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Question 1
Correct
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A 29-year-old primigravida is currently in labor for ten hours and has progressed through the first stage without any complications. However, the midwife has observed CTG abnormalities and palpated the umbilical cord. The obstetric registrar is called and upon checking the CTG, variable decelerations are noted. What is the primary course of action for addressing the cause of these decelerations?
Your Answer: Place hand into vagina to elevate presenting part
Explanation:The situation involves cord prolapse leading to cord compression and variable decelerations on the CTG. The RCOG has issued guidelines (Green-top Guidelines No.50) for managing cord prolapse. The guidelines recommend elevating the presenting part either manually or by filling the urinary bladder to prevent cord compression. If fetal heart rate anomalies persist despite using mechanical methods to prevent compression, tocolysis (such as terbutaline) can be considered while preparing for a caesarean section.
Understanding Umbilical Cord Prolapse
Umbilical cord prolapse is a rare but serious complication that can occur during delivery. It happens when the umbilical cord descends ahead of the presenting part of the fetus, which can lead to compression or spasm of the cord. This can cause fetal hypoxia and potentially irreversible damage or death. Certain factors increase the risk of cord prolapse, such as prematurity, multiparity, polyhydramnios, twin pregnancy, cephalopelvic disproportion, and abnormal presentations like breech or transverse lie.
Around half of all cord prolapses occur when the membranes are artificially ruptured. Diagnosis is usually made when the fetal heart rate becomes abnormal and the cord is palpable vaginally or visible beyond the introitus. Cord prolapse is an obstetric emergency that requires immediate management. The presenting part of the fetus may be pushed back into the uterus to avoid compression, and the cord should be kept warm and moist to prevent vasospasm. The patient may be asked to go on all fours or assume the left lateral position until preparations for an immediate caesarian section have been carried out. Tocolytics may be used to reduce uterine contractions, and retrofilling the bladder with saline can help elevate the presenting part. Although caesarian section is the usual first-line method of delivery, an instrumental vaginal delivery may be possible if the cervix is fully dilated and the head is low.
In conclusion, umbilical cord prolapse is a rare but serious complication that requires prompt recognition and management. Understanding the risk factors and appropriate interventions can help reduce the incidence of fetal mortality associated with this condition.
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This question is part of the following fields:
- Obstetrics
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Question 2
Correct
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A 32-year-old woman visits her physician with concerns about her pregnancy. She is currently 12 weeks pregnant and has been taking folic acid for four months prior to conception. She is curious if she needs to take iron supplements like her friends did during their pregnancies. The doctor orders blood tests to determine if this is necessary.
Hemoglobin: 112g/L (normal range: 115 - 160)
Platelets: 326 * 10^9/L (normal range: 150 - 400)
White blood cells: 4.2 * 10^9/L (normal range: 4.0 - 11.0)
What is the appropriate cut-off for hemoglobin levels to decide when to start treatment for this patient?Your Answer: Haemoglobin less than 110 g/L
Explanation:A cut-off of 110 g/L should be used in the first trimester to determine if iron supplementation is necessary. This is because pregnancy causes a high-volume, low-pressure state which can dilute the blood and lower haemoglobin levels. Therefore, a lower cut-off is used compared to the canonical 115 g/L. In women after delivery, the cut-off is haemoglobin lower than 100 g/L, while in women during the second and third trimesters, it is haemoglobin lower than 105 g/L. Haemoglobin lower than 115 g/L is the cut-off for non-pregnant women, while haemoglobin lower than 120 g/L is never used as a cut-off for iron replacement therapy as it is within the normal range.
During pregnancy, women are checked for anaemia twice – once at the initial booking visit (usually around 8-10 weeks) and again at 28 weeks. The National Institute for Health and Care Excellence (NICE) has set specific cut-off levels to determine if a pregnant woman requires oral iron therapy. These levels are less than 110 g/L in the first trimester, less than 105 g/L in the second and third trimesters, and less than 100 g/L postpartum.
If a woman’s iron levels fall below these cut-offs, she will be prescribed oral ferrous sulfate or ferrous fumarate. It is important to continue this treatment for at least three months after the iron deficiency has been corrected to allow the body to replenish its iron stores. By following these guidelines, healthcare professionals can help ensure that pregnant women receive the appropriate care to prevent and manage anaemia during pregnancy.
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This question is part of the following fields:
- Obstetrics
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Question 3
Incorrect
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You are evaluating a 35-year-old gravida 2 para 1 woman who has presented for her initial prenatal visit. She is currently 12 weeks pregnant.
During her first pregnancy, she had gestational diabetes which was managed with insulin therapy. However, her blood glucose levels are currently within normal limits. She is presently taking 400 µcg folic acid supplements and has no other medication history.
At this clinic visit, a complete set of blood and urine samples are collected.
What alterations would you anticipate observing in a healthy pregnant patient compared to before pregnancy?Your Answer: Increased serum haemoglobin
Correct Answer: Decreased serum urea
Explanation:Physiological Changes During Pregnancy
The human body undergoes significant physiological changes during pregnancy. The cardiovascular system experiences an increase in stroke volume by 30%, heart rate by 15%, and cardiac output by 40%. However, systolic blood pressure remains unchanged, while diastolic blood pressure decreases in the first and second trimesters, returning to non-pregnant levels by term. The enlarged uterus may interfere with venous return, leading to ankle edema, supine hypotension, and varicose veins.
The respiratory system sees an increase in pulmonary ventilation by 40%, with tidal volume increasing from 500 to 700 ml due to the effect of progesterone on the respiratory center. Oxygen requirements increase by only 20%, leading to over-breathing and a fall in pCO2, which can cause a sense of dyspnea accentuated by the elevation of the diaphragm. The basal metabolic rate increases by 15%, possibly due to increased thyroxine and adrenocortical hormones, making warm conditions uncomfortable for women.
The maternal blood volume increases by 30%, mostly in the second half of pregnancy. Red blood cells increase by 20%, but plasma increases by 50%, leading to a decrease in hemoglobin. There is a low-grade increase in coagulant activity, with a rise in fibrinogen and Factors VII, VIII, X. Fibrinolytic activity decreases, returning to normal after delivery, possibly due to placental suppression. This prepares the mother for placental delivery but increases the risk of thromboembolism. Platelet count falls, while white blood cell count and erythrocyte sedimentation rate rise.
