Sba 1 Flashcards
(188 cards)
1
Q
A woman who is nine weeks pregnant comes to the early pregnancy assessment unit
complaining of severe nausea and occasional vomiting. She is not keen on drug
therapy.
What is your advice?
A
Drink ginger syrup.
250 mg
four times a day
2
Q
excessive vomiting for the last three days. She is otherwise asymptomatic , She is admitted and her thyroid function tests
showed a low (TSH) level with raised free (T4).
What is the most important feature to differentiate transient hyperthyroidism of
hyperemesis gravidarum (THHG) from hyperthyroidism?
A
Negative thyroid receptor antibodies titre.
3
Q
transient hyperthyroidism of
hyperemesis gravidarum (THHG) :
Cause :
When does it resolve?
Responsible for ….. of thyroid function abnormalities in pregnancy
Treatment ..
A
Cause : Elevated levels of gonadotropins have a thyrotrophic activity
When does it resolve? by 18 weeks of pregnancy
Responsible for 40 - 70 % of thyroid function abnormalities in pregnancy
Treatment ..no specific treatment, only for hyperemesis
4
Q
A primigravida who is 10 weeks pregnant is complaining of slight vaginal bleeding
and the occasional abdominal colic She has read something about progesterone treatment.
How will you counsel her?
A
There is no strong evidence to recommend the use of any progesterone
therapy.
Vaginally or orally
5
Q
A 20-year-old woman who was nine weeks into her first pregnancy has just had a
complete miscarriage. She is distressed and very tearful. You have explained that
miscarriage does not affect her future fertility. Her partner is worried her anxiety may
persist and be a possible cause of a delayed pregnancy.
What else will you tell them?
A
Her anxiety will most likely disappear in around four months when she gets
over it.
30%
–50% of miscarriage cases experience
anxiety symptoms and 10%–15% experience depressive symptoms, which
commonly persist for up to four months.
6
Q
A woman who is 11+3 weeks pregnant complained of abdominal colic and an attack of
brisk vaginal bleeding. A repeat ultrasound confirmed fetal demise. You diagnosed
inevitable miscarriage. She is considering expectant management.
How will you counsel her?
A
Explain that she is at a higher risk of bleeding
do not
recommend any specific treatment ( at home or at the hospital) if there are no contraindications to various
other treatment options.
7
Q
A woman who is 11 weeks pregnant with confirmed miscarriage . She was still keen on avoiding the
anaesthetic and surgical risks, if possible.
What will you tell her about her chances of not having surgery if she opts for medical
management
A
It avoids the need for surgery in over 70% of women
8
Q
A 20-year-old woman comes to the early pregnancy assessment unit with 7+6 weeks
amenorrhea and mild to moderate vaginal bleeding with the occasional abdominal
pain. She has a positive pregnancy test but refuses a transvaginal ultrasound scan.
How will you handle the situation?
A
Respect her wishes but explain the limitations of a transabdominal (TAS) versus
a transvaginal scan (TVS).
9
Q
A woman who is eight weeks pregnant complains of vaginal bleeding. An ultrasound
scan showed a crown rump length of 7 mm but no visible fetal heart. You advised her
to come for a follow-up scan after seven days. She expressed her concern that waiting
that long may harm the pregnancy or her health.
How will you counter her concern?
A
Assure her that waiting for a repeat scan will have no detrimental effect on the
outcome of the pregnancy or her health.
10
Q
The community midwife calls you about an eight-week pregnant woman who is
complaining of vaginal bleeding and abdominal colic. A repeat scan confirmed fetal
demise. She opted for expectant management. Her bleeding and abdominal pains
have resolved. The woman wants to know how to confirm that miscarriage is
complete.
What is your advice?
A
Repeat a pregnancy test after three weeks.
( clearance of hCG to a level of
2 mIU/mL averaged between two and three weeks)
* less expensive and less time consuming than an
ultrasound scan or a repeat serial human chorionic gonadotropin (beta-hCG)
11
Q
A woman who is 11 weeks pregnant is diagnosed with incomplete miscarriage. She
opts for medical management.
What will you offer her?
A
Vaginal 600 mcg misoprostol
12
Q
A pregnant woman is diagnosed with miscarriage based on absent cardiac pulsation
in repeat scans. She opted for surgical management , She was undecided, however, about an
outpatient setting manual vacuum aspirating (MVA) under a local anaesthetic or a
hospital evacuation curettage (EVA) under a general anaesthetic.
How will you counsel her
A
Explain that the median waiting time, the number of women requiring a blood
transfusion, and the mean blood loss were all lower in an outpatient setting.
Nice : no strong evidence
supports one technique over the other
13
Q
A 23-year-old woman in her second pregnancy presents to you requesting surgical
termination of the pregnancy. She is 11 weeks pregnant, verified by ultrasound scan.
What is the risk of uterine perforation in this case?
A
1–4/1000
14
Q
A 31-year-old woman is booked for surgical termination of pregnancy at nine weeks’
Which of the following options is correct regarding prevention of infective
complications?
A
Doxycycline 200 mg within two hours before the procedure.🌸
OR
500 mg azithromycin within two hours before the procedure.
15
Q
The general practitioner calls you out of hours to ask what to do because she has an
eight-week pregnant woman who is complaining of moderate right abdominal pain
and slight vaginal bleeding.
What is your advice?
A
Immediate referral to the emergency gynaecology unit.
16
Q
a woman who
has seven weeks of amenorrhea but the previous and current ultrasound could not
locate the pregnancy. The human chorionic gonadotropin (BhCG) increased from
800 IU/L to 1600 IU/L after 48 hours. The woman is fit and well with no signs or
symptoms.
What is your next plan?
A
Ultrasound scan within four to seven days
( NICE guidelines recommend scanning within seven days if the BhCG is
1500 IU/mL or higher )
17
Q
The serum BhCG of a symptomless woman with a pregnancy of unknown location
(PUL) has dropped by more than 50% after 48 hours.
What is the next step you advise?
A
Ask her to submit a urine pregnancy test after 14 days if she stays asymptomatic.
18
Q
A woman who is eight weeks pregnant is offered laparoscopic surgical management
of an ectopic pregnancy. She had a previous normal pregnancy and vaginal
delivery.
How will you justify laparoscopic salpingectomy as opposed to salpingostomy?
A
Removing the ectopic pregnancy and keeping the tube will have a significantly
higher incidence of a recurrent ectopic pregnancy requiring repeat surgery.
-( More important reason than requiring more followup visits and tests )
19
Q
A 15-year-old single teenage girl comes to see you because she had an unplanned
pregnancy. She is nine weeks pregnant after failure of an emergency post-coital
contraception. She explains her great inability to handle either the pregnancy care
or the child, if born, for personal and social reasons.
How will you handle the situation?
A
Advise her to involve her parents but endorse her request if two doctors agree
that she has sufficient maturity and understanding to appreciate what is involved.
20
Q
The general practitioner calls to ask about the immediate follow-up of a woman who
had a suction evacuation of a complete molar pregnancy.
What is your advice?
A
🪷Do a urine or blood test for human chorionic gonadotropins (hCG) every two
weeks for eight weeks.
{ If hCG has reverted to normal within 56 urine test is done every two to four weeks for six
months from the date of uterine evacuation
If hCG has not reverted to normal within 56 days of the pregnancy event:six months from subsequent normalization of the
hCG level. }
21
Q
A woman has an evacuation of a partial molar pregnancy. She was 11 weeks
pregnant.
What is your follow-up plan?
A
Serum and urine hCG every two weeks until the levels are normal followed by
one confirmatory normal urine sample after four weeks.
22
Q
Following appropriate treatment of complete and partial molar pregnancies, what
percentage of women need additional chemotherapy in each case, respectively?
A
15% and 0.5%.
23
Q
For molar pregnancy chemotherapy treatment:
If the FIGO 2000 score < 6 …
If the FIGO 2000 score ≥ 7 …
For how long treatment should be continued?
What is the rate of cure for each group?
A
If the FIGO 2000 score < 6 : low risk and should receive single-agent intramuscular methotrexate alternating daily with folinic acid for one week
followed by six rest days
If the FIGO 2000 score ≥ 7 : intravenous
multi-agent chemotherapy 5 agents
* Treatment should continue : until the hCG level has returned to normal, for 6w
Cure rates: group 1 : 100%
Group 2 : 95%
24
Q
A 36-year-old woman has had a suction evacuation because of a complete molar
pregnancy. Her chorionic gonadotropin (hCG) levels started to rise six months after
treatment. Her FIGO 2000 score was assessed as 6.
What is your management?
A
Single-agent intramuscular methotrexate.
