SBAs Flashcards
(274 cards)
1
Q
She has undergone a transcervical resection of fibroid , which agent should be used to prevent
intrauterine adhesions?
A
Hyaluronan gel
2
Q
An 83 year old lady found to have gross ascites with an ovarian mass.
Which is the physiological process responsible for her ascites?
A
. Increased permeability of capillaries / exudative ascites - high in protein -
( and lymphatic
flow markedly decreases to levels as low as 15 ml per hour )
3
Q
Which is the physiological process responsible for Nonmalignant ascites ?
A
increase in production of fluid and the lymphatic system
reaches capacity with flow rates of 200 ml of ascites per hour ( transudative ascites )- low in protein -
4
Q
Which bariatric surgery is a malabsorptive procedure?
A
Roux-en-Y gastric bypass
5
Q
Which factors has good evidence that bariatric surgery improves them ,
& Which has a paucity of evidence?
A
Good evidence:
Success rate of IVF
Resolution of PCOS rate
Maternal outcome
Fetal outcome
NOT : Miscarriage rate
6
Q
A 60 year old woman is experiencing post menopausal bleeding. Her
BMI is 45.
Which type of cancer she is at risk of?
A
endometrioid endometrial cancer
7
Q
she is found to have endometrioid endometrial cancer.BMI=42 , The MRI scan confirms the malignancy to be confined to the one half of the myometrium.
What is the first line of management for her?
A
Its FIGO Stage 1B
Laparoscopic hysterectomy + Bilateral salpingo-oophorectomy ( due to high BMI)
8
Q
56 year old woman undergoes total abdominal hysterectomy for fibroid uterus. What are the steps for enhancing recovery ?
A
1- clear fluid allowed up to 2 hours prior to surgery,
2- avoiding long acting sedative
3- administration of antibiotic prior to incision
4- Thromboprophylaxis ♥️♥️
5- decreasing the volume of intravenous fluid with early feeding
9
Q
How many women in UK are diagnosed with cervical cancer annually before the age of 45?
A
1000
10
Q
. A 26 year old diagnosed with squamous cell cancer of the cervix. She is nulliparous. She has a 2cm tumour on her cervix.What should be the appropriate management?
A
Radical vaginal trachelectomy
( 2 cm is the upper limit of diameter to do this procedure)
11
Q
A 34 year old is diagnosed CIN3 on colposcopy and CIN2 on cervical punch biopsy. She is adamant that she wants an ablation technique rather than an excision. What is the reason, why she will not be suitable for an ablation method.?
A
Her entire transformation zone is not visible
( there is no major discrepancy between the cytology and histology both high grade)
12
Q
What is the depth/length of the tissue that should be removed in transformation zone
(TZ) type 1 /2 /3 ?
A
Type 1 at least 7mm (<10mm)
type 2 : 10 – 15mm
Type 3 :15- 25mm
13
Q
A 27 year old is diagnosed with CIN1 and is on regular colposcopic monitoring. She is now 13 weeks pregnant. What should be her management?
A
🩷🩷Colposcopy should be performed now
A pregnant woman should have colposcopy in late first trimester or early 2nd
trimester for an abnormal cytology.
14
Q
A 41 year old lady has been diagnosed with estrogen positive breast cancer. She is 16 weeks pregnant at present.What should be the management?
A
Systemic Chemotherapy can be given to this patient
1- Systemic chemotherapy is safe in the 2nd trimester of pregnancy but contraindicated in the 1st trimester of pregnancy
2- Radiotherapy & Tamoxifen is
contraindicated until delivery.
3- Breast surgery is considered safe in all trimesters of pregnancy without any risk to the fetus.
15
Q
A 38 year old lady has been diagnosed with ER negative breast
cancer. She received adjuvant chemotherapy. She is planning to
conceive .
What should be the plan for further management?
A
🩷🩷ECHO should be performed in pregnancy to detect cardiomyopathy 🩷🩷
1- should wait at least 2 years after treatment, which is when the risk of cancer recurrence is highest.
2- there aren’t any increase in congenital malformations or stillbirth
among the offspring
3- Echocardiography should be performed during pregnancy in women at risk to detect cardiomyopathy
4- fertility is affected by treatment
16
Q
When to deliver the baby if the mother is on chemotherapy sessions for breast cancer?
A
birth should be more than 2–3 weeks after the last chemotherapy session
17
Q
What are the Considerations about lactation during treatment for breast Cancer?
A
- Women should not breastfeed when taking trastuzumab or tamoxifen or chemotherapy
18
Q
For how long Women on tamoxifen are advised to stop this treatment before trying to conceive?
A
3 months
19
Q
What advice should be given to women planning pregnancy following metastatic breast cancer?
A
should be advised against a further
pregnancy
20
Q
What is the Impact of pregnancy on risk of recurrence of breast Cancer?
A
can be reassured that long-term survival after breast cancer is not adversely affected by pregnancy
🔱 The impact of pregnancy does not seem to be modified by tumour characteristics (e.g. size,
hormone receptor status)
21
Q
What advice should be given to women wishing to breastfeed following treatment for
breast cancer?
A
they can breastfeed from the unaffected breast
22
Q
What is the effect of adjuvant chemotherapy of breast Cancer on fertility ?
A
Chemotherapy-induced gonadotoxicity may cause permanent amenorrhoea with complete loss
of germ cells
23
Q
What is the effect of adjuvant hormonal of breast Cancer therapy on fertility?
A
there is no evidence that it
impairs fertility, but pregnancy is not advised during treatment
24
Q
What is the risk of endometrial hyperplasia without atypia progressing to endometrial cancer ?
A
<5% over 20 years
25
What should the first-line medical treatment of hyperplasia without atypia be?
for a minimum of 6 months :
1- The LNG-IUS should be the first-line medical treatment ( lower regression rate )(encouraged to retain the
for up to 5 years)
2- Continuous progestogens ( medroxyprogesterone 10–20 mg/day or
norethisterone
10–15 mg/day)
🛑 Cyclical progestogens should not be used because they are less effective in inducing regression of
endometrial hyperplasia without atypia
26
How should the follow-up for a patient with hyperplasia without atypia be?
At minimum of 6-monthly intervals
At least two consecutive 6-monthly negative biopsies should be obtained prior to discharge
27
What are the risk factors for relapse hyperplasia without atypia ? How to follow up the patients with those risks?
1- body mass index (BMI) of 35 or greater
2-those treated with oral progestogens
🩷 6-monthly endometrial biopsies are recommended. Once two
consecutive negative endometrial biopsies have been obtained then long-term follow-up should be
considered with annual endometrial biopsies
28
When is surgical management appropriate for women with endometrial hyperplasia without atypia?
* should not be considered as a first-line treatment
* is indicated in :
1-women not wanting to preserve their fertility
2-progression to
atypical hyperplasia occurs during follow-up
3-there is no histological regression of hyperplasia
despite 12 months of treatment
4-there is relapse of endometrial hyperplasia after completing
progestogen treatment
5-there is persistence of bleeding symptoms
6-the woman declines
to undergo endometrial surveillance or comply with medical treatment.
29
What is the role of Endometrial ablation in the management of endometrial hyperplasia without atypia?
not recommended
30
What should the initial management of atypical hyperplasia be?
should undergo a total hysterectomy by laparoscopic approach
🛑 There is no benefit from intraoperative frozen section analysis of the endometrium or routine
lymphadenectomy.
31
How should women with atypical hyperplasia who wish to preserve their fertility or who are not
suitable for surgery be managed?
Pretreatment investigations ( Histology, imaging and tumour marker results) to rule out invasive endometrial cancer or co-existing ovarian
cancer
♥️ First-line treatment with the LNG-IUS should be recommended, with oral progestogens as a
second-best alternative
32
How should women with atypical hyperplasia not undergoing hysterectomy be followed up?
endometrial biopsy every 3 months until two consecutive negative biopsies are obtained
long-term follow-up with endometrial
biopsy every 6–12 months is recommended until a hysterectomy is performed.
33
How should endometrial hyperplasia be managed in women wishing to conceive?
Disease regression should be achieved on at least one endometrial sample before women attempt to
conceive.
🔱 Assisted reproduction may be considered as the live birth rate is higher and it may prevent relapse
compared with women who attempt natural conception.
34
Which HRT preparations is suitable for Women with endometrial hyperplasia?
continuous
combined HRT preparation ( not sequential HRT preparation)
Or continuous progestogen intake using the LNG-IUS
35
What is the risk of developing endometrial hyperplasia on adjuvant treatment for breast cancer?
tamoxifen : increased risks of developing endometrial
hyperplasia and cancer.
aromatase inhibitors (such as anastrozole, exemestane and letrozole) : are not known to increase the risk of endometrial hyperplasia and
cancer
36
Should women on tamoxifen be treated with prophylactic progestogen therapy?
its routine use cannot be recommended
(The effect of the LNG-IUS on breast cancer recurrence
risk remains uncertain)
37
How should women who develop endometrial hyperplasia while on tamoxifen treatment for breast
cancer be managed?
1- The need for tamoxifen should be reassessed
2-management should be according to the histological
classification of endometrial hyperplasia
38
A 50 year old woman complains of menorrhagia.
The gold standard investigation for her is:
Hysteroscopy & Endometrial Biopsy
39
What size of hysteroscope should be used in the outpatient setting?
2.7mm hysteroscope with 3 – 3.5mm sheath
40
Do analgesics given before diagnostic outpatient hysteroscopy ?