The urinary system experiences an increase in blood flow by 30%, with glomerular filtration rate increasing by 30-60%. Salt and water reabsorption increase due to elevated sex steroid levels, leading to increased urinary protein losses. Trace glycosuria is common due to the increased GFR and reduction in tubular reabsorption of filtered glucose.
Calcium requirements increase during pregnancy, especially during the third trimester and lactation. Calcium is transported actively across the placenta, while serum levels of calcium and phosphate fall with a fall in protein. Ionized levels of calcium remain stable, and gut absorption of calcium increases substantially due to increased 1,25 dihydroxy vitamin D.
The liver experiences an increase in alkaline phosphatase by 50%,
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This question is part of the following fields:
- Obstetrics
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Question 4
Incorrect
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A 29-year-old woman arrives at the Emergency Department, worried about her pregnancy. She is currently 32 weeks pregnant and has not experienced any complications. However, during a shopping trip a few hours ago, she felt a sudden rush of fluid from her vagina and noticed that her underwear was wet.
The triage nurse has already taken her vital signs, which are all within normal limits.
What is the initial test that should be performed based on the probable diagnosis?Your Answer: Obstetric abdominal examination
Correct Answer: Speculum examination
Explanation:Preterm prelabour rupture of the membranes (PPROM) is a condition that occurs in approximately 2% of pregnancies, but it is responsible for around 40% of preterm deliveries. This condition can lead to various complications, including prematurity, infection, and pulmonary hypoplasia in the fetus, as well as chorioamnionitis in the mother. To confirm PPROM, a sterile speculum examination should be performed to check for pooling of amniotic fluid in the posterior vaginal vault. However, digital examination should be avoided due to the risk of infection. If pooling of fluid is not observed, testing the fluid for placental alpha microglobulin-1 protein (PAMG-1) or insulin-like growth factor binding protein-1 is recommended. Ultrasound may also be useful to show oligohydramnios.
The management of PPROM involves admission and regular observations to ensure that chorioamnionitis is not developing. Oral erythromycin should be given for ten days, and antenatal corticosteroids should be administered to reduce the risk of respiratory distress syndrome. Delivery should be considered at 34 weeks of gestation, but there is a trade-off between an increased risk of maternal chorioamnionitis and a decreased risk of respiratory distress syndrome as the pregnancy progresses. PPROM is a serious condition that requires prompt diagnosis and management to minimize the risk of complications for both the mother and the fetus.
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This question is part of the following fields:
- Obstetrics
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Question 5
Incorrect
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A 28-year-old woman attends her regular antenatal check at 16 weeks gestation. It is her second pregnancy and she has had no complications.
The nurse is discussing the results of previous tests, checking her urine and measuring her blood pressure. The patient has no protein in her urine and her blood pressure is 102/70 mmHg.
Which of the following describes a normal physiological change in this patient?Your Answer: Blood pressure drops throughout pregnancy
Correct Answer: An increase in heart rate and stroke volume lead to an increase in cardiac output
Explanation:Physiological Changes in Pregnancy
Pregnancy is a time of significant physiological changes in a woman’s body. These changes are mainly driven by progesterone rather than oestrogen. One of the changes is vasodilation, which leads to a drop in blood pressure initially, but it normalizes by term. However, an increase in heart rate and stroke volume leads to an increase in cardiac output.
Another change is a decrease in lower oesophageal sphincter tone and vascular resistance, which causes a drop in blood pressure. This decrease occurs over the first trimester but starts to increase to normal by term. Oestrogen is responsible for this change, and it also causes symptoms of reflux.
Pregnancy also causes a mild anaemia due to a drop in red cell volume. However, this is a dilutional anaemia caused by an increase in plasma volume. Additionally, there is an increase in clotting factors II, VII, IX, and X, which makes pregnancy a hypercoagulable state.
The functional residual capacity (FRC) increases in pregnancy, leading to more rapid breathing and smaller tidal volumes. This decrease in FRC means that oxygen reserve is less in pregnant women. Minute ventilation increases due to increased oxygen consumption and increased CO2 production. This is by increased tidal volume rather than respiratory rate.
Finally, the glomerular filtration rate (GFR) decreases secondary to progesterone, facilitating an increase in fluid retention and an increase in plasma volume. However, there is also an increase in aldosterone, which acts on the kidneys producing water and sodium retention, therefore causing an increase in plasma volume.
In conclusion, pregnancy causes significant physiological changes in a woman’s body, which are mainly driven by progesterone. These changes affect various systems, including the cardiovascular, respiratory, and renal systems.
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This question is part of the following fields:
- Obstetrics
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Question 6
Incorrect
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A 25-year-old woman is on her second day postpartum, following a Caesarean section. She is taking regular paracetamol for pain around the wound site, which has not alleviate her symptoms.
She is breastfeeding and is asking whether there are any other safe analgesics to help with her pain.
What is the recommended medication for this patient's pain management?Your Answer: Tramadol
Correct Answer: Ibuprofen
Explanation:Safe Pain Management Options for Breastfeeding Mothers
Breastfeeding mothers who experience pain may require medication to manage their symptoms. However, certain drugs can be harmful to both the mother and the baby. Here are some safe pain management options for breastfeeding mothers:
Ibuprofen: This is the drug of choice for managing pain in breastfeeding mothers. Although it is contraindicated in pregnancy, its transfer into breast milk is very low.
Codeine: This opioid analgesic can be used during pregnancy, but it should be avoided as the mother approaches delivery due to the risk of respiratory depression in the infant. It should also be avoided when breastfeeding, as it can cause symptoms of overdose in the baby.
Aspirin: While aspirin is used during pregnancy for prophylaxis, its use as an analgesic should be avoided during breastfeeding as it can cause Reye’s syndrome or impair neonatal platelet function.
Indometacin: This NSAID can be used for analgesia in breastfeeding, as the concentration that transfers into breast milk is relatively low.
Tramadol: Although only small amounts of this opioid analgesic are present in breast milk, the manufacturers advise avoidance due to the risk of respiratory depression in the baby.
It is important to consult with a healthcare provider before taking any medication while breastfeeding. Additionally, mothers should be aware of any contraindications and potential side effects of the medication they are taking.
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This question is part of the following fields:
- Obstetrics
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Question 7
Incorrect
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A 26-year-old woman known to be 10 weeks pregnant is admitted to the Surgical Assessment Unit with acute lower abdominal pain and vaginal bleeding. Examination reveals a large uterus and a dilated internal os. An inevitable miscarriage is diagnosed and the patient is taken to theatre for surgical evacuation. This is the patient’s third miscarriage in 3 years.