25
When is Surgical treatment indicated in gestational trophoblastic diseases?
in a placental site trophoblastic tumour because
it is less sensitive to chemotherapy
26
A 28-year-old woman who has received single-agent chemotherapy because of a
persistent rise in her chorionic gonadotropin levels after evacuation of a complete
molar pregnancy asks about her future fertility options.
What will you tell her?
She can conceive but after one year of completion of her treatment and follow-up
27
To improve the results of treatment of gestational trophoblastic disease (GTD), what
audit topic would you recommend?
The proportion of women with GTD registered with the relevant screening
centre.
28
What is the role of the use of syntocinon or prostaglandins in the surgical management of molar pregnancy ?
preferably
without the use of them , to avoid the risk of embolization
29
Which age groups is associated with the smallest risk of
miscarriage?
20–24 years.
The risk is highest in women 35 or more and the man 40 or more years.
30
There are cases of women who have recurrent miscarriages.
What percentage of these women have antiphospholipid antibodies?
15%.
31
What is the live birth rate In women with recurrent miscarriages associated with antiphospholipid antibodies, with no pharmacological intervention ?
as low as 10%
Aspirin plus unfractionated heparin have a 54% success rate
32
Which of the following is an acquired thrombophilia?
A. Antiphospholipid syndrome.
B. Activated protein C resistance.
C. Factor V Leiden.
D. Prothrombin gene mutation.
E. Protein S deficiency.
Antiphospholipid syndrome.
33
A couple who have had three consecutive miscarriages have come to see you for
advice after having a thrombophilia screen. The result showed that she was positive
to one of the antiphospholipid antibodies.
Which of the following is an antiphospholipid antibody?
A. Anti-B2-glycoprotein-1 antibody.
B. Anti-B1-glycoprotein-1 antibody.
C. Anti-B2-glycoprotein-2 antibody.
D. Anti-B2-glycoprotein-3 antibody.
E. Anti-B3-glycoprotein-1 antibody.
Anti-B2-glycoprotein-1 antibody.
34
The antiphospholipid antibodies are :
lupus anticoagulant, anticardiolipin, and
anti-B2-glycoprotein-1 antibody.
35
A couple who have had three consecutive miscarriages have come to see you for
counselling. Genetic screening showed a paternal balanced translocation.
What is their chance of having a healthy baby?
More than 80%
* They have a low risk (0.8%) of pregnancies with
unbalanced karyotyping surviving into the second trimester
36
A 20-year-old woman presents to the family planning clinic. She is requesting
termination of a 10-week pregnancy. She had a surgical termination of a 14-week
pregnancy six months previously. She had problems attending and complying with
the different family planning options offered to her after completion of the termination of her previous pregnancy.
What is your advice for an effective contraception in her situation?
Carry on with the medical termination but have the etonogestrel implant inserted
at the time of mifepristone administration.
37
She has a pituitary macroprolactinoma
and has been treated with bromocriptine for a year. Her prolactin levels have been
normal for the past six months. She is now 11 weeks pregnant and was
advised to continue this medication. She is worried about any risks if she continues this medication while pregnant.
What will you tell her?
Bromocriptine can be continued during pregnancy safely
38
She has a pituitary macroprolactinoma :
* How many patients with hyperprolactinaemia achieve pregnancy
on dopamine agonist treatment.
* rates of spontaneous miscarriage or other complications of pregnancy ( PET ) ?
* risk of Enlargement the adenoma
* when to start Bromocriptine ?
* the role of MRI
80%patients with hyperprolactinaemia achieve pregnancy
on dopamine agonist treatment.
rates of spontaneous miscarriage or other complications of pregnancy ( PET ) ?no increase in the rates
risk of Enlargement the adenoma : macroprolactinomas (30%–35% )\microprolactinomas 2.5%
* when to start Bromocriptine ? usually discontinued early in pregnancy & restarted in 2nd
* the role of MRI : should be performed if the woman develops visual symptoms
39
A 32-year-old nulliparous woman sees you in the antenatal clinic at 22 weeks’
gestation. She has just had a transvaginal scan that showed the cervix to be 22 mm
in length. She has a past history of a cone biopsy of the cervix six years previously
Which of the following options would you recommend for her?
Cervical cerclage surgery
* ultrasound scan between 16
+0 and 24+0 weeks of pregnancy shows a cervical
length of less than 25 mm and who have had either :
1-preterm pre-labour
rupture of membranes in a previous pregnancy or
2- a history of cervical
trauma.
40
A 29-year-old woman in her first pregnancy presents to the labour ward with some
vaginal discharge at 27 w +2d
Speculum examination : cervix to be partially effaced and dilated 3 cm with
bulging amniotic membranes. She is not in pain, and her observations are normal. The
(CTG) is reassuring.
Which is the most appropriate in her management?
Admit, give steroids and book for emergency cerclage.
Consider
‘rescue’ cervical cerclage for women between 16+0 and 27+6 weeks with a dilated cervix and exposed, none-ruptured fetal
membranes.
41
A woman in her second pregnancy at 27 weeks presents to
the labour ward with abdominal pain. She had a normal vaginal delivery at term previously. All observations are within normal
limits
A CTG shows one to two irregular contractions every 10 minutes. The fetal
heart trace is normal. Vaginal examination reveals the cervix to be 50% effaced
but closed.
Which is the most appropriate management option?
Start treatment with oral nifedipine.
Offer nifedipine for tocolysis to women between 24+0 and 33+6 weeks of
pregnancy who have intact membranes and are in suspected or diagnosed
preterm labour
20 mg then 10 mg / 3-4 h for up
to 48 hours
42
What is the effect of Nifedipine in delaying labour?
Effective in delaying birth for up
to seven days.
43
Compare Nifedipine and atosiban effectiveness in delaying birth ?
Comparable effectiveness in delaying birth for up
to seven days
(atosiban : oxytocin receptor antagonists)
44
A woman in her second pregnancy at 30+6 weeks presents to the labour ward with abdominal pain. She had a normal vaginal delivery at term previously. All observations are within normal limits
A CTG shows one to two irregular contractions every 10 minutes. The fetal heart trace is normal.
Vaginal examination reveals the cervix to be 50% effaced but closed.
Which is the most appropriate management option?
Perform transvaginal scan to check the cervical length
* she is 30
+0 weeks pregnant or more, consider transvaginal ultrasound measurement of cervical length as a diagnostic test to determine the
likelihood of birth within 48 hours
45
After Performing transvaginal scan to check the cervical length , in a 30
+0 weeks pregnant or more
With suspected preterm labour how to act according to the results:
* If the cervical length is
>15 mm ..
* If the cervical length is 15 mm or less ..
* if the woman declines the scan ..
* If the cervical length is
>15 mm ..it is unlikely that she is in preterm. Discuss the
benefits and risks of going home versus staying in hospital.
* If the cervical length is 15 mm or less .diagnosed
preterm labour and offer treatment of nifedipine or atosiban.
* if the woman declines the scan ..use fetal
fibronectin if the patient is >30 weeks.
If positive (concentration >50 ng/mL), start preterm labour treatment
If the woman declines both tests, treat as in preterm
labour
46
woman presents to the labour ward at 28 w +4d with abdominal pain. Maternal observations are all within
normal limits. A CTG reveals she is contracting at a rate of three times in 10 minutes,
with a normal fetal heart rate. Speculum examination shows the cervix is effaced and
dilated 3 cm. The ST3 obstetric trainee wants to know the correct dose of magnesium
sulfate for neuroprotection for the baby.
What is the appropriate answer?
4 g intravenous bolus of magnesium sulfate over 15 minutes, followed by an
intravenous infusion of 1 g per hour until the birth or for 24 hours.
* Offer : between 24
+0 and 29+6 weeks
* Consider: between 30+0 and 33+6 weeks of pregnancy
47
monochorionic diamniotic (MCDA) twins undergoes an ultrasound scan at 24 weeks. Twin 1 has an estimated weight at the 20th
centile with the deepest pool of liquor of 1.6 cm. Twin 2 is growing at the 80th centile with the deepest pool of liquor measuring 9.5 cm. Doppler studies on both twins are
normal. The bladders of both twins are visible.
Which is the most likely diagnosis?
🌸Twin-to-twin transfusion syndrome (TTTS) Quintero Stage 1.
the diagnosis is based on the presence of polyhydramnios with a
distended bladder in the recipient and oligohydramnios (deepest vertical
pocket (DVP) <2 cm) with a small or empty bladder in the donor.
48
How may Discordant fetal growth restriction be differentiated from TTTS ?
by the
absence of polyhydramnios in the amniotic sacs, although the small twin may
have oligohydramnios owing to placental insufficiency.