Routine use of opiate analgesia should be avoided
should be advised to consider taking (NSAIDs) around 1 hour before
41
Does cervical preparation reduce uterine trauma in case of outpatient hysteroscopy?
should not be used in
the absence of any evidence of benefit
* Prostaglandin administration has no benefit in postmenopausal
women
42
What are the contraindications of Prostaglandins ?
1-uncontrolled asthma,
2-chronic adrenal failure,
3-acute porphyria,
4-renal or hepatic
impairment
5- breastfeeding
43
What is the difference between rigid & flexible hysteroscopes in the outpatient setting?
* Flexible : less pain
* rigid : provide better
images/ fewer failed procedures / quicker examination time / reduced cost
44
Which uterine distension medium should be used during outpatient hysteroscopy?
carbon dioxide or normal saline : neither is superior in reducing pain
normal saline : 1- reduce the incidence of vasovagal episodes.
2- improved image quality
3- hysteroscopy to be completed more quickly
4- it's required when using bipolar electrosurgery
45
choose the best distention medium that will reduce her risk of
having vasovagal attack in outpatient hysteroscopy ?
Normal Saline
46
Should routine dilatation of the cervical canal be used before insertion of the hysteroscope
in an outpatient setting?
No , should be avoided
unnecessary in the majority of procedures
47
Should topical local anaesthetic be administered before outpatient hysteroscopy?
1- does not reduce pain during the procedure
2- may reduce the incidence of vasovagal reactions
3- should be considered where
application of a cervical tenaculum is necessary.
48
Should injectable local anaesthetic be administered to the cervix and/or paracervix before outpatient
hysteroscopy?
routine administration , particularly in:
1- postmenopausal women.
2- where
larger diameter hysteroscopes are being employed (outer diameter greater than
5mm)
3-need for cervical dilatation : (e.g. cervical stenosis).
49
What are the benefits of injectable local anaesthetic before outpatient
hysteroscopy?
reduction of the pain
🛑 is not
indicated to reduce the incidence of vasovagal reactions
50
Should conscious sedation be used to reduce pain associated with outpatient hysteroscopic procedures?
should not be routinely used
51
1 Does a vaginoscopic approach to outpatient hysteroscopy reduce pain and increase the feasibility of the
procedure?
Yes,& should be the standard technique for outpatient hysteroscopy where blind endometrial biopsy is not required
52
What should be the angle at which the primary trocar is inserted in diagnostic laparoscopy ?
90° to the skin
53
She was admitted for ectopic
pregnancy and needs laparoscopic salpingectomy. She gives history of previous midline laparotomy for bowel surgery.
What would be the best method for verress needle insertion?
Palmer’s point entry ( unless there is history of splenic surgery)
Hasson (open entry) technique can also be used
54
What is The rate of adhesion formation at the umbilicus following midline laparotomy?
& following low transverse incision ?
50% following midline laparotomy
23% following low transverse incision
55
A 21 year old young woman is booked for diagnostic laparoscopy for
chronic pelvic pain. Her BMI is 19.
Her highest risk of complication is:
Vascular injury
in very thin woman the aorta only lies 2.5cm away from the umbilicus
56
A woman is booked in for marsupialization of bartholin’s cyst. She is
being brought into theatre after having an anesthetic.
The following should be checked as per the WHO surgical checklist
🌸 Patient specific concern
57
What should be checked prior to induction on anesthesia as per the WHO surgical checklist?
Allergy status
58
If the risk of ovarian cyst being malignant at age of 46 y is
1:1000.
What would be the risk of malignancy when she turns 50?
3:1000
The risk of ovarian malignancy increases by threefold after the age of 50
59
What is the incidence of chemical peritonitis after laparoscopic ovarian cystectomy for dermoid cyst ?
0.2% - rare -
60
What blood tests should be performed in the assessment of women with ovarian masses?
👉 CA-125 assay does not need to be undertaken in all premenopausal women
👉 (LDH), α-FP and hCG should be measured in all women under age 40 with a
complex ovarian mass because of the possibility of germ cell tumours.
61
What is the single most effective way of evaluating an ovarian mass ?
transvaginal
ultrasonography
62
What is the role of the routine use of CT & (MRI) in the assessment of suspected ovarian masses?
does not improve the sensitivity or specificity obtained by transvaginal ultrasonography
63
What is the best way to estimate the risk of malignancy of ovarian masses?
Risk of Malignancy Index (RMI) is the most widely used model
serum CA-125 (CA-125); menopausal status (M); and ultrasound
score (U).
RMI = U x M x CA-125
64
What is the failure risk of hysteroscopic sterilization?
2 in 1000 - uncommon
65
A 65 year old lady is diagnosed with epithelial ovarian cancer
confined to the fallopian tube and ovary.
Her 5-year survival rate is:
80- 95%
after chemotherapy
66
A woman with Stage 1 ovarian cancer. What should
She have as first line management.
?
Staging surgery with Retroperitoneal lymph node assessment
🛑 Systemic retroperitoneal lymphadenectomy should not be done if it is confined to the ovaries
67
. A staging laparotomy for ovarian cancer involves the following:
1_Laparotomy +2- TAH +3- BSO +4- Infracolic Omentectomy +5- Biopsies of
peritoneal deposit + 6-Biopsy of pelvic & abdominal peritoneum +
7-retroperitoneal lymph node assessment
68
A 59 year old lady is diagnosed with high risk Stage 1c Ovarian
cancer (Grade 3)
She is offered adjuvant chemotherapy with:
6 cycles of carboplatin
The 2nd line drug
would be paclitaxel.
69
What is The FIGO staging of endometrial cancer the histology confirms that the tumour invades
the serosa.?
Stage IIIA
( Serosa or adnexa)
70
What is The FIGO staging of endometrial cancer the histology confirms that the tumour invades cervical stroma ?
Stage II
71
What is The FIGO staging of endometrial cancer the histology confirms that the tumour invades the vagina ?
Stage IIIB
( Vagina or parametrium )
72
What is The FIGO staging of endometrial cancer the histology confirms that the tumour invades pelvic lymph nodes?
Stage IIIC1
73
What is The FIGO staging of endometrial cancer the histology confirms that the tumour invades paraaortic lymph nodes ?
Stage IIIC2
74
What is The FIGO staging of endometrial cancer the histology confirms that the tumour invades bladder or bowel?
Stage 4 A
75
What is The FIGO staging of endometrial cancer the histology confirms that the tumour invades inguinale lymph nodes or distanct metastases?
Stage 4 B
76
What percentage of vulval cancer has association with lichen sclerosis?
33%
77
Which lymph node excision has the lowest morbidity in the management of vulval cancer ?
Sentinel node biopsy
78
What are The disadvantages of having a midline incision for ovarian surgery?
🌸Wound dehiscence risk is higher🌸
slow to enter the abdomen
it is not cosmetically best for the patient
79
What is The advantage of having a midline incision for ovarian surgery?
1- least hemorrhagic
2- least nerve damage than lower transverse incision.
80
What are the characteristic of the Mersilene tape for cervical suture ?
1- a braided suture ( not monofilament )
2- high tensile strength 🌸
3- low tissue
reaction
4- non- absorbable suture
81
Which material should the suprapubic catheter be made of to reduce complications?
100% silicone
82
What is the contraindication for suprapubic catheterization following a gynaecological surgery?
🩷 Anticoagulation therapy for blood clotting disorder
and if a pelvic mass is present.
83
What is The approximate incidence of fistula formation in laparoscopic gynaecological surgery complicated by bladder injury ?
5 %
84
What is the ureteric injury rates
at laparoscopic gynaecological surgery ?
from <1% to 2%
85
What is the method should be used for repair The injury in the
upper 1/3rd of the ureter laparoscopic gynaecological surgery ?
Uretero-ureterostomy
86
What is the method that should be used for repair an injury at
the middle third of the ureter happened during laparoscopic gynaecological surgery ?
uretero-ureterostomy as first choice
trans-uretero-ureterostomy (end-to-side anastomosis) - should
not be used as a first-line
87
What is the method that should be used for repair an injury at the lower third of the ureter happened during laparoscopic gynaecological surgery ?
uretero-neocystostomy (re-implantation of the ureter into
the bladder) should be preferred.
88
A 54 year old sustained bladder injury during laparoscopic assisted
vaginal hysterectomy. She had the catheter for 2 weeks. Prior to
removal of the catheter she needs:
Retrograde cystography
If contrast escape is noted then the
catheter should be left in situ and the test repeated in 1 week.
89
How can Most bladder injuries be sutured ?
in one or two layers
using a 2-0 or 3-0 absorbable suture (such as polyglactin)
A running non-locked repair with the sutures placed 0.5 to
1 cm apart and 0.5 to 1 cm lateral to the cystotomy angles
90
A 54 year old sustained bladder injury during laparoscopic assisted vaginal hysterectomy.what is the incidence of fistula formation ?
5%
91
What is the method that should be used for repair an injury at the lower third of the ureter in case of shortened ureter,?
psoas hitch or a Boari
flap
92
If fistula is suspected after labroscopic bladder injury, how to make the diagnosis?
Micturating cystourethogram
93
A 65 year old lady is having debulking surgery for ovarian cancer.
Excision of external iliac nodes was carried out. 2 months later, she presented with paraesthesia over mons pubis and labia.
Which nerve injury did she sustain during the surgery?
Genitofemoral Nerve
94
When performing hysteroscopy with a 30°
hysteroscope in a retroverted uterus. What should be the
position of the cervical os on view for appropriate hydrodilatation?