What is the percentage chance that she will have a successful pregnancy on her fourth attempt?Your Answer: 65%
Correct Answer: 75%
Explanation:Understanding Miscarriage: Types and Recurrence Rates
Miscarriage is a common experience for many women, but it can still be a difficult and emotional event. It is defined as any pregnancy loss that occurs before 24 weeks of gestation. There are several types of miscarriage, including threatened, inevitable, incomplete, complete, missed, anembryonic, septic, and recurrent. Recurrent miscarriage, which is defined as three or more consecutive losses, is a particular concern for many women. The risk of recurrence is important to consider when offering parental counseling, as it can impact the chances of a successful pregnancy. For women without specific cause for recurrence, the percentage chance of a live birth in a subsequent pregnancy decreases with each miscarriage: 85% after one, 75% after two, and 60% after three. It’s important to remember that while miscarriage can be distressing, the chances of a successful pregnancy increase with each attempt.
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This question is part of the following fields:
- Obstetrics
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Question 8
Incorrect
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A 28-year-old woman presents to the clinic for her lab results. She is currently 20 weeks pregnant and has undergone a glucose tolerance test. The findings are as follows:
- Fasting glucose 6.9 mmol/L
- 2-hour glucose 8.5 mmol/L
What is the best course of action to take next?Your Answer: Metformin
Correct Answer: Insulin
Explanation:Immediate insulin (with or without metformin) should be initiated if the fasting glucose level is >= 7 mmol/l at the time of gestational diabetes diagnosis. In this case, the patient has gestational diabetes and requires prompt insulin therapy. The diagnosis of gestational diabetes is based on a fasting plasma glucose level of > 5.6 mmol/L or a 2-hour plasma glucose level of >/= 7.8 mmol/L. Although dietary advice is important, insulin therapy is necessary when the fasting glucose level is greater than 7 mmol/L. Gliclazide is not recommended for pregnant women due to the risk of neonatal hypoglycaemia. Metformin can be used in gestational diabetes, but insulin is the most appropriate next step when the fasting glucose level is >=7 mmol/L. Insulin and metformin can be used together to manage gestational diabetes. There is no need to repeat the test as the results are conclusive for gestational diabetes.
Gestational diabetes is a common medical disorder affecting around 4% of pregnancies. Risk factors include a high BMI, previous gestational diabetes, and family history of diabetes. Screening is done through an oral glucose tolerance test, and diagnostic thresholds have recently been updated. Management includes self-monitoring of blood glucose, diet and exercise advice, and medication if necessary. For pre-existing diabetes, weight loss and insulin are recommended, and tight glycemic control is important. Targets for self-monitoring include fasting glucose of 5.3 mmol/l and 1-2 hour post-meal glucose levels.
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This question is part of the following fields:
- Obstetrics
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Question 9
Incorrect
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A 28-year-old pregnant woman with type 1 diabetes inquires about the frequency of blood glucose level testing during her pregnancy.
Your Answer: Daily fasting test
Correct Answer: Daily fasting, pre-meal, 1-hour post-meal and bedtime tests.
Explanation:It is important for pregnant individuals with type 1 diabetes to closely monitor their blood glucose levels by testing multiple times throughout the day. This is recommended by NICE NG3.
Gestational diabetes is a common medical disorder affecting around 4% of pregnancies. Risk factors include a high BMI, previous gestational diabetes, and family history of diabetes. Screening is done through an oral glucose tolerance test, and diagnostic thresholds have recently been updated. Management includes self-monitoring of blood glucose, diet and exercise advice, and medication if necessary. For pre-existing diabetes, weight loss and insulin are recommended, and tight glycemic control is important. Targets for self-monitoring include fasting glucose of 5.3 mmol/l and 1-2 hour post-meal glucose levels.
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This question is part of the following fields:
- Obstetrics
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Question 10
Incorrect
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A 32-year-old female presents with intense pruritus during pregnancy, particularly in her hands and feet, which worsens at night. She has no visible rash and has a history of a stillbirth at 36 weeks. What is the most efficient management for her condition?
Your Answer: Anti-fungals
Correct Answer: Ursodeoxycholic acid
Explanation:The patient is likely suffering from obstetric cholestasis, which can increase the risk of premature birth and stillbirth. The main symptom is severe itching, and elevated serum bile acids are typically present. Liver function tests, including bilirubin levels, may not be reliable. The most effective treatment is ursodeoxycholic acid (UDCA), which is now mostly synthetic. While antihistamines and topical menthol creams can provide some relief, UDCA is more likely to improve outcomes.
Intrahepatic Cholestasis of Pregnancy: Symptoms and Management
Intrahepatic cholestasis of pregnancy, also known as obstetric cholestasis, is a condition that affects approximately 1% of pregnancies in the UK. It is characterized by intense itching, particularly on the palms, soles, and abdomen, and may also result in clinically detectable jaundice in around 20% of patients. Raised bilirubin levels are seen in over 90% of cases.
The management of intrahepatic cholestasis of pregnancy typically involves induction of labor at 37-38 weeks, although this practice may not be evidence-based. Ursodeoxycholic acid is also widely used, although the evidence base for its effectiveness is not clear. Additionally, vitamin K supplementation may be recommended.
It is important to note that the recurrence rate of intrahepatic cholestasis of pregnancy in subsequent pregnancies is high, ranging from 45-90%. Therefore, close monitoring and management are necessary for women who have experienced this condition in the past.
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This question is part of the following fields:
- Obstetrics
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Question 11
Correct
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A 35-year-old woman arrives at 28 weeks gestation for her third pregnancy. During an ultrasound at 12 weeks, it was discovered that she was carrying dichorionic diamniotic twins. She is admitted to the hospital due to painless, bright red bleeding per vaginum. She has undergone two previous caesarian sections. What is the probable diagnosis?
Your Answer: Placenta praevia
Explanation:Placenta praevia is a pregnancy complication characterized by the attachment of the placenta to the lower part of the uterus. The main symptom is painless bleeding occurring after the 24th week of gestation. Risk factors include a history of placenta praevia, previous caesarean section, damage to the endometrium, and multiple pregnancies. Placenta praevia frequently results in a high presenting part or abnormal lie due to the placenta’s low position.
Understanding Placenta Praevia
Placenta praevia is a condition where the placenta is located wholly or partially in the lower uterine segment. It is a relatively rare condition, with only 5% of women having a low-lying placenta when scanned at 16-20 weeks gestation. However, the incidence at delivery is only 0.5%, as most placentas tend to rise away from the cervix.
