If at the time of diagnosis of gestational diabetes, the **fasting glucose level is >= 7 mmol/l** **immediate** **insulin** (plus or minus metformin) should be started
123
If a patient has DMT1 and is pregnant - what do they need to take is it puts them as a high risk group? [1]
DMT1 or DMT2 puts patients at high risk of pre-eclampsia, so need to be given **aspirin**
124
Name 5 factors that are high risk for pre-eclampsia [5]
* hypertensive disease in a previous pregnancy
* chronic kidney disease
* autoimmune disease, such as systemic lupus erythematosus or antiphospholipid syndrome
* type 1 or type 2 diabetes
* chronic hypertension
125
Which factors make up the Bishop score? [5]
126
Name a tocolytic [1]
**Terbutaline**
127
A patient presents with umbilical cord prolapse.
You want to perform a c-section.
She has dilated at 4cm.
What can you give to prevent further dilattion? [1]
**Terbutaline**
- Tocolytics may be useful in umbilical cord prolapse to reduce uterine contractions
128
If a pregnant woman reports r**educed fetal movements** then **[]** should be used to confirm fetal heartbeat as a first step
If a pregnant woman reports reduced fetal movements then **handheld Doppler** should be used to confirm fetal heartbeat as a first step
129
If l**ow-lying placenta** is found at the 20-week scan then rescan at **[]** **weeks** to assess
**If low-lying placenta** is found at the **20-week** scan then **rescan at 32 weeks** to assess
130
For how long of the pregnancy do you take:
- Folic acid? [1]
- Vitamin D? [1]
Folic acid: **12 weeks**
Vitamin D: **whole course**
131
Which drugs are CI in breastfeeding? [+]
LAMBASTCC
Lithium
Aspirin
Methotrexate
Benzo
Amiodarone
Sufonylurea
Tetracycline
Carbimazole / Ciprofloxacin
132
Describe whether warfarin and aspirin are ok during pregnancy and breastfeeding [2]
**Warfarin**= not in pregnancy, fine in breastfeeding
**Aspirin**= fine in pregnancy (up to 36wks), not in breastfeeding
133
Describe the effect of pregnancy on serum urea, serum creatitnine and urine proteins
**Reduced** **urea**, **reduced** **creatinine**, **increased urinary protein loss**
134
135
Describe the results seen in quadruple test for Edward's syndrome [4]
↓ AFP
↓ oestriol
↓ hCG
↔ inhibin A
## Footnote
**Down's Syndrome - HI**
H - High hCG
I - High Inhibin
**Edward's Syndrome** - Everything low + anything Inhibin
136
Which of these is a contraindication for using epidural anaesthesia during labour?
Coagulopathy
Obesity
Multiple gestation
Pre-eclampsia
Prolonged labour
**Coagulopathy**
137
All patients dx with PCOS are offered what testing and how often? [1]
**Annual glucose tolerance testing**
138
What percentage of complete molar pregnancies go on to become invasive? [1]
**15%**
139
How do you feed LBW babies who cannot be fed their mother's breast milk? [1]
Low-birthweight infants who cannot be fed their mother’s breast milk should **be fed donor human milk**
140
What volume of amniotic fluid is considered to be consistent with polyhydramnios? [1]
**> 2-3 L of amniotic fluid**
141
What pathology effecting the eyes occurs for babies born pre-32 weeks? [1]
**Retinopathy of prematurity** is an important cause of visual impairment in babies born before 32 weeks gestation
142
PPH - What is the first line 'surgical' intervention? [1]
Postpartum haemorrhage: **intrauterine balloon tamponade** is the first-line 'surgical' intervention if other measures fail
- other options include: B-Lynch suture, ligation of the uterine arteries or internal iliac arteries
143
In which cases is external cephalic version indicated [2] / not indicated [+]?
**Indicated** if **not** in **active** **labour** (indicated by 3/4 cm dilatation) AND if **amniotic sac not ruptured**
● contraindicated if in active labour
● antepartum haemorrhage within the last 7 days
● abnormal cardiotocography
● major uterine anomaly
● ruptured membranes
● multiple pregnancy (except delivery of second twin).