49
What is the treatment of TTTS ? What is the survival rate?
Fetoscopic laser coagulation of the anastomoses
50%–60% survival
rate for both twins and an 80% survival for at least one twin.
50
A 28-year-old primigravida presents to the antenatal clinic with headache.
Which of the following headaches in pregnancy is classified as primary headache?
Tension headache.
& Migraine
51
A 29-year-old woman in her first pregnancy presents at the antenatal clinic complaining of recurrent attacks of migraine. She is now 20 weeks pregnant and is concerned
as she has these attacks once every 10 days. She is enquiring if there is any medication
that she can safely use during the pregnancy to stop these attacks.
Which of the following medications would you consider most appropriate?
Propranolol
(10–40 mg three times a day) has the best evidence of safety in
pregnancy and lactation.
{ If 3-4 attacks a month}
52
A 28-year-old woman is admitted with slight lower abdominal pains and a watery
vaginal discharge. A beta-methasone course is prescribed.
By how much will this management reduce the risk of neonatal death?
31%–40%.
53
A 36-year-old woman with uncontrolled diabetes and who is 29 weeks pregnant is
admitted because of threatened preterm labour.
What is your advice regarding steroids for lung maturity?
Steroids are administered with additional insulin and close monitoring
54
A 32-year-old woman who is 36 weeks pregnant comes to the labour ward because of
upper abdominal pain and slight vaginal bleeding. Her two previous pregnancies
ended in Caesarean section because of placental abruption. She has a normal blood
pressure (BP) and a reactive non-stress test.
What are her chances of having another placental abruption?
19%–25%.
( After one abruption 4.4 % )
55
A 29-year-old pregnant woman has just booked for her antenatal care. Her first
pregnancy ended in a Caesarean section birth because of placenta praevia.
What are her risks (odds ratio, OR) for a recurrence?
9.7
56
A non-sensitized Rh-negative pregnant woman is admitted at 34 weeks with a
moderate amount of vaginal bleeding. She is stable and the bleeding has stopped.
What specific test should you request?
Kleihauer count
57
34 weeks pregnant with recurrent mild vaginal spotting over the
last week She has a normal fundal placenta.
Her history and your clinical examination of her did not reveal any abnormality
speculum examination revealed a small ectropion. Her last cervical smear 18 months
previously showed mild dyskaryosis. She has screened negative for human papilloma
virus (HPV).
How will you conduct the rest of her antenatal care and delivery?
Refer her back to her community antenatal care and delivery.
* No need for steroids, she's not in labour
* No need to repeat smear with HPV negative & mild dyskinesis
58
A woman who is 33 weeks pregnant is admitted with severe abruption
and an estimated blood loss of 1500 mL. An emergency US showed a
large retro-placental haematoma. Fetal heart pulsations negative . She is stabilized with IV saline infusions and prepared for an
emergency CS.
What is your first line empirical treatment while waiting for the coagulation profile
results?
One litre of fresh frozen plasma and 10 units of cryoprecipitate.
59
woman presented with vague abdominal pains , she is
29 weeks pregnant. abdominal examination did not reveal any abnormality. She had a normal BP. Fetal Doppler and CTG could not demonstrate the fetal
heart.
A real-time ultrasound scan augmented with colour Doppler of the fetal heart
and umbilical artery confirmed intrauterine fetal demise. It also showed collapse of
the fetal skull with overlapping bones. These findings were confirmed by a second
scan. She insisted she still feels fetal movements.
How will you handle the situation?
Explain that some pregnant women may sometimes have false positive perceptions of fetal movements, but the baby is definitely dead.
( No need to repeat scan third time)
60
A 36-year-old woman comes to the labour ward with absent fetal movements for the
last six hours. She is 36 weeks pregnant. All investigations confirmed intrauterine
death. She has had two previous vaginal births. After counselling, she was still
undecided about the period of waiting before active intervention.
What is the incidence of the most serious complication if she waits for four or
more weeks?
What to be monitored ? / what is the
first-line intervention ? What percentage of women can achieve vaginal birth with IUFD ?
10 in every 100 women.9
which rises to 30% after
four weeks
* Monitor : blood platelet count and fibrinogen
* first-line intervention : A combination of mifepristone (single 200 mg dose) and a prostaglandin
preparation
* within 24 hours of induction of labour for IUFD
in about 90% of women vaginal birth can be achieved
61
What is the dose of misopristol for termination the pregnancy in the 2nd & 3rd trimester?
The dose is 100 μg six hourly before 26+6 weeks, 25–50 μg four hourly at 27+0
weeks or more.
Vaginal misoprostol is as effective as oral administration but
with fewer side effects
62
A 31-year-old woman presents to the antenatal clinic when she is 22 weeks pregnant.
She has had normal antenatal care until her last visit two weeks previously with no medical history or medications. At this visit, her BP is 145/98 mmHg with significant
proteinuria.
What is your management?
😡 Admit and measure BP every four hours
63
You are admitting a 33-year-old woman with a BP of 170/115 mmHg. Her urine
dipstick showed 1+ proteinuria.
What is the quickest and most convenient method to quantify her proteinuria?
A spot urinary protein: creatinine ratio.
* If an automated reagent-strip reading device is used to detect proteinuria and
a result of 1+ or more is obtained, use a spot urinary protein:creatinine ratio or
24-hour urine collection to quantify proteinuria
64
You are admitting a 33-year-old woman with a BP of 170/115 mmHg. Her urine
dipstick showed 1+ proteinuria
How to monitor this patient?
1- Once proteinuria is quantified, there is no need for further quantification
2- BP every four hours
3- kidney
function, electrolytes, full blood count, transaminases and bilirubin three times
weekly.
4- fetal growth scan, amniotic fluid volume assessment, and
umbilical artery Doppler velocimetry every two weeks.
65
A 29-year-old primiparous woman complains of pruritus in the palm of the hands
and soles of the feet when 32 weeks pregnant.
What is the risk of perinatal mortality because of this obstetric cholestasis?
5.7/1000
66
A 38-year-old primigravida undergoes first trimester screening and the result shows a
low placental-associated plasma protein (PAPP-A) of <0.4 MoM (multiples of the
median).
What is the implication of this result?
She is at a high risk of developing a small-for-gestational-age (SGA) pregnancy
67
A 32-year-old pregnant woman had a history of a previous small-for-gestational-age
baby. Her uterine artery Doppler shows notching at 22 weeks’ gestation, which
normalizes when repeated two weeks later.
How will you continue her antenatal care?
Start serial ultrasound biometry and umbilical artery Doppler at 26–28 weeks of
pregnancy
* Pregnant women with a normal uterine artery Doppler do not require serial
follow-up measurements ( even with a history) - unless they develop specific pregnancy complications
68
You are caring for a 33-year-old pregnant woman who is diagnosed with a small-forgestational-age fetus. At 31 weeks she showed an umbilical flow plasticity index of
>+2 standard deviations (SDs) above the mean for gestational age.
What indices should you use to time delivery?
Ductus venosus Doppler.
* Delivery should not be delayed beyond 37 weeks.
* In the preterm SGA fetus, middle cerebral artery Doppler has limited value for
the prediction of acidaemia and adverse outcomes. It should not be used to
time delivery.
69
A young couple comes to see you at the antenatal clinic. She is 29 years old and
23 weeks pregnant. They have to travel to a ZIKA virus endemic area. She shows you
a National Health Service (NHS) advice about how to avoid mosquito bites, but asks
you if you have any further advice.
What else will you tell her?
🌸 Advise condom use during vaginal, anal and oral sex during travel and for the
duration of the pregnancy.
* during the period of travel and until the end of pregnancy even if they
do not develop any symptoms of infection.
* Zika virus can be transmitted during sexual intercourse. Approximately 80% of
infections are asymptomatic.
70
Which of the followings best describes the detection rate (DR) and the screen positive
rate (SPR) of a combined test?
DR >90% and SPR <2%
71
Which of the followings best describes the detection rate (DR) and the screen positive
rate (SPR) of a combined test?
DR >90% and SPR <2%
72
What is the First trimester combined screening test ?
1- The biochemical markers are: pregnancy-associated plasma protein-A (PAPP-A); and. free -human chorionic gonadotropin (free hCG) : offered between 10
+0 and 14
+1weeks
2- nuchal translucency measured between 11+2 and 14+1
weeks’ gestation.
73
What is the quadruple test ?
alpha-fetoprotein (AFP), human chorionic gonadotropin (hCG), and estriol (uE3) hormone inhibin A
* For women presenting late, or with a crown
–rump length (CRL) >84 mm,
or between 14+2 and 20+0 weeks
74
When should Amniocentesis be performed ?
after 15 weeks of gestation
75
When should Amniocentesis be performed ?
after 15 weeks of gestation
76
What if Amniocentesis performed before 14 weeks of gestation ?