There are several factors associated with placenta praevia, including multiparity, multiple pregnancy, and embryos implanting on a lower segment scar from a previous caesarean section. Clinical features of placenta praevia include shock in proportion to visible loss, no pain, a non-tender uterus, abnormal lie and presentation, and a usually normal fetal heart. Coagulation problems are rare, and small bleeds may occur before larger ones.
Diagnosis of placenta praevia should not involve digital vaginal examination before an ultrasound, as this may provoke severe haemorrhage. The condition is often picked up on routine 20-week abdominal ultrasounds, but the Royal College of Obstetricians and Gynaecologists recommends the use of transvaginal ultrasound for improved accuracy and safety. Placenta praevia is classified into four grades, with grade IV being the most severe, where the placenta completely covers the internal os.
In summary, placenta praevia is a rare condition that can have serious consequences if not diagnosed and managed appropriately. It is important for healthcare professionals to be aware of the associated factors and clinical features, and to use appropriate diagnostic methods for accurate grading and management.
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This question is part of the following fields:
- Obstetrics
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Question 12
Incorrect
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A 29-year-old woman presents to the clinic with concerns about her pregnancy. She is currently at 30 weeks gestation and reports that her pregnancy has been going smoothly thus far. However, over the past few days, she has noticed a decrease in fetal movement. She denies any recent illnesses or feeling unwell and has no significant medical history. On obstetric abdominal examination, there are no notable findings and the patient appears to be in good health. What is the recommended initial management in this case?
Your Answer: Ultrasound scan
Correct Answer: Handheld Doppler
Explanation:When a pregnant woman reports reduced fetal movements after 28 weeks of gestation, the first step recommended by the RCOG guidelines is to use a handheld Doppler to confirm the fetal heartbeat. If the heartbeat cannot be detected, an ultrasound should be offered immediately. However, if a heartbeat is detected, cardiotocography should be used to monitor the heart rate for 20 minutes. Fetal blood sampling is not necessary in this situation. Referral to a fetal medicine unit would only be necessary if no movements had been felt by 24 weeks.
Understanding Reduced Fetal Movements
Introduction:
Reduced fetal movements can indicate fetal distress and are a response to chronic hypoxia in utero. This can lead to stillbirth and fetal growth restriction. It is believed that placental insufficiency may also be linked to reduced fetal movements.Physiology:
Quickening is the first onset of fetal movements, which usually occurs between 18-20 weeks gestation and increases until 32 weeks gestation. Multiparous women may experience fetal movements sooner. Fetal movements should not reduce towards the end of pregnancy. There is no established definition for what constitutes reduced fetal movements, but less than 10 movements within 2 hours (in pregnancies past 28 weeks gestation) is an indication for further assessment.Epidemiology:
Reduced fetal movements affect up to 15% of pregnancies, with 3-5% of pregnant women having recurrent presentations with RFM. Fetal movements should be established by 24 weeks gestation.Risk factors for reduced fetal movements:
Posture, distraction, placental position, medication, fetal position, body habitus, amniotic fluid volume, and fetal size can all affect fetal movement awareness.Investigations:
Fetal movements are usually based on maternal perception, but can also be objectively assessed using handheld Doppler or ultrasonography. Investigations are dependent on gestation at onset of RFM. If concern remains, despite normal CTG, urgent (within 24 hours) ultrasound can be used.Prognosis:
Reduced fetal movements can represent fetal distress, but in 70% of pregnancies with a single episode of reduced fetal movement, there is no onward complication. However, between 40-55% of women who suffer from stillbirth experience reduced fetal movements prior to diagnosis. Recurrent RFM requires further investigations to consider structural or genetic fetal abnormalities. -
This question is part of the following fields:
- Obstetrics
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Question 13
Incorrect
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A 35-year-old para 1+0 has arrived at term in labor. During a vaginal examination, the occiput is palpable posteriorly (near the sacrum). What is the appropriate course of action for managing this patient?
Your Answer: Mothers will generally experience a later urge to push than if position was OA
Correct Answer: The fetal head may rotate spontaneously to an OA position
Explanation:1: The occiput posterior (OP) position during delivery is feasible, but it may result in a longer and more painful labor.
2: If labor progress is slow, augmentation should be considered.
3: The use of Kielland’s forceps is linked to the most favorable outcomes, but it requires specialized skills.
4: Typically, women in the OP position will feel the urge to push earlier than those in the occiput anterior (OA) position.Labour is divided into three stages, with stage 2 being from full dilation to delivery of the fetus. This stage can be further divided into two categories: passive second stage, which occurs without pushing, and active second stage, which involves the process of maternal pushing. The active second stage is less painful than the first stage, as pushing can mask the pain. This stage typically lasts around one hour, but if it lasts longer than that, medical interventions such as Ventouse extraction, forceps delivery, or caesarean section may be necessary. Episiotomy, a surgical cut made in the perineum to widen the vaginal opening, may also be required during crowning. However, this stage is associated with transient fetal bradycardia, which is a temporary decrease in the fetal heart rate.
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This question is part of the following fields:
- Obstetrics
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Question 14
Incorrect
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A 31-year-old woman is on day four postpartum, following an emergency Caesarean section for severe pre-eclampsia. She feels well in herself and is mobilising and breastfeeding well. Her blood pressure has not normalised yet and is 158/106 mmHg today. Urinalysis is negative for protein. Following a long discussion, you decide that she is ready for discharge and can be managed in the community.
Which of the following is correct regarding postnatal hypertension?Your Answer: If blood pressure is found to be > 150/100 mmHg in the community, the patient should be referred back to hospital
Correct Answer: Women who are discharged and are still hypertensive should have their blood pressure checked every other day in the community until targets are achieved
Explanation:Postnatal Hypertension Management: Guidelines for Discharge and Follow-up
Women who experience hypertension during the postnatal period require careful management to ensure their blood pressure is controlled and any underlying causes are addressed. Here are some guidelines for managing postnatal hypertension:
– Women who are discharged and still hypertensive should have their blood pressure checked every other day in the community until targets are achieved.
– The GP at the 6-week postnatal check should convert all women with chronic hypertension (before pregnancy) back to their pre-pregnancy antihypertensive medication, if not contraindicated in breastfeeding.
– If blood pressure is found to be > 150/100 mmHg in the community, the patient should be referred back to the hospital.