12 o’clock with the light cable up
95
When performing hysteroscopy with a 30°
hysteroscope in a antroverted uterus. What should be the
position of the cervical os on view for appropriate hydrodilatation?
6 o’clock with the light cable down
96
When performing hysteroscopy with a 0
hysteroscope , What should be the
position of the cervical os on view for appropriate hydrodilatation?
Central
97
A diagnosis of ruptured ectopic pregnancy is made and the decision for laparoscopy +/- salpingectomy is made. After discussion with her mother, she refuses to consent for the procedure
The Court of Protection could be approached as:
Her refusal is not valid as she is influenced by her mother
98
The validity of consent is based on 3 factors what are they ?
capacity, information and free will.
99
What are The ECG changes that may suggest pulmonary embolism ?
S wave in lead 1; Q wave in lead 3, Inverted T wave in lead 3
S1Q3T3
100
She presents with a pelvic mass. She also complains of hirsutism and voice change. Her testosterone level is 9nmol/L.
which type of ovarian tumor she is suspected to have?
Leydig cell tumor
101
In the risk reporting system in gynaecology. The Following incident need not be included in the trigger list:
Blood loss of 400mls during hysterectomy ( on ≥ 500mls)
102
In the risk reporting system in gynaecology. The Following incident need be included in the trigger list:
1-Delayed diagnosis of ectopic pregnancy
2-Pneumothorax during laparoscopy
3- Unplanned admission to ITU
4- Conflict between surgeons regarding management of case
103
Every trust should have a risk management team for a particular
specialty.
The following personnel need not be part of a gynaecology risk team ?
MDT Coordinator
104
Who should be part of a gynaecology risk team ?
A. Consultant Gynaecologist
B. Ultrasonographer
C. Theatre Practitioner
D. Service Manager
E. lead gynaecology nurse
105
When performing an audit on the outcome of Group B streptococcus infection in Obstetric patients.
She should be proceeding in the following sequence:
A. Identify a standard, Collect data to assess performance, Implement the changes if there is any, Collect data to determine whether care has been improved
106
The statistical test to compare two sets of observations on a single sample
would be:
. Wilcoxon matched pairs test
107
A study is designed to compare the age "distribution " in patients
presenting with ectopic pregnancy. The null hypothesis is that there is
no difference in the age groups of women presenting with ectopic
pregnancy.
The appropriate statistical test is:
X2 test
🪙🪙💰
108
A researcher wants to measure the incidence of angular pregnancy.
The following research methodology should be used:
Longitudinal descriptive study
109
A researcher wants to obtain evidence of association of exposure of
pregnant women to passive smoking and the outcome.
The following research method is appropriate:
Randomised controlled study
110
A 34 year old lady presents to with secondary subfertility. She has
been trying to conceive for 6 months and gives history of regular
normal periods. On investigations, her FSH is 16 IU/L, LH is 10IU/L
and AMH is 3ng/ml. Antral follicle count is 3.
What is that best suit her treatment option ?
Donor Egg IVF
111
What is the normal” AFC can range ?
3-30
112
A 32 year old woman with a BMI of 34 and oligomenorrhoea is
diagnosed to have polycystic ovarian syndrome. What are her risk
factors for developing cancer ?
🌼 Endometrial thickness greater than 7 mm may be hyperplasia 🌼
1- There is no increased risk of ovarian or breast cancer
2-In amenorrhoea: gestogens should be used every 3-4 months to induce bleed
3- If endometrium is thickened : endometrial biopsy and preferably hysteroscopy to exclude hyperplasia.( Not progesterone therapy without biopsy) - risk of endometrial cancer
113
What are the risk factors of developing diabetes if the patient has PCO ?
are over 40 years of age
have relatives with diabetes
developed diabetes during a pregnancy (known as gestational diabetes)
are obese (BMI) of over 30).
114
In PCO patients there is greater risk of developing the long-term health problems, what are they ?
1- Insulin resistance and diabetes
2- High blood pressure and heart disease
3-Cancer : (endometrium)
4-Depression and mood swings
5-Snoring and daytime drowsiness
115
A patient with PCO (Her BMI is 30 kg/m2) tried clomiphene for 6 cycles but with no response (anovulatory).
The next treatment option is:
☀️IVF☀️
Or Ovarian Drilling or clomiphene + metformin or gonadotrophins
🛑 Clomiphene is not advised beyond 6 months
116
She has oligomenorrhoea for 6 months,(BMI/. Her tubal patency test / partner’s semen
analysis )are normal , FSH is 2 IU/L, LH is 2 IU/L and Oestradiol is 500 IU/L.
The single best treatment option is:
Gonadotrophin ( hypothalamic (WHO Type 1) anovulation )
Or (pulsatile GnRH)
117
She had a massive obstetric haemorrhage of 5 L during her second delivery. She is trying to conceive for 2 years. She has been amenorrhoic since her last childbirth.
The best option is:
Gonadotrophin
118
A 32 year old nulliparous lady trying to conceive for 3 years. All routine investigations on her and her partner reveal no abnormality.
What should be the next line of management?
IVF
It is offered to women with unexplained infertility who have not conceived after 2 years
119
She had deep dyspareunia and mild dysmenorrhoea and had a laparoscopy where peritoneal endometriosis was ablated 6 months ago. ASA Stage 1 endometriosis was diagnosed.
What should be the next line of management for infertility?
IVF
IUI is not an option.Surgical treatment for mild or moderate endometriosis is preferred but if it
does not help then IVF is the next step
120
A 28 year old woman has irregular, heavy periods. For the last 6 months, she bleeds every 14 days for 7 days. She presented with secondary subfertility.
The endocrine/blood test necessary is:
🌟 FSH 🌟
Prolactin and testosterone are relevant in oligomenorrhoea
121
Her pelvic ultrasound scan suggests a subseptate uterus but is otherwise normal. She is anxious and wants to discuss her tubal patency test. The best option for her is:
Hysterosalpingogram is the first choice
122
woman had methotrexate for left tubal ectopic pregnancy. She says her G.P. has treated her once for suspected PID but the swabs were negative in GUM clinic.
Best Investigation for tubal patency is:
Laparoscopy & Dye test
Since she has a history of possible PID and also ectopic pregnancy,
123
A 25 year old man presenting with gross oligozoospermia in fertility
clinic. His FSH, LH, Testosterone are low. He had delayed puberty.
What is the most appropriate treatment?
Gonadotrophin
He has hypogonadotrophic hypogonadism
124
A 32 year old man had decreased sperm motility and count on 2 occasions and undergone semen analysis abroad. The Anti sperm antibodies are high.
What is the appropriate management?
IVF/ICSI
significance of antisperm antibodies is unclear and the effectiveness of systemic corticosteroids is uncertain.
125
A man had decreased sperm motility and count on 2 occasions ,other hormonal tests are normal,What is the appropriate management?
IVF/ICSI
idiopathic semen abnormalities should not be offered anti-oestrogens, gonadotrophins, androgens, bromocriptine or kinin-enhancing drugs because they have not been shown to be effective
126
Is there a role for antibiotic treatment in Men with leucocytes in their semen ?
should not be offered unless there is an identified infection
127
A woman is undergoing IVF for unexplained subfertility
During treatment cycle, the following treatment is recommended well into late first trimester of pregnancy:
Progesterone
128
Investigations for a couple show anovulation as the only problem. She has WHO Group 1 ovulatory disorders.
Gonadotrophin therapy should include:
HCG
129
The rate of ectopic pregnancy in U.K. is:
11/1000 pregnancies
130
Maternal mortality rate due to ectopic pregnancy in U.K. is:
0.2/1000 estimated ectopic pregnancies
131
Transvaginal ultrasound confirms a missed
miscarriage of 7 weeks gestation. Clinical observations are normal.
The most appropriate immediate management option is:
Expectant management
132
She presents at
4 + 6 weeks gestation in her first pregnancy with mild vaginal bleeding. She does not have abdominal pain.
She should be offered:
🌼Repeat urine pregnancy test in 1 week 🌼
Below 6 weeks if patient does not have any pain, repeat urine pregnancy test in 1 week before considering ultrasound scan
133
A woman presents at 7 weeks gestation with mild vaginal bleeding and abdominal cramps
She declines transvaginal scan. A transabdominal ultrasound scan shows an intrauterine gestation sac
with yolk sac and foetal pole. CRL is 7 mm. No foetal heart activity is seen.
She should be offered:
🩷Repeat ultrasound in 2 weeks
Pregnancy of uncertain viability should have repeat ultrasound scan – if transvaginal: in 1 week, if transabdominal: in 2 weeks
134
vaginal spotting but no abdominal pain. A transvaginal ultrasound scan gives a diagnosis of
Pregnancy of unknown location. 3 Serum HCG levels at 48 hours intervals are: 386, 350, and 302 mIU/ml.
The best option is:
🌼Review by Senior gynaecologist
In PUL with HCG that has plateaued, should be reviewed by Senior Gynaecologist
135
mild vaginal bleeding and abdominal cramps , a transvaginal scan and found to have a miscarriage corresponding to 8 weeks gestation. She prefers medical management.
The best option is:
🌼Misoprostol 800 mcg oral 🌼
Mifepristone is not recommended for early miscarriage. It is recommended for termination of pregnancy
136
A 17-year-old young woman has a transvaginal ultrasound and the diagnosis of a left tubal ectopic pregnancy is made. She does not want surgery and understands risks and agrees to follow up.