144
**[]** or **[]** are the SSRIs of choice in breastfeeding women
**Sertraline or paroxetine** are the SSRIs of choice in breastfeeding women
145
How do you treat DMT2 in pregnancy? [2]
the management of type 2 diabetes in pregnancy 'women with pre-existing diabetes can be treated with **metformin**, either **alone** or in **combination with insulin'.**
146
Intrahepatic cholestasis of pregnancy increases the risk of **[]**
Stillbirth
147
**Intrahepatic cholestasis of pregnancy increases the risk of stillbirth**
How do you manage birth of baby of mother who is suffering from this? [1]
**induction of labour** is generally offered at **37-38 weeks gestation**
148
If pre-term labour occurs (< 34 weeks) what do you give? [3]
-**Steroids**
-**Erythromycin** for **10 days until delivery** (prevent NEC) if **membranes are broken**
-**Tocolytics** to prevent current **pre-term labour**
149
If pre-term labour occurs at < 30 weeks - what could you consider giving for neuroprotection? [1]
**< 30 weeks** consider **magnesium sulphate** for neuroprotection
150
How long after being called should Cat 1 and 2 C-sections occur? [2]
Cat 1: 30 mins
Cat 2: 75 misn
151
Describe the difference between Actim-Partus and Actim PROM vaginal swabs
**Actim-PROM vaginal swab**
* An Actim-PROM vaginal swab detects **insulin-like growth factor binding protein-1 (IGFBP-1)** in vaginal fluid. The concentration of **IGFBP**-1 is much higher in the **amniotic fluid than in the maternal blood**.
* Therefore, a **positive Actim-PROM** suggests **pre-labour rupture of membranes.**
**Actim-Partus vaginal swab**
- Actim Partus is for identifying **risk of pre-term** and **imminent** **delivery** **after 22 weeks.**
152
When calculating SFH height, how much difference can you allow in cm that means still healthy? [1]
E.g. what is a normal range for SFH height for a baby at 30 weeks? [1]
From 24 weeks of pregnancy, the SFH is equal to gestational weeks with the accuracy and precision of **± 2 cm**. For example, if a patient's SFH is 30 cm, her gestational weeks should be in range of **28–32** weeks of pregnancy.
153
First line treatment in PPD? [1]
**Cognitive behaviour therapy (CBT)** and **sertraline**
154
A patient comes in with low BP, but otherwise normal observations.
She has a distended stomach that is dense but not peritonitic. Her chest has reduced breath sounds.
Last week she harvested 22 eggs.
What is the current presentation? [1]
Describe normal features of this [2]
**Ovarian hyperstimulation syndrome**
- known side effect of **fertility** **treatments**
- characterised by **increase** in **ovarian** **size** and **shifting** of **fluids**
- can result in **ascites** and **pleural** **effusions**
- OHSS is a **hypercoagulable** **state**, so it is important to ensure these patients receive **appropriate thromboprophylaxis**
155
A mother has acute Hep B infection.
How do you treat this to prevent vertical transmission? [2]
**Complete course of vaccination + hepatitis B immunoglobulin** within **24hrs** of **delivery**
## Footnote
**NB**: The same course of action is required for mothers with a chronic hepatitis B infection.
156
Which of the following methods is the best to quantify proteinuria for the diagnosis of pre-eclampsia?
Urine protein:creatinine ratio (PCR)
Urine output
Urinalysis
Urine microscopy, culture and sensitivity (MC&S)
24 h urine collection
Which of the following methods is the best to quantify proteinuria for the diagnosis of pre-eclampsia?
**Urine protein:creatinine ratio (PCR)**
Urine output
Urinalysis
Urine microscopy, culture and sensitivity (MC&S)
24 h urine collection
157
What urine protein:creatinine ratio (PCR) would indicate significant proteinuria for pre-eclampsia? [1]
**A urine PCR of 30 mg/mmol or more** is the threshold for **significant** **proteinuria**. Urine PCR is more accurate and easier to use than a 24 h urine collection test.
158
How do you treat GBS in newborn if you think there is a high risk? [1]
The most effective method of preventing GBS infection in the newborn is **intrapartum** **antibiotic** **prophylaxis**.
- **Antibiotics**, commonly **penicillin**, are **administered intravenously during labour and delivery** if risk factors for GBS infection are present.
159
Post-perineal tear, what treatment do you give and why? [1]
Give **laxatives** to prevent **constipation** and **risk** of **further tears**
160
What does the lambda sign indicate on US? [1]
The lambda sign on ultrasound indicates a **dichorionic** **diamniotic** **twin** **pregnancy**.
161
A lambda sign is seen on US.