– The blood pressure should be checked at least once every two weeks until the woman discontinues antihypertensive treatment.
– The GP at the 6-week postnatal check should stop antihypertensives in all women who required medical treatment in pregnancy, provided their blood pressure is < 130/80 mmHg.
– If a woman still has a blood pressure of ≤ 160/110 mmHg and proteinuria at the 6-week postnatal appointment, despite medical management, she will require a specialist referral to the hospital for further assessment of the underlying causes of hypertension.By following these guidelines, healthcare providers can ensure that women with postnatal hypertension receive appropriate care and support to manage their condition effectively.
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This question is part of the following fields:
- Obstetrics
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Question 15
Correct
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A 28-year-old woman at 36 weeks’ gestation presents with severe abdominal pain and a small amount of vaginal bleeding. The pregnancy has been uncomplicated and previous scans have been normal. On examination, she has tenderness over the uterine fundus, plus:
Investigation Result Normal value
Blood pressure (BP) 90/60 mmHg < 120/< 80 mmHg
Heart rate 110 beats per minute 60–100 beats per minute
Respiratory rate (RR) 18 breaths per minute 12–20 breaths per minute
O2 Saturation 98% 95–100%
What is the diagnosis?Your Answer: Placental abruption
Explanation:Pregnancy Complications: Placental Abruption, Uterine Rupture, Placenta Previa, and Placenta Accreta
During pregnancy, there are several complications that can occur, including placental abruption, uterine rupture, placenta previa, and placenta accreta.
Placental abruption happens when part of the placenta separates prematurely from the uterus. Symptoms include abdominal or back pain, vaginal bleeding (although there may be no bleeding in concealed abruption), a hard abdomen, and eventually shock. Treatment involves hospitalization, resuscitation, and delivery of the baby.
Uterine rupture is rare and usually occurs during labor, especially in women who have had previous uterine surgery. Symptoms include abdominal pain and tenderness, vaginal bleeding, fetal heart rate deterioration, and hypovolemic shock. Emergency exploratory laparotomy with Caesarean section and fluid resuscitation is necessary.
Placenta previa occurs when the placenta attaches to the lower uterine segment and often presents with painless vaginal bleeding after the 28th week. However, severe pain is not a typical symptom. The location of the placenta can be determined through scans.
Placenta accreta happens when the placenta attaches to the myometrium instead of just the endometrium. This can lead to failure of the placenta to separate after delivery, resulting in significant postpartum bleeding.
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This question is part of the following fields:
- Obstetrics
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Question 16
Incorrect
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A 29-year-old pregnant woman attends her 12 week booking appointment at the antenatal clinic. She has no previous medical history and is pregnant for the first time. During the appointment, the midwife takes a blood sample to screen for HIV, rubella, and syphilis, and sends a midstream urine sample for culture to check for asymptomatic bacteriuria. What other infectious disease is routinely screened for during pregnancy?
Your Answer: Hepatitis C
Correct Answer: Hepatitis B
Explanation:Screening for Hepatitis C is not a standard practice during pregnancy, as per NICE guidelines, due to insufficient evidence of its clinical and cost-effectiveness. However, screening for Hepatitis B is conducted during the booking appointment to reduce the risk of mother-child transmission through post-natal interventions. While chlamydia screening is not routinely offered in antenatal care, individuals under 25 years of age are provided with information about their local National Chlamydia Screening Programme, given the higher prevalence of chlamydia in this age group. There is currently no regular screening programme for Group B streptococcus in the UK.
Antenatal Screening Policy
Antenatal screening is an important aspect of prenatal care that helps identify potential health risks for both the mother and the developing fetus. The National Screening Committee (NSC) has recommended a policy for antenatal screening that outlines the conditions for which all pregnant women should be offered screening and those for which screening should not be offered.
The NSC recommends that all pregnant women should be offered screening for anaemia, bacteriuria, blood group, Rhesus status, and anti-red cell antibodies, Down’s syndrome, fetal anomalies, hepatitis B, HIV, neural tube defects, risk factors for pre-eclampsia, syphilis, and other conditions depending on the woman’s medical history.
However, there are certain conditions for which screening should not be offered, such as gestational diabetes, gestational hypertension, and preterm labor. These conditions are typically managed through regular prenatal care and monitoring.
It is important for pregnant women to discuss their screening options with their healthcare provider to ensure that they receive appropriate care and support throughout their pregnancy. By following the NSC’s recommended policy for antenatal screening, healthcare providers can help identify potential health risks early on and provide appropriate interventions to ensure the best possible outcomes for both mother and baby.
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This question is part of the following fields:
- Obstetrics
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Question 17
Correct
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A 32-year-old woman who is 4 weeks postpartum and breastfeeding presents with a history of a painful, erythematosus breast for the past 24 hours.
Her blood pressure is 118/78 mmHg, her heart rate is 72 beats per minute and her temperature is 37.2 degrees celsius. On examination her left breast is tender and erythematosus and warm to touch. There is no palpable lump and no visible fissure. You take a sample of breast milk to send for culture.
What is the most appropriate first line management?Your Answer: Advise to continue breastfeeding and use simple analgesia and warm compresses
Explanation:When managing mastitis in breastfeeding women, it is recommended to continue breastfeeding while using simple analgesia and warm compresses. If breastfeeding is too painful, expressing milk by hand or using a pump is advised to prevent milk stasis, which is often the cause of lactational mastitis. According to NICE clinical knowledge summaries (CKS), oral antibiotics are only necessary if there is an infected nipple fissure, symptoms do not improve after 12-24 hours despite effective milk removal, or breast milk culture is positive. Flucloxacillin is the first-line antibiotic for 10-14 days, while erythromycin or clarithromycin can be used for penicillin-allergic patients. Referral to a surgical team in the hospital is only necessary if a breast abscess is suspected, which is unlikely if there is no palpable lump in the breast.
Breastfeeding Problems and Their Management
Breastfeeding is a natural process, but it can come with its own set of challenges. Some of the minor problems that breastfeeding mothers may encounter include frequent feeding, nipple pain, blocked ducts, and nipple candidiasis. These issues can be managed by seeking advice on proper positioning, trying breast massage, and using appropriate medication.
Mastitis is a more serious problem that affects around 1 in 10 breastfeeding women. It is characterized by symptoms such as fever, nipple fissure, and persistent pain. Treatment involves the use of antibiotics, such as flucloxacillin, for 10-14 days. Breastfeeding or expressing milk should continue during treatment to prevent complications such as breast abscess.