She can have methotrexate if:
🌟Mild lower abdominal discomfort; HCG 4500 IU/ml and left adnexal mass 32 mm
137
Methotrexate can only be given for ectopic pregnancy if patient has :
pain that is not significant,
HCG
less than 5000 and adnexal mass less than 35 mm
although the patient should be counselled that the risk of treatment failure is high at HCG levels greater than 3500
138
A 25-year-old woman with a previous left salpingectomy for ectopic pregnancy is undergoing laparoscopy for a right tubal ectopic pregnancy. She prefers salpingotomy. She should be made aware of the possibility of further treatment in the form of methotrexate or laparoscopy.
The risks of needing further treatment is:
1:5
139
How to monitor Bhcg after Salpingectomy and salpingotomy ?
* salpingotomy, take 1 serum hCG measurement at 7 days after surgery, then 1 serum hCG measurement per week until a negative result is obtained.
* salpingectomy ; they should take a urine pregnancy test after 3 weeks
140
When to offer Anti-D immunoglobulin prophylaxis in ectopic pregnancy or miscarriage?
at a dose of 250 IU (50 micrograms) to all rhesus-negative women who have a 👉surgical procedure to manage an ectopic pregnancy or a miscarriage.
141
When NOT to offer Anti-D immunoglobulin prophylaxis in ectopic pregnancy or miscarriage?
medical management for an ectopic pregnancy or miscarriage
or
• have a threatened miscarriage or
• have a complete miscarriage or
• have a pregnancy of unknown location
142
A 33 year old IT professional has a job that involves sitting infront of
a computer monitor for long hours and presents with 3 consecutive 1st
trimester miscarriages. She drinks 10 cups of coffee and smokes 10
cigarettes a day. All her 3 previous conceptions were with her
husband who is a 48 year old IT professional.
The most likely risk factor is:
🌼Her husband’s age🌼
Advanced maternal age of 35 and above and paternal age of 40 and above are risk factors
143
In women with recurrent miscarriage, antiphospholipid antibodies are
present in:
15%
144
A woman presents to the early pregnancy unit with a third
consecutive 1st trimester miscarriage. Along with the products of
conception being sent for histology, a chromosomal analysis is also
being requested. She has already been referred to the recurrent
miscarriage clinic. She wants the investigations to be ordered now, to
avoid delay.
The following investigation is necessary:
✨ Lupus anticoagulant
*Parental karyotyping should be performed only where there is unbalanced structural chromosomal abnormality on testing the products of conception.
*Women with 2nd trimester miscarriage should be tested for hereditary thrombophilias
145
What are the normal parameters of urodynamic results ( bladder capacity - first desire to void - residual volume ) ?
bladder capacity - normal: 450-500ml
first desire to void - normal: 150-200 ml
residual volume < 50ml
146
Mrs. Green’s urodynamic results are as follows. She has initial
residual volume of 90 ml and 1st desire to void at 140 ml. Her
maximum capacity is 380 ml. During filling phase, systolic detrusor
activity is seen which increased with tap water but not with cough in
supine position. She did leak a little urine during repeated coughing in
the erect posture. She had a Keilland forceps delivery 10 years ago
and since then has urinary leakage on standing and straining mostly.
She also wakes up at night a few times to go to the toilet.
What is the likely diagnosis?
Detrusor overactivity
147
80. A 35 year old women presents with a history of frequency, urgency,
nocturia and occasional suprapubic pain. Urodynamic investigations
shows: 1st urge to void at 100 ml. There was no detrusor activity
during filling phase and no leakage on coughing. The maximum
bladder capacity was 400 ml. Bladder filling was painful. Cystoscopy
was normal.
What is the likely diagnosis?
Painful bladder syndrome/ sensory urgency
( characterized by pain during filling phase )
148
Painful bladder syndrome ( interstitial cystitis )vs overactive bladder ?
Urge urinary incontinence is a common feature of OAB, whereas pelvic pain is typically associated with IC.
149
A 40-year-old woman suffers from dysuria, severe frequency,
nocturia and urgency. She also complains of pain or pressure in the
suprapubic area. She has been treated with antibiotics for suspected
UTI in the past by her GP. On 3 occasions, MSU revealed ‘mixed
growth’. She has deep dyspareunia and the pain persists for a few
days after intercourse. Bladder capacity is around 400 ml. Initial
cystoscopy was normal but on repeat filling, some petechial
haemorrhage was seen.
What is the most likely diagnosis?
Painful bladder syndrome/ sensory urgency
Petechial haemorrhages are found in Interstitial cystitis. Sensory urgency is
considered the milder end of the spectrum of Painful bladder syndrome, while
Interstitial cystitis is the extreme end.
150
A woman who had 4 vaginal deliveries out of which 1 was a difficult forceps delivery
She presents for the first time with symptoms of Stress urinary incontinence and on clinical examination incontinence is demonstrated on coughing.
What would be the choice of investigation/ test on her first visit?
🌼Pelvic floor muscle tone clinical assessment
before pelvic floor muscle training
151
A woman does not have symptoms of UTI but tests positive for both
leucocytes & nitrites on urine dipstick at first visit.
What should be the appropriate management?
🌼Send MSU – c/s & prescribe antibiotics only if culture is positive
do not treat if
they are asymptomatic even if leucocytes and nitrites are positive. Instead,
send mid stream urine for culture and sensitivity and treat if positive.
152
Preferred 2nd line investigation for women with symptoms of voiding
difficulty after bladder scan is:
Catheterization post void for residual volume
bladder scan should be used first because of acceptability and less adverse effects.
153
A 35-year-old woman presents to urogynaecology clinic with
predominantly urinary symptoms.
Cystoscopy should be booked if
Persistent bladder pain
154
A 64-year-old woman who has four normal deliveries presents to
clinic with a history of leaking urine on coughing, sneezing. On
examination, she has demonstrable stress incontinence. She does not
give history of any other urinary symptoms.
The following is the next step in management:
🩷Sling surgery
where detailed history and clinical examination
suggests pure stress urinary incontinence, will not need urodynamics prior to surgery.
155
An elderly woman with cognitive disability and limited mobility is
distressed with frequent bedding and clothing changes due to urinary
incontinence contamination.
The preferred management plan would be:
Suprapubic catheterization
156
An 80-year-old hypertensive lady has Overactive bladder symptoms.
The single best option for drug therapy:
⭐Darifenacin⭐
Oxybutinin, Tolteradine ( Detrusitol) and Darifenacin are first line drugs for Overactive
bladder syndrome. However, Oxybutinin is superior but not well tolerated by elderly frail
ladies
157
A 45-year-old woman with OAB diagnosed clinically is put on
oxybutynin tablets but is unable to tolerate the medicines after 4
weeks. The next step would be
Change to transdermal medication
If oxybutynin is effective but not tolerated orally, transdermal oxybutynin is an
option.
158
A provisional diagnosis of interstitial cystitis
is made.
Most definitive feature in bladder biopsy in Insterstitial cystitis ?
Mast cells
159
persistent leakage of flatus and faeces. She had a complex forceps delivery when she and a 3B perineal tear. Pelvic floor exercises have not helped.
The next management option is:
Endo anal ultrasound
160
19-year-old sexually active woman with history of 3 termination of pregnancies. She normally uses Combined oral contraceptive pills but admits to missing pills on occasions. She gives a history of using condoms regularly. She had been to the GUM clinic and had been treated for Chlamydia and Gonorrhoea in the past.
What contraceptive advice should be given?
Depo Medroxy Progesterone Acetate
161
A 18-year-old woman presents with a history of postcoital bleeding
for the last two months. She has been in a relationship for three
months and is taking the combined oral contraceptive.
The most appropriate investigation is:
🩷Endocervical swab
18 year old with postcoital bleeding: Chlamydia needs to be excluded
162
A 23-year-old woman presents with a history of pelvic pain and deep
dyspareunia for the past 5 months. She and her partner received
treatment for Chlamydia six months ago.
The most appropriate investigation is:
🩷Transvaginal ultrasound scan
can reveal
hydrosalpinx, tuboovarian mass and exclude other differentials eg. Ovarian
cysts or endometrioma
163
A 22-year-old woman has presented to A&E giving a history of
sexual assault involving vaginal intercourse.
Which of the following investigation is NOT necessary?
⭐Rectal swab
necessary ;
Vulval swab
/Perineal swab
Swab from the speculum
/ Swab from lubricant
164
Which of the following disease is not sexually transmitted in A 4-year-old child ?
A. Gonorrhoea
B. Syphilis
C. Herpes simplex
D. Chlamydia
E. HIV (Did not have congenital HIV)
🌟Herpes simplex
STI indicative of child sexual abuse are: Gonorrhoea (over 1 year), Syphilis
and HIV (if congenital infection excluded), Chlamydia (over 3 years).
165
A 28 y lady is prescribed microgynon and is being counselled regarding venous
thromboembolism (VTE) risks of the pill.
What is her VTE risk?
10-15:100,000 women/year
166
she is breast-feeding presents to the family planning clinic requesting
contraceptive pills.
Which one of the following is not a contraindication for her?
🌟 Is on Broad spectrum antibiotics (unlike COC pills)
contraindications :
1-Has Active hepatic disease
2-Have Recurrent follicular cyst in ovary
3- Has Undiagnosed vaginal bleeding
4-Is on Carbamazepine for epilepsy
167
A 29 year old with BMI of 32 kg/m2 Para 1 is requesting
sterilization.