When would be the advised delivery period? [1]
**37 weeks**
162
Describe how you treat anaemia post birth [2]
**If asymptomatic:**
- Oral Ferrous fumarate 200mg OD
**If severe:**
- give IV iron
163
A mother has just given birth and is noted to be anaemic. She also suffers from hypothyroidism.
Describe how you would treat this patient [2]
**Oral Ferrous fumarate 200mg OD**
- But: oral iron **decreases** the **absorption** of oral **Levothyroxine**; **advise** **patients** to take **at least 4 hours apart**.
164
Which pathologies does the combined test and quadruple test specifically test for? [2]
The **combined test** is carried out between 10-14 weeks gestation and tests for **Down syndrome, Edward syndrome and Patau syndrome**
**The quadruple test** is carried out between 15-20 weeks gestation and tests for **Down syndrome**
165
When presenting a obstetric case, how do you introduce the case? [5]
Name
Age
Parity
Problem
Solution
166
When would you expect to be able feel a 'free head' till in a pregnancy of a nulliparous women? [1]
In a **nulliparous** woman the foetal head **doesn't engage until 37 weeks** (so it is 'free' to move around in uterus)
## Footnote
**NB**: Engagement: when the baby's head is even with the ischial spines. The baby is said to be 'engaged' when the largest part of the head has entered the pelvis.
167
**Careful** [] to look for [] is the first-line **investigation** for **preterm prelabour rupture of the membranes**
- what is 2nd line?
Careful **speculum** **examination** to look for pooling of **amniotic fluid** in the **posterior vaginal vault** is the first-line investigation for **preterm prelabour rupture of the membranes**
- if pooling of fluid is not observed NICE recommend testing the fluid for placental alpha microglobulin-1 protein (PAMG-1) (e.g. AmniSureµ) or insulin-like growth factor binding protein-1
168
What investigations should you perform if a pregnant patient experiences a reduction in foetal movements:
- < 24 weeks [2]
- 24 - 28 weeks [1]
- > 28 weeks [4]
**< 24 weeks:**
- onward referral should be made to a maternal fetal medicine unit if fetal movements haven't been felt before
- if have - perfom a handheld doppler
**24-28 weeks**:
- a **handheld** **Doppler** should be used to confirm presence of fetal heartbeat.
**> 28 weeks:**
- **Handheld** **Doppler**
- **Immediate** **ultrasound** if **NO** **heartbeart** detected
- If **heartbeat** **present**: **CTG** for 20 mins
- If **concerns** still exist - urgnt **ultrasound**
169
Describe how SFH growth changes throughout pregnancy [2]
**First 20 weeks**:
- grows by 2cm a week
**From 20 weeks+**:
- grows by 1cm week
170
If fetal movements have not yet been felt by **[]** weeks, referral should be made to a maternal fetal medicine unit
If fetal movements have not yet been felt by **24 weeks**, referral should be made to a maternal fetal medicine unit
## Footnote
We don't abort moving babies and 24 weeks is the point at which abortion is no longer allowed
171
which of the following describes Wood's screw manoeuvre?
* Press on the posterior shoulder
* Put the mother on all fours on the floor
* Put your hand in the vagina and attempt to rotate the foetus 180 degrees
* Hyperflex the mothers legs onto her abdomen and apply suprapubic pressure
* Push the head back in and do an emergency caesarean section
Put your hand in the vagina and attempt to rotate the foetus 180 degrees
172
173
Explain a risk factor that causes 50% of cord prolapses [2]
**premature rupture of membranes** causing cord prolapse is because the **baby is not yet engaged** in the pelvis when the **membrane is ruptured which allows** the cord if suspended below the baby to **become compressed**
174
What would be a key differential to distinguish between ectopic and miscarriage? [1]
3. Ectopic pregnancy- **classic cervical excitation** is more common in ectopic vs miscarriage
- '**Chandelier's sign'**
175
How many days can be hcg be detected in the blood? [1]
From day 8 +
176
Which one of the following statements regarding hepatitis B and pregnancy is correct?
Without intervention the vertical transmission rate is around 3%
Only at risk groups should be screened for hepatitis B during pregnancy
Around 30% of mothers with hepatitis B develop pre-eclampsia
It is safe for a mother with hepatitis B to breastfeed her newborn
All pregnant women with hepatitis B should take oral ribavirin in the last trimester of pregnancy
It is safe for a mother with hepatitis B to breastfeed her newborn
| Hep B: Breastfeeding
## Footnote
**NB**: Ribavirin is contraindicated in pregnancy due to its teratogenic effects. For pregnant women with high viral loads, tenofovir is the preferred antiviral medication as it has a good safety profile in pregnancy and is effective in reducing the risk of vertical transmission
177
Magnesium sulphate - monitor ... [2]?