It has a higher fetal loss rate and
increased incidence of fetal talipes and respiratory morbidity
77
What is The risk of miscarriage following amniocentesis ?
1%
The risk of miscarriage following CVS is slightly higher
78
If the risk of having a term pregnancy affected with Down syndrome is ...........
or higher, calculated by either a combined or quadruple test, the pregnancy is
regarded as higher risk and the woman will be offered a diagnostic test.
1 / 150
79
A 37-year-old pregnant woman has been diagnosed with monochorionic diamniotic
(MCDA) twins. She agreed to screening for Down syndrome at 13+4 weeks.
Which of the following screenings best describes her available option
Either combined or quadruple test
80
A 37-year-old pregnant woman has been diagnosed with triplet pregnancy She agreed to screening for Down syndrome at 13+4 weeks
Which screenings best describes her available option
nuchal translucency and maternal age
81
A 25-year-old has just had her 20-week scan. The fetus is found to have
holoprosencephaly and bilateral cleft palate. The cardiac ultrasound scan shows a
ventricular septal defect. Which is most likely to be associated with these ultrasound scan
findings?
Patau syndrome
trisomy 13.
82
The screening midwife has shown you a result of a combined test for a 19-year-old
woman. It reads as follows:
bHCG: 0.2 MoM
PAPP-A: 0.3 MoM
NT: 2.5 mm
Risk of Down syndrome: 1:170.
What will be your next step?
The woman should be counselled about Edward and Patau syndromes
83
What is the normal range for hCG and PAPP-A based on multiples of median (MoM) values ?
normal (0.5−2.5 MoM) or abnormal (low: ≤0.49 MoM and high: >2.5 MoM)
84
What are the changes in The biochemical markers in Trisomy 21 ?
BhCG high
PAPP-A low
uE3 low
AFP low
Inhibin-A high
85
What are the changes in The biochemical markers in Trisomy 13 - 18 ?
BhCG low
PAPP-A low
uE3 low
AFP normal
Inhibin-A normal
86
A woman has just had her dating ultrasound scan. The sonographer has clearly
documented two gestational sacs (T-sign) and confirmed 10-week MCDA viable
twins. The woman asks you for further information about MCDA twins.
1- should special fetal echocardiographic assessment be done routinely in MCDA ?
2- TTTS complicates ....... of monochorionic diamniotic twins.
3- is TTTS more common in MCDA pregnancies or MCMA ?
4- when is Chorionicity better assessed by ultrasound ?
5- MCDA twins are ....of twins’ pregnancies
1- should special fetal echocardiographic assessment be done routinely in MCDA ? No
detailed ultrasound scan which
includes extended views of the fetal heart. A special fetal echocardiographic
assessment should be considered in the assessment of severe TTTS
2- TTTS complicates ..10- 15 % of monochorionic diamniotic twins.
3- is TTTS more common in MCDA pregnancies or MCMA ? MCDA
4- when is Chorionicity better assessed by ultrasound ? 14 w
5- MCDA twins are 80 % of twins’ pregnancies
87
Which of the following describes best the risk of structural abnormalities in all
pregnancies ?
2%–3%.
88
A 17-year-old woman attends the antenatal clinic for her 20-week scan. The sonographer has confirmed the presence of an isolated large gastroschisis. The woman is
committed to her pregnancy.
What is your next step?
Offer serial growth scans
* Babies with gastroschisis are at high risk of growth restriction (30%)
89
What is gastroschisis ?
Incidence?
Babies with gastroschisis are at high risk of ...
association with chromosomal
abnormality / aneuploidy ?
Caesarean section is usually indicated for ...
prognosis ..
gastroschisis : free loops of bowel are seen floating in the amniotic cavity with no covering membrane.
Incidence : 1 in 2500
–3000 live births
Babies with gastroschisis are at high risk of growth restriction (30%)
association with chromosomal
abnormality / aneuploidy : not increased
Caesarean section is usually indicated for obstetric indication
prognosis following early neonatal surgery is
(80%–90% survival).
90
What is Exomphalos ?
umbilical cord insertion?
incidence ..
association with chromosomal abnormality?
association with structural abnormalities ?
What is Exomphalos : It is a midline defect in which the herniated contents are covered by a membrane
umbilical cord insertion : into the apex of the lesion
incidence ..1 in 5000 live births
association with chromosomal abnormality : up to 60%
association with structural abnormalities : 30%–70%
91
A woman attends the antenatal clinic for her 18–20-week scan. The sonographer has
demonstrated ‘lemon and banana’ sign and the baby is diagnosed with Arnold–Chiari
syndrome.
What is the ‘banana’ sign?
Deformed cerebellum
92
The
‘ ‘banana’ signs is associated with ...?
1- cranial features seen on ultrasound
that are associated with spina bifida
2_ Arnold–Chiari malformation (type II)
93
What does the lemon sign indicate?
may indicate the presence of spina bifida before 24 weeks.
94
What is Arnold-Chiari malformation Chiari type 2?
downward displacement of the medulla, fourth ventricle and cerebellum into the cervical spinal canal leading to obliteration of the
cisterna magna
* nearly always associated with a form of spina bifida called myelomeningocele.
95
What is prune belly syndrome?
lower urinary tract obstruction with an enlarged
bladder, bilateral hydronephrosis and reduced amniotic
fluid. + Poor development of the abdominal muscles.
It is associated with high mortality from pulmonary hypoplasia.
96
A pregnant woman has just had her 20-week anomaly scan. Her baby is diagnosed
with ventricular septal defect and its femur length is at the 5th centile.
What is the most appropriate next step?
Offer amniocentesis.
There is a strong association between congenital heart disease and aneuploidy 40 %
97
A pregnant woman complaining of reduced fetal movements at 26 weeks is referred
for an ultrasound scan. The scan shows fetal hydrothorax, ascites and massive skin
oedema. She is rhesus positive and all her antibody tests are negative.
What is the proportion of this condition as a cause of perinatal mortality?
3%
Non-immune hydrops fetalis (NIHF) is an uncommon condition
98
What are The major causes of NIHF ( Non-immune hydrops fetalis )?
1- chromosomal abnormality
2- structural cardiovascular disease
3- cardiac dysrhythmias
4- abnormalities of the fetal thorax
5- haematological disorders
6- infections ( parvovirus B19, cytomegalovirus, syphilis and toxoplasmosis.)
99
A pregnant woman has just had her 12-week ultrasound scan. The scan shows a live
severely hydropic baby.
What is the most appropriate investigation you would like to offer next?
Karyotyping
100
A woman has booked her pregnancy at 27 weeks’ gestation. She has an ultrasound
scan that shows multiple congenital abnormalities. She is offered amniocentesis and
the baby is diagnosed with Edward syndrome (Trisomy 18). She asks for termination
of the pregnancy.
Based on the 1967 United Kingdom Abortion (amended in 1990), which ground will
support her request?
Ground D.
101
A pregnant woman has just had her 12-week scan. She is diagnosed with a dichorionic diamniotic (DCDA) twin pregnancy. She queries the chance of having them
prematurely.
What proportion of all twins deliver before 37 weeks?
60%
Recommendations: elective birth from 36 weeks and 0 days for monochorionic
twins and 37 weeks and 0 days for dichorionic twins
For triplet pregnancies from 35 weeks and 0
days
102
A pregnant woman with MCDA twins has just had a scan at 21 weeks in the fetal
medicine unit. Twin 1’s estimated weight is 40% less than the estimated weight for
twin 2, and is diagnosed with sacral agenesis and right diaphragmatic hernia. No
obvious anomaly is seen in twin 2 and it’s growth and amniotic fluid are normal.
What is the management option you would like to offer her?
Selective fetocide with cord occlusion for twin 1
* Anomalies such as anencephaly or diaphragmatic hernia are typically complicated by polyhydramnios and place the normal co-twin at risk of severe
preterm delivery owing to uterine distension.
* In monochorionic twins, selective feticide by intracardiac potassium chloride
cannot be used owing to the vascular anastomoses 👉 Cord occlusive techniques
103
A woman has had her scan at 24 weeks as the symphysiofundal height (SFH) height
measures more than for the estimated date. The scan demonstrates severe
polyhydramnios. The sonographer could not see one of the fetal organs.
What is the most likely missing organ/s in the scan?
Fetal stomach.
diagnosis of oesophageal atresia
104
What is the sonographic feature of duodenal atresia.?