The gynaecologist should avoid doing the procedure because:
🩷She is less than 30 years of age
Other causes: who do not have children, who decide during pregnancy, who have
had a recent relationship loss
168
Regarding hysteroscopic sterilization
It should not be done in less than....
The insert is made of...
The mechanism is ...
Hysterosalpingogram is suggested...
It should not be done in less than....30
The insert is made of...metal
The mechanism is ...fibrosis
🌼 Hysterosalpingogram is suggested...3 months post procedure 🛑
169
Regarding emergency contraception.
Levonelle can be given upto...
Ella One can be given upto...
Copper IUCD can be used upto ...
Which one is the most effective. ?
What is The Failure rate ?
Levonelle can be given upto...3 days (72 hours)
Ella One can be given upto...5 days (120 hours)
Copper IUCD can be used upto ...5 days (120 hours)
🌟the most effective is Copper IUCD
🌟The Failure rate : less than 1 %
170
A 47 y lady presents with severe menopausal symptoms mainly vasomotor symptoms and low
mood.she has a history of migraines while on the contraceptive pill.
What is the best choice of HRT for her?
Sequential combined therapy
as LMP not > 12 months
171
Regarding premature ovarian failure :
How to make a Diagnosis ?
Is Anti-mullerian hormone test compulsory for diagnosis ?
Can contraceptive pill or HRT be offered ?
The risk of breast cancer ?
Diagnosis : if elevated FSH levels on 2 blood
samples taken 4-6 weeks apart.
AMH is Not compulsory for diagnosis
🪂 She can be offered contraceptive pill or HRT, unless contraindicated🌼
risk of breast cancer : lower risk of breast cancer , HRT does not appear to increase the risk of breast cancer in younger menopausal women under the age of 50
172
common complications of endometrial ablation for menorrhagia :
🩷Vaginal discharge
increased period pain or cramping and need for additional surgery
173
A 32-year-old lady presented with soreness of vulva and superficial dyspareunia. On examination of the vulva there are erosive lesions and a diagnosis of lichen planus is made.
Which fact is true about lichen planus?
Topical steroids are safe to use in pregnancy and breast-feeding
174
A 27-year-old lady presented to labour ward at 20 weeks in her 1st
pregnancy with lower abdominal pain a trans vaginal ultrasound
showed cervical length of 15mm. She has no history of note.
What is her treatment option?
🩷Prophylactic vaginal progesterone
Prophylactic vaginal progesterone should be given to women with no history
of preterm birth or mid-trimester loss with cervical length of less than 25mm
between 16 and 24 weeks gestation
175
A 33-year-old lady primiparous presents at 34 weeks gestation to
labour ward with a history of gush of fluid per vaginum. This was
confirmed on speculum examination.
Which test best confirms chorioamnionitis?
🌼 White blood cell counts 16+ temperatures 37.7° C
combination of clinical assessment and tests (CRP, WBC and fetal heart rate using CTG to diagnose intrauterine infection
176
A 35 year old lady who has raised BMI of 35 kg/m2 and is
Type 2 diabetic on Gliclizide, ramipril and simvastatin. She wants
to get pregnant and has come to your clinic for pre-pregnancy
counselling.
What to advice her ?
Stop ramipril and simvastatin
Gliclizide is not safe in pregnancy
🩷 Advice her to keep her HBA1c level below 48mmol/l *HbAc1 : < 6.5 %
Advice her to take folic acid 5 mg
177
complains of feeling unwell with pyrexia and rigors. She had an
instrumental delivery three days ago. She had an episiotomy that was
sutured and she is taking regular paracetamol for pain relief but no
other complications.
What should prompt an urgent referral to the hospital?
pyrexia more than 38°C
●
sustained tachycardia more than 90 beats/minute
🌼breathlessness (respiratory rate more than 20 breaths/minute; a serious symptom)🐠
●
abdominal or chest pain
●
diarrhoea and/or vomiting
●
uterine or renal angle pain and tenderness
●
woman is generally unwell or seems unduly anxious or distressed.1
178
She presents with abdominal pain and heavy lochia after a vaginal delivery two days
ago. On examination her temperature was 38.5°C, her pulse was 120
beats per minute and her respiratory rate was 25 breaths per minute.
On palpation she had a tender uterus.
What is the most appropriate immediate management?
Broad spectrum antibiotics
179
If A diagnosis of pueperal sepsis was made , What investigations should be performed?
1- Blood cultures are the key investigation and should be obtained prior to antibiotic
administration; antibiotic treatment should be started without waiting for microbiology results.
2- Serum lactate should be measured within 6 hours : ≥ 4 mmol/l is indicative of tissue hypoperfusion
3- CBC , urea, electrolytes , CRP
180
If A diagnosis of pueperal sepsis was made , Which antibiotics should be used ? When?
* Broad spectrum antibiotics should be administered within 1 hour of suspicion of sepsis
* Broad spectrum antibiotics : either piperacillin/tazobactam or a carbapenem plus clindamycin
🌼 Co-amoxiclav
: Does not cover MRSA, Pseudomonas or ESBL
🩷Clindamycin
Covers most streptococci and staphylococci, including many MRSA,🩷
🌼Metronidazole
: Only covers anaerobes
🌼 Piperacillin/tazobactam and carbapenem : Covers most organisms except MRSA
👉 ESBLs: 👉 meropenem + gentamicin
181
who is 25 weeks pregnant comes in contact with a child who has developed chicken pox. She is
not immune to chicken pox.
regarding VZIG :
effective when given upto ...
They are potentially infectious after exposure if they receive VZIG from ...
If they don't receive vZIG from ...
A second dose of VZIG ...
if the patient has developed chicken pox ..
*effective when given upto : up to 10 days after contact (in the case of continuous exposures, this is defined as 10 days from the appearance of the rash in the index case)
🌟They are potentially infectious after exposure if they receive VZIG from ...8–28 days
If they don't receive vZIG from ...8–21 days
A second dose of VZIG ... if a further exposure is reported after 3 weeks of the last dose
if the patient has developed chicken pox ...VZIG has no therapeutic benefit
182
. A 32-year-old lady presents to antenatal clinic at 22 weeks gestation with genital Herpes. She has never had herpes in the past , about counseling her :
* Is CS indicated for delivery ..?
* is Aciclovir licensed to be used in pregnancy ?
*should Patient be referred to fetal medicine
?
* Daily suppressive aciclovir ..
* should Treatment be delayed till diagnosis is confirmed ?
* is CS indicated for delivery ..No vaginal delivery
anticipated if delivery does not ensue within the next 6 weeks ( CS indicated if first episode genital herpes in the third trimester )
* is Aciclovir licensed to be used in pregnancy ? No
* should Patient be referred to fetal medicine
? No referred for review by an obstetrician
🩷Daily suppressive aciclovir ..400 mg three times daily should be considered
from 36 weeks of gestation 🩷
* should Treatment be delayed till diagnosis is confirmed ? should not be delayed
( 400 mg three times daily, usually for 5 days).
183
A 34-year-old lady has had recurrent attacks of herpes this year. She is 20weeks pregnant
, about her further management :
* Risk of Neonatal herpes ..
* risk of preterm labour, preterm rupture of membranes ...
* Risk of Neonatal herpes ..Low
* risk of preterm labour, preterm rupture of membranes : No increased risk
184
she has positive treponomal serology. She is then admitted to the antenatal ward for treatment
What is the rate of Jarisch-Herxheimer reaction ?
40%
Complicate 45% of syphilis treatment in pregnancy by penicillin
185
Relative contraindications where ECV (external cephalic version ) might be more complicated:
Small-for-gestational-age fetus with abnormal
Doppler parameters
Proteinuric pre-eclampsia
Oligohydramnios
Major fetal anomalies
🌟Scarred uterus (previous Caesarean section)
Unstable lie
186
Absolute contraindications for ECV ( External cephalic version ) ;
1- where an absolute reason for caesarean section already exists
( Ante–partum haemorrhage { (less than 1 week) } - Placenta praevia )
2- Multiple pregnancy
(except after delivery of a
first twin)
3- Ruptured membranes
4- there is rhesus isoimmunisation
5- abnormal electronic fetal monitoring (EFM)
187
A woman with insulin dependent diabetes mellitus
presents to the antenatal clinic at 7 weeks. She wants to know about the risks to her baby.
Which of the following is not associated with diabetes?
A. Caudal regression syndrome
B. cystic hygroma
C. holoprosencephaly
D. ventricular septal defect
E. Transposition of great vessels
cystic hygroma
188
Which are the fetal anomalies associated with diabetes?
Caudal regression syndrome
holoprosencephaly
ventricular septal defect
Transposition of great vessels
189
A 30-year old multigravida with a clinically big baby has delivered the head of the baby but there is difficulty in delivering the shoulders. Which is the appropriate manoeuvre in these clinical
emergencies ?
Woodscrew manoeuvre
190
A 45-year lady attends the colposcopy clinic with a high-grade
dyskaryosis on smear. She is para 5 and comes to the clinic with her
12-year-old daughter. She does not speak any English but her daughter
does speak good English but is scared to stay for the procedure.
What is the most appropriate thing to do?
Reschedule the appointment and book a professional interpreter
191
A 45-year lady attends the colposcopy clinic with a high-grade
dyskaryosis on smear. She is para 5 and comes to the clinic with her
12-year-old daughter. She does not speak any English but her daughter
does speak good English but is scared to stay for the procedure.
What is the most appropriate thing to do?
Reschedule the appointment and book a professional interpreter
192
A 25-year-old lady comes to your antenatal clinic with her husband.