Breast engorgement is another common problem that causes breast pain in breastfeeding women. It occurs in the first few days after birth and affects both breasts. Hand expression of milk can help relieve the discomfort of engorgement. Raynaud’s disease of the nipple is a less common problem that causes nipple pain and blanching. Treatment involves minimizing exposure to cold, using heat packs, and avoiding caffeine and smoking.
If a breastfed baby loses more than 10% of their birth weight in the first week of life, it may be a sign of poor weight gain. This should prompt consideration of the above breastfeeding problems and an expert review of feeding. Monitoring of weight should continue until weight gain is satisfactory.
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This question is part of the following fields:
- Obstetrics
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Question 18
Incorrect
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A 29-year-old woman is admitted to the labour ward at 38+4 weeks gestation. This is her first pregnancy and she reports that contractions began approximately 12 hours ago. Upon examination, her cervix is positioned anteriorly, is soft, and is effaced at around 60-70%. Cervical dilation is estimated at around 3-4 cm and the fetal head is located at the level of the ischial spines. No interventions have been performed yet.
What is the recommended intervention at this point?Your Answer: Amniotomy
Correct Answer: No interventions required
Explanation:The patient’s cervical dilation is 3-4 cm with a fetal station of 0, and her Bishop’s score is 10. Since her labor has only been ongoing for 10 hours, no interventions are necessary. A Bishop’s score of 8 or higher indicates a high likelihood of spontaneous labor, and for first-time mothers, the first stage of labor can last up to 12 hours. If the Bishop’s score is less than 5, induction may be necessary, and vaginal prostaglandin E2 is the preferred method.
If other methods fail to induce labor or if vaginal prostaglandin E2 is not suitable, amniotomy may be performed. However, this procedure carries the risk of infection, umbilical cord prolapse, and breech presentation if the fetal head is not engaged. Maternal oxytocin infusion may be used if labor is not progressing, but it is not appropriate in this scenario at this stage due to the risk of uterine hyperstimulation.
A membrane sweep is a procedure where a finger is inserted vaginally and through the cervix to separate the chorionic membrane from the decidua. This is an adjunct to labor induction and is typically offered to first-time mothers at 40/41 weeks.
Induction of labour is a process where labour is artificially started and is required in about 20% of pregnancies. It is indicated in cases of prolonged pregnancy, prelabour premature rupture of the membranes, maternal medical problems, diabetic mother over 38 weeks, pre-eclampsia, obstetric cholestasis, and intrauterine fetal death. The Bishop score is used to assess whether induction of labour is necessary and includes cervical position, consistency, effacement, dilation, and fetal station. A score of less than 5 indicates that labour is unlikely to start without induction, while a score of 8 or more indicates a high chance of spontaneous labour or response to interventions made to induce labour.
Possible methods of induction include membrane sweep, vaginal prostaglandin E2, oral prostaglandin E1, maternal oxytocin infusion, amniotomy, and cervical ripening balloon. The NICE guidelines recommend vaginal prostaglandins or oral misoprostol if the Bishop score is less than or equal to 6, while amniotomy and an intravenous oxytocin infusion are recommended if the score is greater than 6.
The main complication of induction of labour is uterine hyperstimulation, which refers to prolonged and frequent uterine contractions that can interrupt blood flow to the intervillous space and result in fetal hypoxemia and acidemia. Uterine rupture is a rare but serious complication. Management includes removing vaginal prostaglandins and stopping the oxytocin infusion if one has been started, and considering tocolysis.
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This question is part of the following fields:
- Obstetrics
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Question 19
Incorrect
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The technician performed an ultrasonographic examination on a pregnant woman and obtained a median scan of the 7-week-old embryo. Using the ultrasound machine, the technician marked the most superior point of the embryo's head and the most inferior point of the embryo. The technician then measured the distance between the marks. What is the calculation that the technician made?
Your Answer: Crown–heel length
Correct Answer: Crown–rump length
Explanation:Choosing the Appropriate Measurement for Estimating Embryonic Age
When estimating the age of an embryo, it is important to choose the appropriate measurement based on the anatomy and timing of the scan. In the case of a scan taken at 7 weeks post-fertilisation, the crown-rump length is the most appropriate measurement to use. The greatest width is not used for estimating embryonic age, while the greatest length is only suitable for early embryos in the third and early fourth weeks. Crown-heel length may be used for 8-week-old embryos, but requires visibility of the lower limb. Crown-elbow length is not applicable in this case as the limbs cannot be visualised. It is important to consider the specific circumstances of the scan when choosing the appropriate measurement for estimating embryonic age.
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This question is part of the following fields:
- Obstetrics
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Question 20
Incorrect
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A 26-year-old woman comes to you at 18 weeks’ gestation, feeling very anxious. She spent one day last week taking care of her sick nephew who had cold symptoms, and a few days later, her nephew developed a facial rash resembling a ‘slapped cheek’. The patient informs you that she herself had some myalgia and fever for two days, and today she developed a rash on her trunk and back.
Upon examination, her temperature is 37.7 °C and there is a maculopapular rash on her trunk and back with a lace-like appearance.
The blood tests reveal:
rubella: immunoglobulin M (IgM) negative, immunoglobulin G (IgG) positive
parvovirus B19: IgM positive, IgG negative.
What should be the next course of action in managing this patient?Your Answer: Give one dose of varicella-zoster virus (VZV) immunoglobulin and review in five days
Correct Answer: Arrange urgent referral to a specialist Fetal Medicine Unit (to be seen within 4 weeks) and do serial ultrasound scans
Explanation:Management of Parvovirus B19 Infection in Pregnancy
Parvovirus B19 infection in pregnancy can have detrimental effects on the developing fetus. Therefore, it is important to manage the infection appropriately. Here are some key steps to take:
1. Arrange urgent referral to a specialist Fetal Medicine Unit (to be seen within 4 weeks) and do serial ultrasound scans to monitor fetal growth and assess for complications.
2. Arrange fetal blood sampling and transfusion if there is an indication of fetal infection.
3. Advise the woman to avoid going to work and contact with other pregnant women for at least five days to prevent transmission of the infection.
4. Give one dose of varicella-zoster virus (VZV) immunoglobulin and review in five days if the woman was exposed to chickenpox and is not immune to VZV.
5. Suggest paracetamol as required and plenty of fluids at present for the management of myalgia and arthralgia associated with the infection.