‘double bubble’ sign
105
A woman has had her first trimester combined risk calculated as 1:50. Chorionic villus
sampling is offered and accepted. An uncomplicated procedure is performed and she
is informed that the first result will be within 72 hours.
What type of test is usually used to give the first cytogenetic result?
Quantitative fluorescent polymerase chain reaction (QF-PCR)
* does not require cell culture whereas
karyotyping does
106
A 36-year-old woman with a BMI of 19 kg/m2 has become pregnant following a
successful second attempt at in vitro fertilization. She is healthy but smokes 5–10
cigarettes a day. The 19-week anomaly scan did not show any obvious abnormality.
What further management would you like to recommend?
Uterine artery Doppler scan at 20–24 weeks.
three minor risk factors for a small-for-gestationalage (SGA) baby :
IVF
BMI <20 or 25–34.9
Smoking 1–10/day
107
What are the Minor Risks for a small-for-gestationalage (SGA) baby ?
1- Age >35
2- IVF
3- BMI <20 or 25–34.9
4- Smoking 1–10/day
5- Pregnancy interval <6 months
6- Pregnancy interval >60 months
7- Previous pre-eclampsia
108
What is the management if the woman has Minor Risks for a small-for-gestationalage (SGA) baby ?
3 risk factors: offer
uterine artery Doppler at
20–24 weeks
* If abnormal: offer serial
growth and umbilical
artery Doppler scans
from 26–28 weeks
* If normal: offer third
trimester growth and
Doppler scan
( abnormal: defined as a pulsatility index [PI] >95th centile ) and/or notching .
109
What are the Major Risk
Factors for SGA ?
1_ Age >40,
2- smokes >11/day
3- Cocaine diabetic vasculopathy
4-Maternal/paternal SGA
5-Previous SGA/stillbirth
6-Renal impairment
7-Antiphospholipid syndrome.
8-PAPPA<0.4 MoM
9-Chronic hypertension
10- Echogenic (bright) bowels
110
What is the management if the woman has Major Risk
Factors for SGA ?
One risk factor: offer serial
growth and umbilical
artery Doppler scans
from 26–28 weeks
111
If the woman is Unsuitable for
Serial SFH
( symphysis-fundal height ) what is the management to lower the risk of SGA ?
BMI >35
- Fibroids
Offer serial growth and
umbilical artery Doppler
scans from 26–28 weeks
112
A 26-week pregnant woman is referred for an ultrasound scan after she presented
with an episode of reduced fetal movements. The fetal Doppler assessment shows
middle cerebral artery peak velocity multiple of the mean (MoM) at 2 and mild
fetal ascites. You noted that her booked blood results show anti-K antibodies level
of 2 IU/mL.
What is the most appropriate management?
Arrange for fetal blood sampling and/or transfusion
* Refer to a fetal medicine specialist for invasive treatment if the middle cerebral
artery peak velocity rises above 1.5 MoM
113
A pregnant woman has just had her 20-week anomaly scan. There is no obvious fetal
anomaly seen on the scan but the umbilical cord contains only two blood vessels.
What further management would you like to recommend?
Third trimester growth scan and neonatal renal and cardiac scan
* An isolated single umbilical artery does not warrant invasive testing for
fetal aneuploidy
114
The airport authorities are on the phone. A woman has refused to go through the
airport body scanner as she is seven weeks pregnant and worried about fetal radiation
exposure.
What would be your advice?
Reassure the woman
115
Your year ST 1 junior colleague wants to know why electronic fetal monitoring (EFM)
is the recommended method of intrapartum fetal surveillance for high-risk
pregnancies.
What will you tell him?
It is sensitive in detecting abnormalities in fetal heart rate pattern { not specific }
* ( its specificity for detection of fetal hypoxia remains low and
therefore confirmatory tests such as fetal scalp blood sampling become
necessary.)
116
A 33-year-old woman is induced at 38 weeks because of mild pre-eclampsia. She
wants to know how she would benefit from continuous electronic fetal monitoring as
she felt it may limit her freedom of movement during labour.
What will you tell her?
It will help reduce the incidence of neonatal seizures
* ( no significant difference in
cerebral palsy or perinatal death rate ) .
117
A 28-year-old woman in her first pregnancy is 36 weeks with an uncomplicated
pregnancy. She would like to have a home delivery and wants to know more information about Planning birth at home .
Planning birth at home is associated with an overall small increase (0.4%) in the risk of a
baby having a poor outcome.
118
A 37-year-old primigravida attends the labour ward complaining of irregular contractions. She is 38 weeks pregnant. The ultrasound scan performed at 36 weeks
showed the placenta to be posterior and high, with a normally grown baby. She
conceived by in vitro fertilization (IVF). Her admission cardiotocography (CTG)
shows a baseline rate of 145 beats per minute (bpm), variability of 10–15 bpm,
accelerations, no decelerations, and she is contracting once every 10 minutes. Vaginal
examination showed the cervix to be partially effaced and dilated 2 cm with intact
membranes. The head is 5/5 palpable. All her observations are normal.
Which of the following options would you do next?
Admit her to the antenatal ward
* She is still in the latent phase of labour but the high head indicates high risk of
cord prolapse
119
A 28-year-old in her first pregnancy is induced at term plus 10 days. The CTG was
normal before induction of labour; she was dilated 6 cm four hours previously and
now is dilated 8 cm on vaginal examination. She has uterine contractions at a rate of
two every 10 minutes. The CTG shows a baseline rate of 150 bpm, good variability
and infrequent shallow variable deceleration.
What is the next most appropriate action?
Assess in two hours without augmentation.
( She is dilated 8 cm and progressing well; there is no need for augmentation with syntocinon )
120
A woman at 37 weeks in her first pregnancy is admitted for induction of
labour
as her baby has ultrasound-confirmed IUGR . In early
labour, the CTG shows a baseline rate of 150 bpm, variability of 5 bpm, and infrequent
variable decelerations, dropping from baseline by 60 bpm or less and taking
60 seconds to recover, recorded over the previous 45 minutes.
She is contracting once
every 10 minutes and the cervix is dilated 1 cm and 2 cm long.
What is the most appropriate next step?
🌸 Artificial rupture of membranes (ARM).🌸
* The recorded variable deceleration indicates a non-reassuring trace with need
for conservative measures ( ARM allows checking liquor for blood or meconium and fetal blood sampling
if required )
* Non-reassuring CTG is not enough to decide to book a Caesarean section.
121
A woman in her first pregnancy, presents with decreased fetal movements for
24 hours. She is 34 weeks pregnant. A non-stress CTG shows the fetal heart rate is
180 bpm, variability is 3 bpm, and there have been unprovoked persistent decelerations for the last 20 minutes.
What is the most appropriate management option?
Category 1 Caesarean section
* We do not know for how long the CTG was abnormal, and she is complaining
of diminished fetal movements with multiple CTG abnormalities.5
122
What are the 4 CS Categories ?
Category 1 is urgent delivery when there is immediate threat to life of woman
or fetus. The decision-to-delivery interval should not exceed 30 minutes.
Category 2: is the need for early delivery when there is maternal or fetal
compromise but no immediate threat to life of woman or fetus, e.g. failure to
progress in labour.
Category 3 : is when there is no maternal or fetal compromise but early delivery
is required, e.g. breech presentation in early labour.
Category 4 : is no compromise and Caesarean section is carried out at a time to
suit the woman and maternity services.
123
A low-risk woman in her first pregnancy is in advanced labour. She is progressing
well. One hour previously the cervix was dilated 7 cm and the head was at the spines.
She has epidural analgesia for pain relief. The midwife is concerned about the CTG,
and asks for your input.
The CTG shows a baseline rate of 155 bpm and has recorded a sinusoidal pattern for
the last 30 minutes.
What is the most appropriate management option?
🌟 Category 1 Caesarean section
A sinusoidal trace is suspicious of fetal anaemia. Fetal blood sampling will not
detect fetal anaemia, therefore category 1 Caesarean section is required.
124
A 28-year-old nulliparous woman on the midwifery-led unit is in advanced
labour. She has had an uncomplicated pregnancy. She has made acceptable
progress in the first stage of labour. She is now contracting three times every 10
minutes, the cervix is fully dilated and the head is 1 cm above the ischial spines
in occipitotransverse position. She has been in the second stage of labour for
30 minutes.
Which of the following management options would you recommend?
Start syntocinon.
* ( She has made slow progress as the head is still above the spines )
125
A 34-year-old nulliparous woman in the second stage of labour has been pushing for
the last two hours and is exhausted. The CTG is normal; the head is 1 cm above the
ischial spines, in occipitoanterior position.
Which would be the most appropriate action?