She is 20weeks pregnant in her second pregnancy. She had a 4.6kg
baby delivered by forceps in Pakistan 5 years ago. She described to
midwife who can understand her language that the baby's shoulder got
stuck at time of delivery. She does not speak any English and her
partner speaks limited English. She is keen to have a vaginal delivery
What is the most appropriate thing to do?
Reschedule the appointment and book a professional
interpreter
193
A 23-year-old nulliparous lady presented with chronic pelvic pain, an
ultrasound scan showed a 4cm endometrioma on her right ovary.
What is the best management option?
Ovarian cystectom
194
Regarding physiological changes in pregnancy in thyroid function
What are the changes in
the level of thyroxine-binding globulin
glomerular filtration
free thyroid hormones
* increase level of thyroid -binding globulin
in response to oestrogen stimulation &
Reduced clearance of thyroxine-binding globulin ✨
* increased glomerular filtration rate
* increasing
clearance of free thyroid hormones.
195
A 34 year old lady in her first pregnancy has hypothyroidism and is
on Levothyroxine 125ugm/day and is seen in the combined endocrine
clinic at 13 weeks gestation.
In what increment should thyroxine be adjusted?
25 µg
196
What is the radiation risk to the fetus by a computed tomography?
< 0.005 mGy
197
. A 32-year-old lady at 36 weeks gestation presents with headache of
acute onset not relieved with paracetamol. What is the imaging modality of choice to exclude cerebral venous
thrombosis ?
MRV
198
What is the incidence of dural puncture after epidurals?
0.5-2.5%
199
What is the incidence of post dural puncture headache if there is accidental dural puncture?
70-80%
200
What is the incidence of post dural puncture headache if there is accidental dural puncture?
70-80%
201
A 30-year-old lady in her second pregnancy has anterior placenta
praevia. She has had a previous caesarean section. Ultrasound reveals placenta accreta.
At what gestation should the delivery be planned?
36-37 week’s gestation
202
A 25-year-old lady in her first pregnancy has vasa praevia at her 20 week scan which was confirmed by transvaginal scan.
What would be her further management?
Rescan in third trimester
15% of cases the vasa praevia can resolve
203
A 25-year-old lady in her first pregnancy has vasa praevia at her 20
week scan which was confirmed by transvaginal scan.
What is the incidence of the vasa praevia resolving?
15%
204
A 25-year-old lady in her first pregnancy has vasa praevia at her 32 week scan which was confirmed by transvaginal scan. She has not had any vaginal bleeding.
At what gestation should she be delivered?
35-37 weeks
205
A 32-year-old lady in her second pregnancy is seen in the antenatal
clinic at 16 weeks pregnancy. Her booking bloods show presence of
anti K antibodies.
What will be the next step in management?
Refer to fetal medicine
Anti -K antibodies referral should take place once detected, as severe anaemia
can occur even with low titre
206
A 32-year-old lady in her second pregnancy is seen in the antenatal
clinic at 16 weeks pregnancy. Her booking bloods show presence of
anti c antibodies. The antibody level titre is 8iu/ml
What will be the next step in management?
Refer to fetal medicine
Referral to fetal medicine should be made once anti-c levels are>7.5iu/ml as
this correlates with a moderate risk of HDFN.
207
A diagnostic test is applied to 1800 women to assess susceptibility to
obstetric cholestasis. The prevalence of Obstetric Cholestasis (OC) is
1%.
OC Present
OC Absent
Test Positive
70
345
Test Negative
40
1345
The false positive rate is:
21%
FP/(FP+TN) = 345/(345+1345)
208
Test Positive
70 OC Present
345 OC Absent
Test Negative
40 OC Present
1345
. OC Absent
The false negative rate is:
37 %
FN/(TP+ FN) = 40/(70+40)
209
A 43 year old had colposcopy and cervical biopsy for CIN2 on
cytology. The biopsy was mislabeled with another patient’s name. The
biopsy showed microinvasive cancer.
What would be the next step of management?
Complete risk management form and initiate investigation
210
A 34 year old lady presents to her GP at 23 weeks gestation in her
first pregnancy with chicken pox rash, which developed this morning.
She is pyrexial but otherwise feels well.
What will be the next step in her management?
Oral Aciclovir ( 800 mg five times a day for 7 days )
Oral aciclovir should be prescribed for pregnant women with chicken pox if they present within 24 hours of onset of the rash and if they are 20 weeks of gestation or beyond. IV aciclovir should be given to all pregnant women with severe chicken pox.
211
A 23 year old lady at 22weeks gestation is referred by her GP with flu
like symptoms and temperature of 39°C with chills and rigors. She has
recently returned from Nigeria after visiting her family.
Which one of the following will rule out a diagnosis of Malaria?
Three negative blood film 12-24 hours apart
(rapid antigen test is Not sensitive)
212
A 34 year old lady with monochorionic diamniotic twin pregnancy
presents to Day Assessment Unit with reduced fetal movements.
Ultrasound scan showed fetal demise of one twin.
What is the incidence of intrauterine death of the second twin?
12%
213
A 34 year old lady with monochorionic diamniotic twin pregnancy
presents to Day Assessment Unit with reduced fetal movements.
Ultrasound scan showed fetal demise of one twin.
What is the incidence of neurological abnormality in the second twin?
18%
214
A 26 year old lady presents to labour ward with abdominal pain
mainly on the right side and nausea at 20 weeks gestation. On
examination she is tender on the right side of her abdomen. She has a
white cell count of 14x 10 9
/L. Her ultrasound scan is inconclusive.
What would be the next step in her management?
MRI
215
A 40 year old lady is having a caesarean section for placenta praevia.
You are consenting her in the antenatal clinic.
What is her risk of having a hysterectomy?
11in 100
216
A 41 year old lady 36 weeks gestation presents to labour ward with
chest pain. An ECG is performed.Which ECG changes in not a normal variation in
pregnancy?
ST elevation
Most sensitive and specific marker is ST elevation, which normally appears
within a few minutes of onset of symptoms.
217
A 26 year lady delivered 10 days ago is behaving abnormally since
yesterday. She is having hallucinations and is concerned about the
baby. She has a supportive family and they report that her behaviour
has changed suddenly.
What should the community midwives action be?
Urgent referral to mother and baby unit
Postpartum psychosis is a psychiatric emergency;
218
A 34 year old lady in her first pregnancy has had recurrent attacks of
herpes this year. She is 20 weeks pregnant and you see her in antenatal
clinic.
What would be the further management?
Daily suppressive therapy aciclovir 400 mg TDS from 36 weeks
219
A 36 year old lady presents to labour ward at 24 weeks gestation with
abdominal pain. A HVS and MSU has shown group B streptococcus.
What is her further management?
Oral antibiotics now and IV antibiotics in labour
220
A 25 year old lady has β thalassemia and is seen in the pre –
pregnancy clinic.
Which of the following advice :
Safety of Deferiprone ...
Safety of Desferrioxamine ...
chelation agent in first trimester pregnancy ..
marker of glycaemic control ...
Safety of Deferiprone ... should be discontinued 3 months before conception
Safety of Desferrioxamine ...should be avoided in the first trimester
chelation agent in first trimester pregnancy .. unsafe
🩷🩷marker of glycaemic control ...Serum fructosamine
221
A 34 year old lady in her second pregnancy is seen in the Antenatal
clinic at 18 weeks gestation with a cervical length of 21 mm. She has
history of preterm pre labour rupture of membranes in her last
pregnancy.
What is her best management option?
Prophylactic cervical cerclage
Consider prophylactic cervical cerclage for women in whom TVS reveal
cervical length of less than25mm and who have either had history of preterm
prelabour rupture of membranes
222
Which of these vaccinations is contraindicated in pregnancy?
A. Inactivated influenza vaccine
B. Pertussis (whooping cough) vaccine
C. Inactivated polio vaccine
D. Diphtheria toxoid
E. Mumps
Mumps
223
Which of these vaccinations is contraindicated in pregnancy?
A. Inactivated influenza vaccine
B. Pertussis (whooping cough) vaccine
C. Inactivated polio vaccine
D. Diphtheria toxoid
E. Mumps
Mumps
224
Name vaccinations which are contraindicated in pregnancy?
BCG
MMR (measles-mumps-rubella)
Oral cholera
Rotavirus
Varicella
Zoster (Zostavax)
225
A 36 year old lady with β thalassemia with a history of splenectomy is
seen in the Antenatal Clinic at 12 weeks gestation. Her platelet count is
400x 10 9
/l.
What about her thromboprophylaxis?
She had undergone spleenectomy 👉 Aspirin 75 mg /d
Spleenectomy+ plt count > 600,000 👉 Aspirin 75 mg + LMWH
Plt count> 600,000 without spleenectomy 👉 only Aspirin 75 mg
226
A 30 year old woman is seen on the postnatal ward very confused and
hallucinating of seeing a monster trying to take her baby away. She is
unable to sleep and goes through stages where she feels low and at
other times when she feels agitated.
What is the most common mental health problem in pregnancy?
psychosis
227
What is the incidence of psychosis in pregnancy ?
1 / 1000 in post partum period
228
A 33 year old woman is seen in the antenatal clinic at 10 weeks
gestation. This is her second pregnancy and had an uncomplicated
labour and delivery for her first baby. She is on Lithium for a severe
mental health problem and wishes to have home birth. She is in clinic
to discuss her medication.
She should be informed that
🌟The lithium should be stopped gradually
Over 4 weeks; risk of fetal cardiac anomalies may not be reduced when it is stopped.