It is important to confirm the diagnosis of parvovirus B19 infection with serology on at least two separate samples and to monitor the woman and fetus closely for potential complications. With appropriate management, the risk of fetal morbidity and mortality can be reduced.
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This question is part of the following fields:
- Obstetrics
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Question 21
Incorrect
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Samantha is a 28-year-old woman who has been diagnosed with epilepsy and is currently taking carbamazepine. She has just given birth to a baby boy and is uncertain about breastfeeding. Samantha is worried that her medication may harm her baby if she continues to breastfeed. What guidance would you offer Samantha regarding her antiepileptic medication and breastfeeding?
Your Answer: Switch to lamotrigine, continue breastfeeding
Correct Answer: Continue carbamazepine, continue breastfeeding
Explanation:Mothers often have concerns about the use of antiepileptic medication during and after pregnancy, particularly when it comes to breastfeeding. However, according to a comprehensive document released by the Royal College of Obstetricians and Gynaecologists, nearly all antiepileptic drugs are safe to use while breastfeeding. This is because only negligible amounts of the medication are passed to the baby through breast milk, and studies have not shown any negative impact on the child’s cognitive development. Therefore, it is recommended that mothers continue their current antiepileptic regime and are encouraged to breastfeed. It is important to note that stopping the medication without consulting a neurologist can lead to further seizures.
Pregnancy and breastfeeding can be a concern for women with epilepsy. It is generally recommended that women continue taking their medication during pregnancy, as the risks of uncontrolled seizures outweigh the potential risks to the fetus. However, it is important for women to take folic acid before pregnancy to reduce the risk of neural tube defects. The use of antiepileptic medication during pregnancy can increase the risk of congenital defects, but this risk is still relatively low. It is recommended to aim for monotherapy and there is no need to monitor drug levels. Sodium valproate is associated with neural tube defects, while carbamazepine is considered the least teratogenic of the older antiepileptics. Phenytoin is associated with cleft palate, and lamotrigine may require a dose increase during pregnancy. Breastfeeding is generally safe for mothers taking antiepileptics, except for barbiturates. Pregnant women taking phenytoin should be given vitamin K in the last month of pregnancy to prevent clotting disorders in the newborn.
A warning has been issued about the use of sodium valproate during pregnancy and in women of childbearing age. New evidence suggests a significant risk of neurodevelopmental delay in children following maternal use of this medication. Therefore, it should only be used if clearly necessary and under specialist neurological or psychiatric advice. It is important for women with epilepsy to discuss their options with their healthcare provider and make informed decisions about their treatment during pregnancy and breastfeeding.
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This question is part of the following fields:
- Obstetrics
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Question 22
Incorrect
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A 25-year-old patient visits the antenatal clinic after her 20-week scan reveals a low-lying placenta. She is concerned about what this means and if any action needs to be taken. This is her first pregnancy, and she has not experienced any complications thus far. She has no known medical conditions and does not take any regular medications. The patient mentions that her mother had a placenta-related issue that resulted in significant bleeding, and she is worried that the same may happen to her. What steps would you take to assist this patient?
Your Answer: Rescan at 28 weeks
Correct Answer: Rescan at 32 weeks
Explanation:In the event that a low-lying placenta is detected during the 20-week scan, it is recommended to undergo a follow-up scan at 32 weeks for further evaluation.
Management and Prognosis of Placenta Praevia
Placenta praevia is a condition where the placenta is located wholly or partially in the lower uterine segment. If a low-lying placenta is detected at the 20-week scan, a rescan is recommended at 32 weeks. There is no need to limit activity or intercourse unless there is bleeding. If the placenta is still present at 32 weeks and is grade I/II, then a scan every two weeks is recommended. A final ultrasound at 36-37 weeks is necessary to determine the method of delivery. For grades III/IV, an elective caesarean section is recommended between 37-38 weeks. However, if the placenta is grade I, a trial of vaginal delivery may be offered. If a woman with known placenta praevia goes into labour before the elective caesarean section, an emergency caesarean section should be performed due to the risk of post-partum haemorrhage.
In cases where placenta praevia is accompanied by bleeding, the woman should be admitted and an ABC approach should be taken to stabilise her. If stabilisation is not possible, an emergency caesarean section should be performed. If the woman is in labour or has reached term, an emergency caesarean section is also necessary.
The prognosis for placenta praevia has improved significantly, and death is now extremely rare. The major cause of death in women with placenta praevia is post-partum haemorrhage.
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This question is part of the following fields:
- Obstetrics
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Question 23
Correct
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A 28-year-old woman para 1+0 is 36+5 weeks pregnant and is being monitored and treated for pre-eclampsia. Her current treatment is with labetalol and her blood pressure has been well controlled. During her antenatal clinic visit, she reports a severe headache, one episode of vomiting, and blurred vision. Her blood pressure is currently 154/98 mmHg. Upon examination, papilloedema is observed. As a result, she is admitted to the hospital. What is the appropriate course of action?
Your Answer: IV magnesium sulphate and plan immediate delivery
Explanation:This patient is suffering from severe pre-eclampsia, evidenced by moderate hypertension and symptoms of headache and vomiting. According to NICE guidelines, delivery should be carried out within 24-48 hours for women with pre-eclampsia and mild to moderate hypertension after 37 weeks. Magnesium sulphate is recommended for the treatment of severe hypertension or pre-eclampsia in women who have already experienced seizures. IV magnesium sulphate should also be considered if delivery is planned within 24 hours or if there is a risk of eclampsia. Although IV hydralazine may lower blood pressure, immediate delivery and protection against eclampsia are required due to the patient’s presenting symptoms. IM beclomethasone is unnecessary as the patient is past 36 weeks. IV calcium gluconate is used to treat magnesium toxicity and is not indicated in this case. While delivery should be planned, the patient also requires protection against the development of eclampsia and seizures.
Pre-eclampsia is a condition that occurs during pregnancy and is characterized by high blood pressure, proteinuria, and edema. It can lead to complications such as eclampsia, neurological issues, fetal growth problems, liver involvement, and cardiac failure. Severe pre-eclampsia is marked by hypertension, proteinuria, headache, visual disturbances, and other symptoms. Risk factors for pre-eclampsia include hypertension in a previous pregnancy, chronic kidney disease, autoimmune disease, diabetes, chronic hypertension, first pregnancy, and age over 40. Aspirin may be recommended for women with high or moderate risk factors. Treatment involves emergency assessment, admission for observation, and medication such as labetalol, nifedipine, or hydralazine. Delivery of the baby is the most important step in management, with timing depending on the individual case.