Magnesium sulphate - monitor **reflexes + respiratory rate**
178
As per NICE guidelines; the following would warrant continuous CTG monitoring if any of the following are present or arise during labour [5]
* suspected chorioamnionitis or sepsis, or a temperature of 38°C or above
* severe hypertension 160/110 mmHg or above
* oxytocin use
* the presence of significant meconium
* fresh vaginal bleeding that develops in labour - this was a new point added to the guidelines in 2014
179
How does uterine hyperstimulation present? [2]
Name two risks of uterine hyperstimulation [2]
**Prolonged** and **frequent** **contractions**
**Complications include:**
- Uterine rupture
- Interupted blood flow and fetal hypoxia
180
Which vitamin is important to avoid in pregnancy and why? [1]
Name a food that has a high dose [1]
**Vitamin A:** causes birth defects
Liver has lots of vitamin A
181
What is important to note about the presentation of placenta praevia? [1]
Painless (generally)
182
What is the first line tx for PPH? [2]
**Uterine massage** AND **emptying bladder** (via a catheter)
183
What is the range of weeks that you would give c/steroids if preterm rupture of membranes is imminent? [1]
**34-36 weeks**
184
Name a key risk factor for placenta accreta [1]
**Previous C-section**
185
A patient presents with unexplained PV bleeding.
When would a vaginal exam be contraindicated and why? [2]
If placenta praevia suspected - can cause a risk of haem.
186
When does an amniotic fluid embolism occur? [1]
**During** or **after** labour
187
How does amniotic fluid embolisms present? *What is the presenting triad? [3]*
**Hypotension**
**Hypoxia**
**Coagulopathy** (Increased PT)
188
A patient has surgery to remove molar pregnancy
However, 4 weeks later they still feel unwell and have a high bHCG.
What is the most likely dx? [1]
**choriocarcinoma**
- is a cancer that happens when cells that were part of a normal pregnancy or a molar pregnancy become cancerous
189
What is the first line tx for UTI in 3rd trimester of pregnancy? [1]
Amoxicillin
Trimethoprim can be used but better not to
190
Which of the following medications can cause Ebstein's anomaly if used during pregnancy?
Carbamazepine
Which of the following medications can cause Ebstein's anomaly if used during pregnancy?
Carbamazepine
Amitriptyline
Lithium
Clozapine
Sodium valproate
**Lithium**
191
Which examination finding would indicate an ectopic pregnancy compared to a miscarriage? [1]
**Cervical excitation** in ectopic but not miscarriage
192
A patient has a miscarriage at 12 weeks. There is suspicison of a infection, so a surgical approach is taken.
Would you use manual or electrical vacuum aspiration? [1]
Why? [1]
**Post 10 weeks**: use **electrical evacuation**
193
A patient has a threatened miscarriage.
They reveal that they have previously has a miscarriage.
How does this impact your treatment? *I.e. what would normally do vs in this situtation*
In women with a **previous miscarriage**, use of **vaginal**
**micronized** **progesterone** (400mg twice daily) NICE
2021
Otherwise - just observe
194
Which of the following best describes the follow-up of women with gestational diabetes?
* A fasting plasma glucose test should be performed by the General Practitioner (GP) at 6–13 weeks postpartum
* A fasting plasma glucose test should be performed every two years due to the increased risk of developing type II diabetes mellitus
* A two-hour oral glucose tolerance test (OGTT) should be performed at 24–28 weeks in future pregnancies
* A two-hour glucose tolerance test should be performed at the six-week postnatal check
* Blood glucose should not be tested before discharge, as medication has been discontinued
* **A fasting plasma glucose test should be performed by the General Practitioner (GP) at 6–13 weeks postpartum**
195
Polyhydramnios is diagnosed when the amniotic fluid index is **>[]** cm or if the deepest vertical pool is **>[] **cm.
Polyhydramnios is diagnosed when the amniotic fluid index is **>25 cm** or if the deepest vertical pool is **>8 cm**.