If this is the only medication working consider stopping and restarting in second trimester.
229
A 26 year old woman in her first pregnancy was diagnosed with
gestational diabetes at 29 weeks. She is now 36 weeks and has come to
discuss mode and timing of delivery.
This is correct about her delivery:
🌟Offer induction of labour at 40+4 weeks if she is diet controlled and
the BMs are well controlled
* Offer induction or CS at (37_39 )weeks to women with type 1&type 2
230
A 26 year old woman in her first pregnancy was diagnosed with
gestational diabetes at 29 weeks. She is now 4 weeks postpartum and
wants to discuss further monitoring.
🍄 Yearly fasting blood glucose
fasting plasma glucose 6 to13 weeks postnatal and yearly plasma glucose if the fasting plasma glucose is normal
231
A 34 year old woman G3P2 wishes to discuss testing for gestational
diabetes.
She should be offered screening if she
Had gestational diabetes in her first pregnancy but not in the second
pregnancy ( even )
232
Risk factors for screening gestational diabetes
1- BMI {above} 30 kg/m2
2- previous macrosomic baby weighing {4.5 } kg or more
3- previous gestational diabetes
4- family history of diabetes ({first-degree} relative with diabetes)
233
A 27 year old Type 1 diabetic is seen in the diabetic antenatal clinic at
35 weeks gestation. Her insulin requirement has increased recently in
the pregnancy. This is her second pregnancy and her first delivery was
by caesarean section for fetal distress.
How to monitor her glucose in labour
🫔 Sliding scale with IV dextrose and insulin if the BM <4mmol/L in labour( or > 7)
* Capillary glucose is monitored every { hour} ensuring it is maintained between 4 and 7mmol/l
234
A 22 year old G1P0 presents to the maternity triage with no fetal
movements for 12 hours. An ultrasound confirms an intrauterine fetal
death at 29 weeks gestation.
Her risk of having disseminated intravascular coagulopathy within 4
weeks is:
10%
235
A 22 year old G1P0 presents to the maternity triage with no fetal
movements for 12 hours. An ultrasound confirms an intrauterine fetal
death (IUFD) at 29 weeks gestation.
Which infections should she not be screened for, as they are not associated
with IUFD?
Mumps
236
Which infections should she be screened for, as they are associated
with IUFD?
Cytomegalovirus
Parvo virus
Listeria
Toxoplasmosis
rubella
herpes simplex
Treponema
237
A 19 year old lady who had a stillbirth at 38 weeks has come to see
you 2 weeks after delivery. She has agreed to have a post-mortem
What percentage of stillbirths has congenital anomalies?
6%
less than 10% and more that 2%
238
A 40 year old G1P0 is unfortunately diagnosed as having an intrauterine fetal death at 40 weeks and 1 day. Cervical examination shows a bishop score of 2. She is very worried about the side effects of the method of induction of labour.
What is the most cost effective method of induction?
Misoprostol
239
A 33 year old woman with previous uncomplicated caesarean section
is having induction of labour at 37 weeks for obstetric cholestasis. She
has an epidural and has been complaining of constant pain along the
scar for the last hour.
The following may be signs of a scar rupture:
🌤️Fetal head sliding up
Haematuria rather than Anuria is a likely sign.
240
A woman brings her baby to the hospital a few days after delivery for
hearing assessment. The test shows that the baby has sensory neural
hearing loss. She also has microcephaly, hepatosplenomegaly and a
rash on the trunk. Blood test showed low platelets. Further test shows
that baby has a Patent Ductus Arteriosus. On questioning she
mentioned that she had a bad flu earlier in the pregnancy.
The most like cause of the congenital illness is:
Rubella
Congenital heart defects especially Patent Ductus Arteriosus (PDA) is a feature of congenital rubella
241
A pregnant woman suffering from migraine is seen in the antenatal
clinic at 15 weeks gestation , discuss:
* The effect of pregnancy on migraine...
* Risk of pre eclampsia ..
* The risk of having a stroke ..
* The risk of myocardial infarction ...
* Initial first line treatment is ...
*The effect of pregnancy on migraine...🩷 Pregnancy can lead to a reduction in frequency and severity of attacks
* Risk of pre eclampsia ..more than 2 times and not 5 times
* The risk of having a stroke ..the risk of stroke is higher than the risk of myocardial infarction
* Initial first line treatment is ...rest, hydration, simple analgesia, antiemetics and avoiding precipitating factors
242
A 27 year old woman with a prolonged labour has now reached full
dilatation and been pushing for the last 2 hours , in comparison between instrumental
delivery and /or caesarean section at second stage :
* There is increased risk of hemorrhoids with ...
* difficulties conceiving ...
* the role of Consultant presence ...
* incidence of Constipation during a year following delivery ...
* the risk of maternal morbidity for
CS after an unsuccessful forceps delivery compared to
an unsuccessful ventouse delivery.
* There is increased risk of hemorrhoids with ...the same
* difficulties conceiving ...CS
* the role of Consultant presence ...reduce CS rates at second stage
* incidence of Constipation during a year following delivery ...operative delivery
* the risk of maternal morbidity for
CS after an unsuccessful forceps delivery compared to
an unsuccessful ventouse delivery.
... no difference ( an attempt at operative vaginal delivery prior to CS does not result in increased rates of immediate maternal morbidity
compared to CS without attempt at operative vaginal delivery)
243
discussing management of Post Partum Haemorrhage (PPH),
* Oxytocics reduces risk of PPH by ...
* A drug licensed in the UK for PPH prophylaxis ...
* Intravenous access must be obtained with a ... gauge cannula
* Oxytocics reduces risk of PPH by ...60 % 🌟🌟
* licensed in the UK for PPH prophylaxis ...Carbetocin
* Intravenous access must be obtained with a 14 or 16 gauge cannula
244
She is 28 w pregnant , HIV
positive on combined antiretroviral therapy. Her CD4 count is 450cells
/μl and viral load <50copies /ml.
What is the estimated Mother to Child Transmission (MTCT) in such a woman in UK?
0.57%
With women on cART and very low (undetectable viral load) the Mother to child transmission rate is about 0.57%
245
A 30 year old woman HIV positive mother of one presents as a late
booker to the antenatal clinic. She is 28 weeks pregnant, well and is
not on any medications for her HIV. Her viral load is < 50copies /ml
and CD4 count 450cells /μl
The following statement is correct about her management:
🩷She can be started on zidovudine monotherapy
undetectable VL (on two different assays) known as Elite controllers: Pregnant women in this group should be treated with cART or monotherapy with zidovudine
( no evidence that cART is superior to zidovudine alone in reducing vaginal shedding )
246
A 24 year old woman who delivered about 8 hours ago is complaining
of feeling unwell. Her labour was uncomplicated and this was her first
delivery. Her temperature is 39°C, pulse is 120bpm and blood pressure
is 90/50mmHg. She has developed a rash on inner part of her left thigh
and there is a high suspicion of sepsis.
Which organism is the most likely cause of the sepsis?
Streptococcus pyogenes
(Group A beta haemolytic streptococci - GAS )
247
She sustained a third degree tear (3c), which was repaired appropriately in theatre.
And want to discuss:
* The recurrence rate in subsequent delivery is ...
* The incidence of anal sphincter injury after vaginal delivery is
* The recurrence rate in subsequent delivery is ...5-7%
* The incidence of anal sphincter injury after vaginal delivery is ..3% 🌟
248
To discuss vaginal birth after caesarean section :
* Risk of placenta previa after 1 previous CS ..
* Risk of placenta previa after 2 previous CS ..
* risk of scar dehiscence after 1 previous CS ..
* risk of scar dehiscence after 2 previous CS ..
* risk of birth related perinatal death in women having a trial of vaginal birth after CS ..
* Risk of placenta previa after 1 previous CS ..1%
* Risk of placenta previa after 2 previous CS ..1.7%
* risk of scar dehiscence after 1 previous CS ..0.5%
* risk of scar dehiscence after 2 previous CS .. 1.4%
* risk of birth related perinatal death in women having a trial of vaginal birth after CS ..same as a woman having her first vaginal delivery
249
27 year old woman G1P0 with an uncomplicated pregnancy wishes
to discuss the pros and cons of having a home birth.
She should be informed that there is no significant difference in:
Neonatal outcome
250
A 40 year old woman with a prolonged second stage of labour is having a trial of instrumental delivery. Comparing between vacuum extraction, forceps delivery :
* association with cephalheamatoma
* association with maternal trauma
* association with the need for phototherapy
* association with the use of multiple instruments
* More likely to fail
* association with cephalheamatoma : vacuum
* association with maternal trauma : forceps
* association with the need for phototherapy : vacuum
* association with the use of multiple instruments : forceps 🩷🩷
* More likely to fail : vacuum
251
A 32 year old lady has dichorionic diamniotic twin pregnancy Her growth scans has been normal. She is planning to fly to her mother’s house for delivery.
Up to what gestation can she safely fly?
32 weeks
Air travel is allowed till 36 weeks in an uncomplicated singleton pregnancy
252
A 34 year old primiparous woman is seen in antenatal clinic at 30
weeks. She asks whether she can fly to India in pregnancy.
What are the contraindications for flight travel?
She suffers from severe asthma🌟🌟
severe anemia <7.5g/dl
recent sickling crisis,
serious cardiac and respiratory disease
recent gastrointestinal surgery
a fracture
253
A 42 year old primigravida is in spontaneous labour at term. She is
progressing well with 3:10 regular contractions and is 7 cm dilated.