Emergency Caesarean section
* She is exhausted thus it is unlikely that there
would be any further progress.
126
A 36-year-old nulliparous woman in the second stage of labour has been pushing for
30 minutes. The CTG shows a fetal heart rate of 170 bpm, reduced variability and late
decelerations having occurred for the last 25 minutes. Vaginal examination shows the
head to be at the ischial spines in occipitoposterior position.
Which management options would be most appropriate?
🌸Fetal blood sampling🌸
* Trial of instrumental delivery should not be performed if there is an abnormal
CTG, unless the fetal blood sampling result is normal
* Normal fetal blood sampling result is reassuring. She can keep pushing or have
a trial of instrumental delivery if the result is normal.
* In an abnormal fetal blood sampling result, there is no place for a trial of
instrumental delivery.
127
A 32-year-old primigravida is in labour at term. She was started on an oxytocin
infusion four hours previously because of slow progress. There is clear liquor draining.
The CTG shows five contractions every 10 minutes, a baseline rate of 155 bpm,
variability of 5-10 bpm, early decelerations in more than 50% of the contractions,
and occasional accelerations for the last 90 minutes. Vaginal examination shows the
head to be 1 cm above the ischial spines, in a right occipitoposterior position, and the
cervix is dilated 7 cm. She has progressed 3 cm over the last four hours.
Which of the following options would be most appropriate for her management?
🌟Reassure and examine in four hours.
A progress of 3 cm in four hours is acceptable./.no need to Reduce syntocinon.
or Stop syntocinon.
128
A 36-year-old woman with three previous Caesarean sections was booked for repeat
elective Caesarean section at 39 weeks. She declined tubal ligation as she wishes to
have more children.
What is her risk of placenta praevia in her next pregnancy?
2.8%.
* women with one, two, three or more previous Caesarean deliveries experience a 1%, 1.7% or 2.8% risk, respectively
129
A 27-year-old woman in her second pregnancy presents to the labour ward at 39 weeks’
gestation with painful uterine contractions. Her first baby was delivered by emergency
Caesarean section due to slow progress in labour three years previously. She is very keen to
have a vaginal delivery. Your junior registrar asks you about the signs of uterine rupture
Which is the most common in women with uterine rupture
during labour?
Abnormal CTG
and is present
in 70 % of cases
130
What is the risk of Scar rupture in vaginal birth after CS ?
0.5%.
131
A 23-year-old nulliparous woman has been pushing for two hours. The head is not
palpable abdominally, the cervix is fully dilated, and on vaginal examination, the
head is in right occipitoposterior position with minimal caput. The station is 1 cm
below the ischial spine. The CTG is reassuring.
Which of the following management options would be the most appropriate?
🩷Instrumental delivery in theatre
* She is station plus 1 cm (mid-cavity)
132
What is the difference between Low instrumental & Mid-cavity instrumental ?
Low instrumental: leading point of the skull (not caput) is at station plus 2 cm
or more and not on the pelvic
floor.
Mid-cavity instrumental
: fetal head is no more than one-fifth palpable per
abdomen and the leading point of the skull is station zero or plus 1 cm.
133
You are teaching the ST 2 trainee the basic principles of forceps delivery.
Which type of episiotomy would be most appropriate to reduce the risk of severe
perineal tear?
A mediolateral episiotomy with an angle of 60 degrees away from the midline
134
A 32-year-old woman had a forceps delivery due to maternal exhaustion. All her
observations are normal, and the placenta was delivered complete. Perineal examination revealed a torn external anal sphincter to about 80%. She was counselled,
consented and taken to theatre for repair.
Which techniques do you recommend to accomplish the repair of the external anal
sphincter?
End-to-end method using 3/0 PDS
* full thickness external anal sphincter tear, either an overlapping
or an end-to-end
* partial thickness (all 3a and some 3b) tears, use end-to-end technique.
135
A 32-year-old woman has a forceps delivery due to maternal exhaustion. All her
observations are normal, and the placenta is delivered complete. Perineal examination
revealed partial thickness torn external and internal anal sphincters. She was counselled, consented and taken to theatre for repair. The internal anal sphincter was
identified separately when the patient was examined under anaesthesia.
Which techniques do you recommend to accomplish the repair of the anal sphincters?
Each sphincter should be repaired separately using the end-to-end method
136
A 30-year-old woman in her second pregnancy presents in the antenatal clinic at
28 weeks’ gestation for counselling. Her first pregnancy ended in a spontaneous
vaginal delivery at 41 weeks. This was complicated by a third degree tear, which
was repaired in theatre.
She had mild incontinence of flatus during the first three months after delivery but
recovered completely by the end of five months. She would like to know about the
risk of faecal incontinence.
What is her risk of faecal incontinence if she has a normal vaginal delivery in this
pregnancy without complications?
17% : risk of faecal incontinence
* The risk of sustaining a further third- or fourth-degree tear after a subsequent
delivery is 5%–7%.
137
A 33-year-old woman in her second pregnancy presents to the labour ward at
39 weeks with painful uterine contractions every three minutes. Vaginal examination
shows the cervix to be dilated 6 cm and effaced. The head is 3 cm above the ischial
spines. The membranes are ruptured. You could easily feel the anterior fontanel and
the supraorbital ridges. Fetal heart rate is normal. Her first pregnancy ended in a
normal uncomplicated vaginal delivery.
Which of the following is the best management option?
🩷 Reassess in two hours.
* This is a brow presentation and in most cases the head either flexes back to
vertex presentation or extends more to become a face presentation.
Depending on what happens over the next two hours
138
A 24-year-old woman had a normal vaginal delivery 20 minutes previously; this was
complicated by brisk postpartum haemorrhage. She lost 1500 mL blood and is responding to medical management but is still bleeding slightly. A decision is made to transfuse.
Which of the following should she receive?
Leucocyte-depleted red cells.
* leucocyte depletion reduces the risk of cytomegalovirus
(CMV) transmission.
139
You are called to assist in a case of massive obstetric haemorrhage. The patient is
60 kg and has already had six units of red cells.
Which of the following is the appropriate dose of fresh frozen plasma?
800 mL.
* Fresh frozen plasma at a dose of 12–15 mL/kg should be administered for
every six units of red cells during major obstetric haemorrhage.
* The subsequent fresh frozen plasma transfusion should be guided by the
results of clotting tests aiming to
maintain PT / aPTT ratios
at less than one and a half times normal
140
You are called to assist in a case of massive obstetric haemorrhage. The patient is
60 kg and has already had six units of red cells.
Which of the following is the appropriate dose of Cryoprecipitate ?
standard dose of two
five-unit pools should be administered early in major obstetric haemorrhage and subsequent cryoprecipitate
transfusion should be guided by fibrinogen results, aiming to keep a fibrinogen
level of more than 1.5 g/L.
141
A patient in early labour enquires about the risk of accidental dural puncture if she
has epidural analgesia.
What is the risk of dural puncture?
0.5%–2.5%.
* Epidural headache is usually in the fronto-occipital regions and radiates to the
neck. It is characteristically worse on standing and typically develops 24
–48
hours
typically lasts for 7
–10 days but can last
up to 6 weeks
142
As an ST 5 preparing for your completion of a certified training, you are asked to
look into the department Caesarean section rate, compare it with other lowCaesarean section rate countries and propose some changes in the practices at your
department. You find that the rate of vaginal birth after Caesarean section in your
unit is 30%.
To how much should this practice be increased in order to reduce the overall
Caesarean section rate substantially?
70%–75%.
143
As an ST 5 preparing for your completion of a certified training, you are asked to look
into the department Caesarean section rate, compare it with other low-Caesarean
section rate countries and propose some changes in the practices at your department.
You find that the rate of vaginal delivery for breech presentation was very low at
only 7%.
To how much should vaginal delivery for breech presentations be increased in order
to reduce the overall Caesarean section rate substantially?
21 %
144
A 31-year-old woman who was infertile for three years is now pregnant on in vitro
fertilization (IVF).
What is the risk of occurrence of vasa praevia during the current pregnancy?
1/300.
* The reported incidence of vasa praevia is one in 2000 to one in 6000 pregnancies,
145
What are the risk factors for vasa praevia ?
1- bilobed placenta or succenturiate lobe where the fetal vessels run through the
membranes joining the separate lobes together
2- history of low-lying placenta
in the second trimester
3- multiple pregnancy
4- IVF
146
A 35-year-old woman achieved her second pregnancy after IVF.
What is her increased risk of developing placenta praevia compared to her first
naturally conceived pregnancy?