196
A 28-year-old female attends the Antenatal clinic for a check-up. She is 28 weeks into her pregnancy. Her blood pressure is recorded as 160/128 mmHg. She reports suffering from headaches over the last two days. A urine sample is immediately checked for proteinuria, which, together with hypertension, would indicate pre-eclampsia. Her urine sample shows ++ protein. The patient is admitted for monitoring and treatment.
What is the definition of proteinuria?
Persistent urinary protein of > 300 mg/12 hours
Persistent urinary protein of > 250 mg/24 hours
Persistent urinary protein of > 300 mg/24 hours
Persistent urinary protein of > 100 mg/24 hours
Persistent urinary protein of > 400 mg/12 hours
#15881
**Persistent urinary protein of > 300 mg/24 hours**
197
Describe how you manage hypertension after birth of child? *e.g. if they have suffered from pre-eclampsia*
Females who are **discharged** and are **still hypertensive** should have their **blood pressure checked** **every other day in the community** until **targets are achieved**
198
Which medication given in pregnancy is most likely cause NTD? [1]
Phenytoin
Valproate
Lamotrigine
Levetiracetam
Carbamazepine
**Valproate**
199
which drug of abuse is most likely to causes intestinal atresia if given in pregnant?
ketamine
cocaine
alcohol
MDMA
heroin
which drug of abuse is most likely to causes intestinal atresia if given in pregnant?
**cocaine**
- Cocaine use during pregnancy can lead to vascular disruptions due to its vasoconstrictive effects. These disruptions can impair blood flow to the developing intestines, leading to ischemia and subsequent intestinal atresia
200
Name a biomarker that can indicate pre-eclampsia [1]
**Low placental growth factor**
201
Which of the following analgesics is contraindicated in females who are breastfeeding?
Aspirin
Codeine
Naproxen
Paracetamol
Tramadol
Which of the following analgesics is contraindicated in females who are breastfeeding?
**Aspirin**
- Paracetamol and ibuprofen are safe for pain relief during breastfeeding. Codeine or other opiates can be sparingly used when these are ineffective. **Aspirin is not recommended due to the risk of Reye’s disease, a fatal condition causing infant liver failure and brainstem dysfunction**. Aspirin may also lead to thrombocytopenia, agranulocytosis, haemorrhage, erythema nodosum, and nausea or vomiting; hence its avoidance is essential during breastfeeding and in children.
202
Which of the following would you use to assess risk of fetal demise
ductus venosus
umbilical artery doppler
uterine artery dopplers
middle cerebral artery
Which of the following would you use to assess risk of fetal demise
**ductus venosus**
umbilical artery doppler
uterine artery dopplers
middle cerebral artery
203
Which of the following would you use to assess fetal oxygenation
ductus venosus
umbilical artery doppler
uterine artery dopplers
middle cerebral artery
Which of the following would you use to assess fetal oxygenation
ductus venosus
umbilical artery doppler
uterine artery dopplers
**middle cerebral artery**
204
A patient who is 35 weeks gestation, has sudden PROM followed by bright red vaginal bleeding.
The fetal HR is 90bpm
What is the most likely dx? [1]
**Vasa praevia**:
- **rupture of membranes** can cause **rupture** of the **fetal vessels and subsequent fetal haemorrhage**.
- The **classical triad of clinical features is painless vaginal bleeding, rupture of membranes and fetal bradycardia** (fetal heart rate < 100bpm)
205
Which of the following best describes CMV in pregnancy
* Infection is most likely in first trimester; biggest risk to baby in first trimester
* Infection is most likely in first trimester; biggest risk to baby in third trimester
* Infection is most likely in third trimester; biggest risk to baby in third trimester
* Infection is most likely in third trimester; biggest risk to baby in first trimester
* Infection is most likely in third trimester; biggest risk to baby in first trimester
206
With approximately 40,000 infected children per year, congenital **[]** infection is the most common cause of **congenital non-genetic hearing loss**
With approximately 40,000 infected children per year, congenital **CMV** **infection** is the most common cause of congenital non-genetic hearing loss
207
Uterine hyperstimulation is diagnosed where there is any of the following: [2]
Uterine hyperstimulation is diagnosed where there is any of the following: **more than six contractions in ten minutes**, **< 60 s between contractions**.
208
A 35-year-old woman with a history of one previous caesarean section presents in labour at 39 weeks. After 12 hours of labour with minimal cervical dilation, the decision is made to perform a repeat caesarean section.
Which of the following is the most common indication for a caesarean section?
Answer
a.
Cord prolapse
b.
Breech presentation
c.