She ruptured her membranes spontaneously 6 hours ago and the liquor
is clear. The CTG is pathological. A fetal blood sampling is performed
and the fetal lactate is 4.3mmol/l.
What should be the next step of management?
Repeat FBS in 20 - 30 mins 🌼🌼
Lactate levels <4.2 is normal
4.2 – 4.8, repeat FBS should be done in 20 – 30 mins
>4.8 – delivery should be considered.
254
A 42 year old primigravida is being seen in antenatal clinic at 38
weeks. She has come to discuss timing of delivery. She is being
advised to have induction of labour at 40 weeks due to increased risk
of stillbirth.
What is the risk of stillbirth at her age?
2 in 1000 at 39 – 40 weeks
compared to 1 in 1000 for women <35 years of age
255
What are the risks associated with maternal hypovitaminosis D:
🌠 Primary Caesarean Section
2- preeclampsia, hypertension
3- low birthweight of the baby
4- bacterial vaginosis in the mother
5- fetal wheeze and asthma
6- neonatal hypocalcemia.
256
A 32 year old primiparous lady has been induced for postdates. She
has progressed to full dilatation with syntocinon infusion. She has been
pushing for an hour and is contracting 4: 10. The CTG is pathological
and delivery should be expedited. On examination, the vertex is at
spines and is in left occipito transverse postion. There is 1+ caput with
no moulding. Decision is made to use a posterior cup for delivery.
What is the flexion point at which the cup should be applied?
On the sagittal suture 3cm in front of the posterior fontanelle
257
Which of the following is a characteristic of Remifentanil PCA( Patient controlled Analgesia) during labour?
* How many will require Entonox in addition ..
* It acts within .... mins of giving the drug
* Continuous fetal monitoring requirement
* risk of failure
* Maternal monitoring
🩷* How many will require Entonox in addition ..1 in 8 women
* It acts within 5 mins of giving the drug
* Continuous fetal monitoring requirement : not required
* risk of failure 1 in 10
* Maternal monitoring Oxygen saturation monitoring is required but BP monitoring is not needed.
258
A 32 year old woman, who is 33 weeks pregnant in her second
pregnancy, is worried about group B streptococcus infection of her
newborn. She is in the antenatal clinic and wants GBS screening.
Intrapartum antibiotics prophylaxis should be offered to women if:
GBS is detected on vaginal swab taken for whitish vaginal discharge
at 12 weeks of pregnancy
259
5. A 28 year old woman with monochorionic diamniotic twins is seen in
Foetal Medicine Clinic. She is suspected to have Twin to Twin
Transfusion syndrome.
On ultrasound, the following criteria is not necessary for diagnosis:
Hydrops of one twin
260
A 32 year old woman has generalised pruritus but no rash. She had
obstetrics cholestasis in her previous pregnancy. Routine blood tests
are being done 2 weekly to diagnose/ assess obstetrics cholestasis.
The following blood test is not generally helpful in diagnosis of obstetric
cholestasis:
Alkaline phosphatase
261
A 28 year old woman is 28 weeks pregnant in her second pregnancy.
She had an elective caesarean section for breech presentation in her
previous pregnancy. Her 20 weeks foetal anomaly scan suggested a
low-lying placenta covering the internal cervical os. She is being
counselled in the antenatal clinic.
The following management plan should be instituted:
Transvaginal scan at 32 weeks
262
A 34 year old woman just had an uncomplicated vaginal delivery.
This is her 4th vaginal delivery. Her serum haemoglobin is 8.8g/dl.
The prophylactic oxytocic of choice is:
🌼Syntometrine ( unless hypertensive )
( Oxytocin is the first line prophylaxis for low risk delivery )
( Carbetocin is not yet recommended. )
263
A 28 year old woman presents at 32 weeks gestation with threatened
preterm labour. She is being given corticosteroids for foetal lung
maturity. Tocolysis is therefore being considered.
The most effective tocolytic (may or may not be licenced in U.K.) is
Nifedipine (calcium channel blocker)
264
A 37 year old woman has presented at 10 weeks gestation. She has a
child with Trisomy 21. She wants to discuss screening tests as well as
definitive investigations to exclude Chromosomal abnormalities.
about Amniocentesis and CVS:
* CVS should be performed
* Early amniocentesis (before 14 weeks) is associated with ..
* risk of emergency delivery with Amniocentesis in the 3rd trimester ..
* Amniocentesis in Hepatitis B or C carriers
* CVS should be performed after 10 weeks
* Early amniocentesis (before 14 weeks) is associated with .. talipes, miscarriage and
respiratory problems
* risk of emergency delivery with Amniocentesis in the 3rd trimester ..No increased risk
* Amniocentesis in Hepatitis B or C carriers can be done
265
about antenatal corticosteroid administration to
prevent respiratory distress syndrome in newborn:
Is given upto ..
In twins at increased risk of preterm delivery, given upto 34+6 weeks
gestation ( & singleton)
266
A 25 year old woman in her first pregnancy presents at 32 weeks
gestation with a second episode of reduced foetal movement. On
clinical examination she has a small for gestational age foetus.
The following tests cannot be done to assess:
Formal foetal count (Kick chart)
No evidence
267
A 30 year old woman in her second pregnancy is seen in the antenatal
clinic at 15weeks gestation. Red cell antibodies have been detected in
the booking blood. Her combined serum test for chromosomal
anomalies has come back high risk.
In her management :
* is Amniocentesis contraindicated ?
* . Refer to Foetal Medicine unit if Anti D titres ..
* Refer to Foetal Medicine unit if Anti c titres ..
* Refer to Foetal Medicine unit if Anti K titres ..
* Refer to Foetal Medicine unit if Anti E and Anti c antibodies ..
* is Amniocentesis contraindicated ? No
* . Refer to Foetal Medicine unit if Anti D titres ..> 4 IU/ml
* Refer to Foetal Medicine unit if Anti c titres ..> 7.5 IU/ml
* Refer to Foetal Medicine unit if Anti K titres ..presence of
any
* Refer to Foetal Medicine unit if Anti E and Anti c antibodies .. when detected
268
A 30 year old Rh (D) negative woman is having an emergency
caesarean section for major placenta praevia and heavy antepartum
haemorrhage at 30 weeks gestation. She has had her routine antibody
testing at 28 weeks, when no antibody was detected and had her
prophylactic Anti D Immunoglobulin. Cell salvage and reinfusion of
her blood is done since she is Jehova’s witness.
In her treatment, she should have:
1500 IU of Anti D Immunoglobulin if cord blood group is D positive
( 30-45 minutes after reinfusion, Kleihauer should be done to see if additional Anti D is needed)
269
A 28 year old woman presents to labour ward 12 hours after a normal
uncomplicated vaginal delivery, hypotensive, pyrexial and tachypnoic.
Her lactate is 6 mmol/l. She develops severe pain in her lower limbs.
Deep vein thrombosis is suspected but Doppler ultrasound is negative.
In her management, the following should be avoided:
Analgesics including NSAIDs
( since NSAID s impede the ability of the polymorphs to fight Group A streptococcus infection )
( Suspected to have necrotising fasciitis caused by GAS )
270
In the Confidential Enquiry of Maternal Death and Morbidities, 2015,
which was the leading indirect cause of maternal death?
Cardiac Disease
271
A 34 year old P2 lady unfortunately sustained a spinal cord injury
above T4 level. She has given birth to her 2nd child and is planning to
breast feed the baby Breast-feeding is affected in the following manner:
🩷 Delayed ( above T4 )
- need support in the form of visual stimulation or oxytocin nasal spray
Long-term breastfeeding is maintained. Autonomic dysreflexia is rare in breastfeeding
272
She ruptured her membranes 2 hours ago and the liquor is
clear. She is now 5cm dilated and is contracting 4:10. The CTG has a
baseline of 155bpm, variability is 5 – 10 bpm and late decelerations
with >50% contractions for 30 mins. FBS was attempted twice (by
resident consultant) and this failed. There was acceleration on fetal
scalp stimulation.
What should be the next step of management?
Continue labour 🌼
there is acceleration on fetal scalp stimulation, it is likely that the baby is not decompensating.
273
A ST3 trainee is being supervised for third degree tear repair of a 26
year old primiparous who sustained a 3rd degree tear during forceps
delivery which was also performed by the trainee. The ST3 trainee has
done 2 other repairs before this.
Which of the following work placed based assessment tools should be
used?
Formative OSAT should be used for supervised learning event.
274
The on call registrar
assessed her and the findings were: Cervix – full dilatation; vertex at -
1; direct occiputo-posterior postion, caput 2+ and moulding 1+. She
was recommended a trial of instrumental +/- emergency caesarean
section and was transferred to theatre.
The following statement is true about the impact of a caesarean section
* The risk of laceration to bladder, bowel and uterine extension is ..
* Caesarean section at full dilatation has more than ... times risk of intraoperative trauma compared to CS at first stage of labour
* Risk of Maternal haemorrhage of >1000mls is ..
* risk Clavicle fracture and brachial plexus injury ..
* Maternal sepsis and wound infection risk ..
* The risk of laceration to bladder, bowel and uterine extension is 10 - 27 % 🎁
* Caesarean section at full dilatation has more than .double.. times risk of intraoperative trauma compared to CS at first stage of labour
* Risk of Maternal haemorrhage of >1000mls is 5- 10 %
* risk Clavicle fracture and brachial plexus injury lower than operative delivery
* Maternal sepsis and wound infection risk : low rate