Three-fold
147
Among mothers who conceived by IVF who did not have a previous natural
pregnancy, What is her increased risk of developing placenta praevia ?
six-fold higher risk compared to naturally conceived
pregnancies
148
A 27-year-old Asian woman in her first pregnancy is known to have thalassemia
major. She is 28 weeks pregnant. She comes to the emergency department with
shortness of breath that has rapidly deteriorated. Despite resuscitation, she died
within 20 minutes.
What is the most likely cause of death?
Cardiac failure
* Cardiac failure is the primary cause of death in over 50% of thalassemia cases
( iron overload )
149
A 19-year-old woman in her first pregnancy presents to the emergency department
with sudden breathlessness. On examination, her lips are swollen. Her pulse is
110 beats/minute (bpm) and her blood pressure (BP) is 100/60 mmHg. Chest examination
shows generalized diminished air entry. She denies any medical history of any illnesses.
What would be the best immediate action?
0.5 ml of 1:1000 adrenaline intramuscularly
( which can be repeated after
five minutes if there is no effect )
150
A 35-year-old primigravida pregnant at 32 weeks presents to the emergency department with severe vaginal bleeding. She collapses and is unresponsive. Cardiopulmonary resuscitation (CPR) has been started but there is no response for four minutes.
Which of the following is the most appropriate course of action?
Caesarean section immediately with no interruption to administer CPR
* ( No need for checking fetal life : Perimortem Caesarean section should be considered a resuscitative procedure
to be performed primarily in the interests of maternal, not fetal, survival.
151
A 24-year-old woman in her fifth pregnancy has delivered normally 20 minutes
previously. She had active management of the third stage. The midwife noticed severe
vaginal bleeding just after the placental birth and the uterus was lax. The blood loss
was estimated as 1500 ml. After the emergency call, the anaesthetist arrived and is
controlling her airway, has inserted two wide-bore cannulas, is running in crystalloid
rapidly, and has requested cross-matched blood.
What is your next step?
Bimanual uterine massage
152
A 33-year-old woman in her fifth pregnancy has just delivered a living baby of 4 kg by
the midwife. Upon delivery of the placenta, there was excessive blood loss and the midwife feels a lump in the vagina. You arrived and diagnosed an acute uterine
inversion. She is vitally stable and you are attempting to reverse the position of the
uterus, but the cervix is tightly contracted, preventing the fundus of the uterus from
being repositioned.
What is your next step?
Examination under anaesthesia and hydrostatic replacement in theatre
153
A 33-year-old woman presents to the emergency department on day 5 after a Caesarean
birth with a disturbed level of consciousness, pulse of 120 bpm, respiratory rate of
26/min and BP of 90/50 mmHg. There was no vaginal bleeding. On assessment, the
multidisciplinary team decided to draw blood for cultures and lactate and start intravenous antibiotic, intravenous fluids, and assisted ventilation.
What is the suitable level of care?
Level 3 care ( needing ventilation )
154
What are the level of care in the hospital ?
Level 0: hospital admission only.
Level 1: a higher degree of observation or monitoring, special expertise or
facility,
Level 2: having an uncorrected major physiological abnormality
Level 3: needing ventilation.
155
On expulsion of the head, the head remains tightly applied to the vulva.
The midwife activated the emergency buzzer and declared that there is shoulder
dystocia. You attended immediately.
How will you confirm your diagnosis?
Do a mild traction in an axial direction to confirm the diagnosis
156
A 24-year-old woman with three previous Caesarean deliveries comes to the antenatal
clinic at 32 weeks’ gestation with confirmed diagnosis of placenta praevia with no
evidence of morbid adherence. However, the Doppler scan showed there is vasa
praevia.
What is your plan of care?
Elective delivery by Caesarean section at 37 weeks with immediate umbilical
cord clamping.
{ ( 35-37 ) & immediate not defer cord clamping}
157
A 24-year-old woman in her third pregnancy with two previous uneventful full-term
vaginal deliveries presents to the emergency department at 37 weeks of gestation with
nausea, occasional vomiting and a severe pain in the right iliac region. She is generally
unwell. On examination she was normotensive at 100/50 mmHg, with a pulse of
100 bpm and a temperature of 37.8 C. Her abdomen showed localized rigidity and
tenderness in the right iliac region. Ultrasound scan showed enlarged noncompressible appendix. The general surgeon decided to do an appendectomy and
asks your advice regarding the need to deliver.
What will be your advice to him?
Do appendectomy and wait for spontaneous onset of labour
158
You are an ST5 on call for the labour ward. You are asked to review a primigravid
woman in induced labour at 41 weeks plus five days of gestation. She received epidural
anaesthesia and she is free of pain. She is on an oxytocin drip at 10 mU/min.
The woman has been in the active 2nd stage for two and a half hours. On abdominal
examination, the head is 0/5 palpable per abdomen. Estimated fetal weight is 4 kg.
Cardiotocography (CTG) is reassuring with five uterine contractions in the last
10 minutes, each lasted for 30–40 seconds. Vaginal examination shows left
occipitotransverse position ++ station with diffuse caput ++ and molding ++. You
decide to deliver by a Caesarean section.
What can you do to deliver the baby safely?
🌟Reverse breech extraction ( (grasping
one or both fetal feet at the fundus of the uterus and applying steady traction in
the downward direction)
* carries a significantly lower risk of extension of the
uterine incision compared to the push fetal disimpaction method
159
A 32-year-old woman is on her third pregnancy with two previous uncomplicated
vaginal deliveries. She presented in labour. She has a twin pregnancy and both babies
are in a cephalic presentation. The pregnancy has been uncomplicated to date and
both twins are above the 50th centile for growth with no discordant growth. The CTG
has been normal throughout labour. The first twin is delivered uneventfully. The
second twin is found to be transverse.
What would be the best immediate action?
External cephalic version.
* Internal podalic version and breech extraction can be performed for the second
twin, after a failed cephalic version attempt
160
A 38-year-old woman, on her third pregnancy, presents to the emergency department
at 37 weeks of gestation with a stabbing pain in the epigastrium that radiates to the
back and left arm.
What is the most relevant laboratory marker to be requested?
Tropinin I ( and troponin T are the specific biomarkers of choice
for diagnosing myocardial infarction.)
* other cardiac markers
: myoglobin, creatinine kinase, creatinine
kinase isoenzyme
– can be increased significantly in labour or CS
161
A 29-year-old primigravida in her first pregnancy attends the antenatal clinic at 32
weeks’ gestation. She is fit and well with no comorbidities. She had a vasovagal
fainting episode and underwent an electrocardiogram (ECG), which was normal.
Which of the following features would have prompted suspicion of an underlying
abnormality?
🌟 Right shift in the QRS axis
It is normal to see a left shift in QRS axis but a right shift may indicate right
ventricular hypertrophy
162
A 34-year-old Pakistani woman in her third pregnancy attends the antenatal clinic at
36 weeks for a labour plan. She tells you she is on a beta-blocker as she suffered from
rheumatic heart disease as a child.
Which of the following therapies should she avoid in the second stage of labour?
🌼 Intravenous ergometrine
* Rheumatic endocarditis causes mitral stenosis in 75% of cases /
Ergometrine causes rapid autotransfusion and can precipitate pulmonary
oedema.
163
primigravida of African origin with a BMI of 38 kg/m2 attends the
emergency department with shortness of breath, oedema and tachycardia. She has
no proteinuria but admits to a family history of hypertrophic cardiomyopathy. she is hypertensive at 153/100 mmHg and needs treatment prior to
investigations.
Which antihypertensive would be most appropriate?
Labetalol.
164
primigravida of African origin with a BMI of 38 kg/m2 attends the
emergency department with shortness of breath, oedema and tachycardia. She has
no proteinuria but admits to a family history of hypertrophic cardiomyopathy. she is hypertensive at 153/100 mmHg and needs treatment prior to
investigations.
Which antihypertensive would be most appropriate?
Labetalol.
165
30-week pregnant woman known to be a brittle asthmatic. She complains of shortness
of breath, widespread wheeze and is tachycardic at 98 bpm. She takes salbutamol
100 mcg two puffs as required, a salmeterol/fluticasone 50/500 inhaler twice daily
and theophylline 500 mg twice daily. On this admission, there is no evidence of
pneumonia and her oxygen saturations are 98%.
How would you change her medication?
Salbutamol 2.5 mg nebulizer and prednisolone 40 mg orally for five days
( Doses lower than 40 mg prednisolone are not as effective )
166
A 24-year-old woman in her second pregnancy presents at 12 weeks’ gestation with
confirmed venous thromboembolism (VTE).
How would you advise her with regard to her treatment?
Commence therapeutic LMWH for three to six months and then convert to a
prophylactic dose
167
A Pregnant attends the obstetric day unit with persistent vomiting. She is known to have type 2 diabetes and does not recall how much insulin
she is taking.