Placenta praevia
d.
Maternal request
e.
Failure to progress in labour
**Failure to progress in labour** is the most common indication for a caesarean section, especially in the context of prolonged labour without adequate cervical dilation. The other options are less common indications:
209
A 30-year-old woman undergoes a vaginal delivery. After the birth, the placenta fails to deliver spontaneously despite active management of the third stage of labour. Manual removal of the placenta is performed.
What is the most significant immediate complication associated with manual removal of the placenta?
Answer
a.
Uterine inversion
b.
Infection
c.
Uterine rupture
d.
Postpartum hemorrhage
e.
Amniotic fluid embolism
**Postpartum hemorrhage** is the most significant and immediate complication associated with manual removal of the placenta due to uterine atony or retained placental fragments. The other options are less likely because:
A) Uterine inversion is rare and typically occurs with excessive cord traction.
C) Infection is a risk but usually a later complication.
D) Uterine rupture is more associated with labour after a previous caesarean or excessive uterine activity.
E) Amniotic fluid embolism is a rare but severe event not directly linked to manual placental removal.
210
A 26-year-old primigravida is in the second stage of labour and has been pushing for over 2 hours. The obstetrician decides to perform an assisted vaginal delivery but needs to choose between ventouse and forceps.
Which of the factors below would be more significant in leading the obstetrician to choose forceps over ventouse in this scenario?
Answer
a.
Failure to progress
b.
Absence of caput succedaneum
c.
Fetal bradycardia
d.
Presence of epidural analgesia
e.
Maternal exhaustion
Forceps are often preferred in cases of maternal exhaustion as they need less active maternal involvement with the procedure. The other options are less influential in this decision:
B) Fetal bradycardia can indicate the need for an urgent delivery but doesn’t necessarily favor one instrument over the other.
C) Failure to progress might lead to either option depending on specific circumstances.
D) Absence of caput succedaneum is more relevant for ventouse rather than forceps delivery
E) Presence of epidural analgesia would be one of the factors contributing to the choice, but not the most significant. A forceps delivery could also be carried out with pudendal block.
211
A 24-year-old woman presents with severe lower abdominal pain and vaginal bleeding. Her β-hCG level is 2000 IU/L, and transvaginal ultrasound reveals an adnexal mass and no intrauterine pregnancy.
Which of the following is the most appropriate next step in management?
Answer
a.
Repeat β-hCG in 48 hours
b.
Pelvic MRI
c.
Methotrexate therapy
d.
Surgical management
e.
Expectant management
212
A 32-year-old nulliparous woman, who is 36 weeks' pregnant, presents for external cephalic version after discovering her baby is in breech presentation.
Which of the following drugs can be used to improve the success rate of external cephalic version?
Nifedipine
Magnesium sulphate
Indomethacin
Terbutaline
Atosiban
**Terbutaline**
- According to Royal College of Obstetricians, a tocolytic agent with beta-mimetic effect (ie. beta-2 receptor agonists such as terbutaline, ritodrine and salbutamol) can be used to improve the success rate of external cephalic version, as they cause relaxation of uterine muscles. Potential side effects include tachycardia, palpitation and flushing.
213
214
215
A 45-year-old woman presents with right hip pain that has been worsening over the past month. On examination, there is no significant hip pathology, but she reports a history of ovarian cysts.
Explain the mechanism causing the referred pain to the hip [1]
**Referred pain** to the hip from an **ovarian mass** occurs due to the **shared innervation of the ovary and the hip region by the obturator nerve (L2-L4).** The ovary is located near the pelvic sidewall, and when an ovarian mass enlarges or irritates surrounding tissues, **it can stimulate the obturator nerve**, leading to pain referred to the medial thigh, groin, and hip. This reflects the phenomenon of viscerosomatic convergence, where visceral organ pain is perceived as musculoskeletal pain.
216
A 55-year-old postmenopausal woman presents with abdominal bloating, early satiety, and weight loss. On examination, there is a palpable pelvic mass. CA-125 is elevated. What is the most likely type of ovarian tumor?
A) Germ cell tumor
B) Granulosa cell tumor
C) Serous epithelial tumor
D) Dysgerminoma
E) Sertoli-Leydig cell tumor
A 55-year-old postmenopausal woman presents with abdominal bloating, early satiety, and weight loss. On examination, there is a palpable pelvic mass. CA-125 is elevated. What is the most likely type of ovarian tumor?
A) Germ cell tumor
B) Granulosa cell tumor
**C) Serous epithelial tumor**
D) Dysgerminoma
E) Sertoli-Leydig cell tumor
217
A 50-year-old woman presents with unexplained weight loss, abdominal pain, and a pelvic mass. Imaging reveals bilateral ovarian masses. Histology confirms signet-ring cells. What is the most likely diagnosis, and what is the origin of this condition? [1]
The most likely diagnosis is a **Krukenberg tumor**, which is a metastatic ovarian tumor, typically originating from a gastrointestinal primary, most commonly gastric adenocarcinoma.
Key Features:
Krukenberg tumors are characterized histologically by signet-ring cells.
They often present bilaterally and can cause abdominal or pelvic pain, bloating, or ascites.
218
A 42-year-old woman with a long-standing history of endometriosis presents with pelvic pain and a complex ovarian mass on ultrasound. According to NICE guidelines, what is the most likely type of ovarian tumor associated with endometriosis?
A) Dysgerminoma
B) Mucinous cystadenoma
C) Clear cell carcinoma
D) Sertoli-Leydig cell tumor
E) Serous cystadenocarcinoma
**C) Clear cell carcinoma**
219
A woman with ovarian cancer presents with pelvic pain and bloating. Imaging reveals spread of the tumor to the fallopian tubes and the peritoneum within the pelvis. There is no involvement of lymph nodes or distant metastasis. What is the most likely stage of her ovarian cancer?
A) Stage I
B) Stage II
C) Stage III
D) Stage IV
A woman with ovarian cancer presents with pelvic pain and bloating. Imaging reveals spread of the tumor to the fallopian tubes and the peritoneum within the pelvis. There is no involvement of lymph nodes or distant metastasis. What is the most likely stage of her ovarian cancer?
A) Stage I
**B) Stage II**
C) Stage III
D) Stage IV
220
A 65-year-old woman with ovarian cancer is found to have omental deposits and involvement of para-aortic lymph nodes on CT. No distant metastases are detected. What is the most appropriate FIGO stage?
A) Stage I
B) Stage II
C) Stage III
D) Stage IV
**C) Stage III**
221
This scan was for an anomaly scan.
What sign can be seen? [1]
What pathology does this indicate? [1]
**Lemon sign** - **spina bifida**
222
This scan was for an anomaly scan.
What sign can be seen? [1]
What pathology does this indicate? [1]
**Banana sign - spina bifida**
- banana sign describes the way the cerebellum is wrapped tightly around the brainstem as a result of spinal cord tethering and downward migration of the posterior fossa contents
223
This scan was for an anomaly scan.
What sign can be seen? [1]
What pathology does this indicate? [1]
**Lemon sign** - **spina bifida**
224
This scan was for an anomaly scan.
What sign can be seen? [1]
What pathology does this indicate? [1]
**Banana sign - spina bifida**
- banana sign describes the way the cerebellum is wrapped tightly around the brainstem as a result of spinal cord tethering and downward migration of the posterior fossa contents
225
What is the difference between anencephaly and acrania? [1]
226
What anomaly is seen in this US scan? [1]
227
An anamoly scan is given and they detect holoprosencephaly.
What is this? [1]
**Holoprosencephaly**:
- birth defect (congenital condition) that causes the fetal brain to not properly separate into the right and left hemispheres (halves).
228
What anomaly is seen in this US scan? [1]
**Talipes**
- Talipes, commonly known as clubfoot, is a congenital deformity of the foot and ankle where the foot is twisted out of its normal position. This condition can vary in severity and may affect one or both feet.
229
# Lecture
Which anomolies can be detected on the anomaly scan? [+]
Spina bifida
Anencephaly
Hydrocephalous
Major heart problems
Exomphalos/g astrochisis
Major kidney problem
Major limb
Abnormalities
230
# Lecture
Which soft markers on US at anomaly scan would indicate a baby has Down's Syndrome? [5]
* Ventriculomegaly
* Choroid plexus cyst
* Hyperecogenic bowel - Echogenic foci in heart ‘golf ball’
* Bilat RPD
* Sandal gap (large gap between the big toe and the second toe)
* Polydactyly
231
What considerations need to be given for nuchal translucency and BMI? [1]
Can't give if obese
232
Which drugs apart from terbutaline can be used as tocolytics? [3]
Nifedipine
MgS (beta mimetic)
Indomethacin (prostaglandins inhibitor)