On examination, she has a respiratory rate of 22/min, she is tachycardic (110
bpm) and appears dehydrated. She is apyrexial. You perform an arterial blood gas test.
Which are you likely to find?
pH : 7.25 pO2 (mmHg) : 129.
pCO2 (mmHg) : 16 HCO3 (mEq/L) : 9
* Diabetic ketoacidosis is characterized by :
1- acidosis (venous pH <7.3 )
2- bicarbonate <15 mmol/L
3- glucose
>11 mmol/L
168
A 20-year-old woman, a known epileptic, attends the medical antenatal clinic for
preconceptual counselling. She has been seizure free for two years.
Which of the following medications would you advise her against because of the risk
of congenital malformation?
🌟 Sodium valproate.
* Spina bifida is reported in 1%–2% of patients taking sodium valproate.
Up to 10% of women taking sodium valproate had babies with congenital
malformations.
169
A 34-year-old woman presents to the obstetric unit via ambulance after collapsing in
the supermarket. She has previously suffered two miscarriages and is 28 weeks
pregnant. On examination, she appears confused and complains she is dizzy. You
elicit a right-sided hemiparesis. She is apyrexial and all observations are stable.
What would be your first investigation of choice?
Computed tomography venogram
* recurrent miscarriages should prompt you to think about
thrombophilias, most likely causing a venous sinus thrombosis
170
A 39-year-old woman presents with right upper quadrant pain and polydipsia in her
third trimester. She appears jaundiced and tells you that she has been vomiting for
two days. On examination, she has a BMI of 35 kg/m2 and blood tests show a raised
alanine transaminase with hyperuricemia. Her creatinine is normal and she shows a
mild leucocytosis. Her BP is 149/100 mmHg and she has 3+ proteinuria.
Which of the following is most likely the cause of her clinical picture?
Acute fatty liver of pregnancy
( Pre-eclampsia usually has an element of renal compromise if liver function
tests are abnormal.)
171
Acute fatty liver of pregnancy :
* When does it occur ?
* What are the Predisposing factors?
* Symptoms
* Lab
* Treatment
* When does it occur : late in the third trimester of pregnancy — 36 weeks is the average
* What are the Predisposing factors : male fetus, history of AFLP, and multiple gestations.
* Symptoms : nausea, vomiting, anorexia, and abdominal pain — some patients present with hypertension and proteinuria / jaundice, ascites, coagulation disorders, and confusion, develops rapidly
* Lab : Leukocytosis (over 11000 ) - Elevated transaminases - Elevated bilirubin - Hypoglycemia Elevated uric acid
* Treatment : Supportive management and prompt delivery are the cornerstones of therapy.
172
A 32-year-old diabetic woman had an instrumental delivery two hours previously.
Antenatally she complained of severe lethargy but is found to have normal haemoglobin. You are called to see her as she has become confused and bradycardic. Her
observations record a temperature of 35 C, heart rate of 45 bpm and oxygen saturations of 80% on air. Blood glucose level is 4 mmol/L, she is hyponatraemic and has
decreased reflexes.
What will the patient need following initial supportive treatment?
IV levothyroxine
* This patient is likely to have myxoedema coma from undiagnosed
hypothyroidism.
( Hypoglycemia often cause tachycardia )
173
A primigravida in her second trimester attends your antenatal clinic complaining of
palpitations and tremors. Her heart rate is 110 bpm. She is fit and well otherwise but
explains she has lost a lot of weight and has been vomiting excessively in the
mornings. Her mother suffers with arthritis but there is no other family history
of note.
What is the most likely blood picture you will see?
TSH < 1
T3 > 30
T4 > 20
174
A 17-year-old primigravida attends the early pregnancy assessment unit at six weeks’
gestation. She complains of a headache and blood-stained vomiting, stating she has
been feeling awful for several days and ‘unable to keep anything down’. Her boyfriend tells you she has not stopped vomiting.
Which of the following is likely to be the results of her arterial blood gas?
metabolic alkalosis :
pH is >7.45
HCO3 >26
175
Sickle cell disease (SCD) is the most common inherited condition worldwide.
The recommended daily dose of folic acid for pregnant women with SCD is:
5 mg daily throughout pregnancy
176
A 26-year-old woman with SCD is admitted at 18 weeks with symptoms of chest pain,
tachypnoea, cough and shortness of breath. Chest X-ray shows a new infiltrate
throughout the lung fields.
What is the most likely diagnosis?
Acute chest syndrome
* Acute chest syndrome is the most common complication in women with SCD
in pregnancy after acute pain.
177
A 28-year-old woman with a BMI of 25 kg/m2 books into the antenatal clinic at 12
weeks. Two years previously she had a confirmed unprovoked iliofemoral
thrombosis in her left leg.
Your advice regarding thromboprophylaxis during this pregnancy is:
To use LMWH throughout the pregnancy and for six weeks postpartum
178
A 28-year-old woman with a BMI of 25 kg/m2 books into the antenatal clinic at 12
weeks. Two years previously she had a confirmed iliofemoral thrombosis in her left
leg after major knee surgery.
Your advice regarding thromboprophylaxis should be:
To use LMWH from 28 weeks and for 10 days postpartum
179
A 28-year-old woman with a BMI of 35 kg/m2 presents to the antenatal clinic for a
booking. She has confirmed anti-phospholipid syndrome (APLS). She has no previous
history of venous thrombosis, but was tested after a stillbirth at term and was found
to have a positive lupus anticoagulant test on two occasions, 12 weeks apart. She is a
non-smoker.
She asks about the risk of venous thrombosis and the role of LMWH in her pregnancy.
You advise her that she should ...
Commence with LMWH at 28 weeks and for six weeks postpartum.
( 2 risk factors : BMI of 35 kg/m2 + stillbirth )
* APLS + 3 risk factors 👉 should receive thromboprophylaxis throughout the antenatal period and for six weeks postpartum.
* APLS + 2 risk factors 👉 from 28 weeks and for six
weeks postpartum.
* APLS + 1 risk factor 👉 should be offered LMWH for 10 days postpartum
180
A pregnant woman attends antenatal clinic at 12 weeks. She has systemic lupus
erythematosus (SLE). Her disease is well controlled and she has not had a flare for
six months. She asks about her risk of a flare of SLE in pregnancy.
You tell her that
She has a 25%–60% increased risk of a flare in pregnancy.
Musculoskeletal
flares are less common but renal and haematological flares
more common.
181
What are the risk factors for increased risk of a flare in pregnancy in systemic lupus
erythematosus (SLE) patients ?
1- Active disease in the six months prior to pregnancy,
2-discontinuation of antimalarial medication
3- history of lupus nephritis
182
A pregnant woman attends the antenatal clinic at 12 weeks. She has SLE. She is
currently in remission. She asks about live birth rates in women with SLE.
You tell her that the chances of a live birth are :
80%–90%.
* Main issues with systemic lupus erythematosus (SLE) are:
1-the higher rate of
fetal loss,
2-pre-eclampsia,
3-fetal growth restriction
4-neonatal lupus.
183
A primigravida who has anti-Ro antibodies attends antenatal clinic. She asks you
about the risk of her baby having congenital heart block (CHB).
You tell her the risk is:
2%
184
A 24-year-old primigravida with SLE asks about drug therapy in pregnancy as she is
planning to become pregnant soon.
With regard to hydroxychloroquine therapy, you tell her that she should
Continue therapy because of the beneficial effects of the drug on her SLE
* reduction in
flare and in neonatal CHB and neonatal lupus.
185
A 24-year-old primigravida with SLE asks about drug therapy in pregnancy as she is
planning to become pregnant soon.
With regard to non-steroidal anti-inflammatory drug (NSAID) therapy, you tell
her that:
They are safe in the first and second trimester only.
186
A 26-year-old woman with rheumatoid arthritis (RA) attends antenatal clinic at 10
weeks. She is concerned about a flare up of her RA during pregnancy.
You tell her that during her pregnancy the risk of a disease flare up is:
Reduced
187
A 26-year-old woman consults you because she is contemplating a pregnancy. She has
RA and is taking methotrexate.
Your advice regarding methotrexate and pregnancy is:
To stop treatment for at least three months prior to pregnancy and during
pregnancy.
188
A woman with RA has delivered normally one week previously and is now experiencing a flare of her disease. Her rheumatologist advises a course of prednisolone,
starting at 20 mg twice daily. She is breastfeeding and is concerned about the risks to
her baby.
With regard to steroid therapy and breastfeeding:
She should express and discard for four hours after taking the
medication.
* ( At a dose above 20 mg twice daily )