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This question is part of the following fields:
- Obstetrics
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Question 24
Incorrect
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A 29-year-old woman is being monitored with cardiotocography (CTG) during her labor. What would be considered an 'abnormal' characteristic of the CTG tracings?
Your Answer: Baseline heart rate of 160 beats/minute
Correct Answer: A single prolonged deceleration lasting 3 minutes or more
Explanation:Cardiotocography (CTG) is a medical procedure that measures pressure changes in the uterus using either internal or external pressure transducers. It is used to monitor the fetal heart rate, which normally ranges between 100-160 beats per minute. There are several features that can be observed during a CTG, including baseline bradycardia (heart rate below 100 beats per minute), which can be caused by increased fetal vagal tone or maternal beta-blocker use. Baseline tachycardia (heart rate above 160 beats per minute) can be caused by maternal pyrexia, chorioamnionitis, hypoxia, or prematurity. Loss of baseline variability (less than 5 beats per minute) can be caused by prematurity or hypoxia. Early deceleration, which is a decrease in heart rate that starts with the onset of a contraction and returns to normal after the contraction, is usually harmless and indicates head compression. Late deceleration, on the other hand, is a decrease in heart rate that lags behind the onset of a contraction and does not return to normal until after 30 seconds following the end of the contraction. This can indicate fetal distress, such as asphyxia or placental insufficiency. Variable decelerations, which are independent of contractions, may indicate cord compression.
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This question is part of the following fields:
- Obstetrics
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Question 25
Incorrect
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A 26-year-old para 1+0 comes to the clinic at 36 weeks complaining of painless vaginal bleeding. She mentions having occasional spotting for the past 4 weeks, but it has become more frequent and heavier. Her blood pressure is 125/80 mmHg, and her heart rate is 85 bpm. During the examination, her abdomen is soft and non-tender, and the fetal head is not engaged and high. What further examination should you conduct to confirm your initial suspected diagnosis?
Your Answer: Cardiotocography of the fetus
Correct Answer: Transvaginal ultrasound
Explanation:The results are typical of placenta praevia, according to the findings.
The RCOG suggests transvaginal ultrasound as it enhances the precision of placental positioning and is deemed to be safe.Understanding Placenta Praevia
Placenta praevia is a condition where the placenta is located wholly or partially in the lower uterine segment. It is a relatively rare condition, with only 5% of women having a low-lying placenta when scanned at 16-20 weeks gestation. However, the incidence at delivery is only 0.5%, as most placentas tend to rise away from the cervix.
There are several factors associated with placenta praevia, including multiparity, multiple pregnancy, and embryos implanting on a lower segment scar from a previous caesarean section. Clinical features of placenta praevia include shock in proportion to visible loss, no pain, a non-tender uterus, abnormal lie and presentation, and a usually normal fetal heart. Coagulation problems are rare, and small bleeds may occur before larger ones.
Diagnosis of placenta praevia should not involve digital vaginal examination before an ultrasound, as this may provoke severe haemorrhage. The condition is often picked up on routine 20-week abdominal ultrasounds, but the Royal College of Obstetricians and Gynaecologists recommends the use of transvaginal ultrasound for improved accuracy and safety. Placenta praevia is classified into four grades, with grade IV being the most severe, where the placenta completely covers the internal os.
In summary, placenta praevia is a rare condition that can have serious consequences if not diagnosed and managed appropriately. It is important for healthcare professionals to be aware of the associated factors and clinical features, and to use appropriate diagnostic methods for accurate grading and management.
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This question is part of the following fields:
- Obstetrics
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Question 26
Incorrect
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A 29-year-old woman on day one postpartum who is breastfeeding is concerned about the safety of her pain medication. When you arrive, you find that the patient was prescribed acetaminophen for pain relief, but when she was offered this, she told the midwife it cannot be used as it can have detrimental effects for her baby. She wants to know if there are any other options. You explain that acetaminophen is safe to use while breastfeeding. Which of the following analgesics is another safe first line treatment to use in women who are breastfeeding?
Your Answer: Codeine
Correct Answer: Paracetamol
Explanation:Safe Pain Relief Options for Breastfeeding Mothers: A Guide to Medications
Breastfeeding mothers often experience pain and discomfort, and it is important to know which pain relief options are safe to use while nursing. Paracetamol and ibuprofen are considered safe and can be used as first-line medication for analgesia. Codeine and other opiates can be used sparingly as third-line medication, but caution must be taken as some women may be slow metabolizers and it can cause drowsiness and respiratory depression in the infant. Aspirin is contraindicated due to the risk of Reye’s disease and other side-effects. Naproxen is generally safe, but paracetamol and ibuprofen should be the mainstay of analgesia. Tramadol can be used with caution and should be prescribed by a specialist. It is important to advise the woman on the safe use of medication and to monitor for any signs of toxicity in the infant.
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This question is part of the following fields:
- Obstetrics
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Question 27
Correct
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A 32-year-old woman who is 32 weeks pregnant presents with vaginal bleeding and is diagnosed with placenta accreta. What is the primary risk factor associated with this condition?
Your Answer: Previous caesarean sections
Explanation:Understanding Placenta Accreta
Placenta accreta is a condition where the placenta attaches to the myometrium instead of the decidua basalis, which can lead to postpartum hemorrhage. This condition is caused by a defective decidua basalis. There are three types of placenta accreta, which are categorized based on the degree of invasion. The first type is accreta, where the chorionic villi attach to the myometrium. The second type is increta, where the chorionic villi invade into the myometrium. The third type is percreta, where the chorionic villi invade through the perimetrium.
There are certain risk factors that increase the likelihood of developing placenta accreta, such as having a previous caesarean section or placenta previa. It is important for healthcare providers to be aware of these risk factors and monitor patients closely during pregnancy and delivery. Early detection and management of placenta accreta can help prevent complications and ensure the best possible outcome for both the mother and baby.
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This question is part of the following fields:
- Obstetrics
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Question 28
Incorrect
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A 28-year-old pregnant woman is undergoing screening for gestational diabetes. She has no significant medical history and this is her first pregnancy. During the screening, her fasting blood glucose level is measured at 7.2 mmol/L. What is the best course of action for management?
Your Answer: Trial of lifestyle changes for 1-2 weeks
Correct Answer: Start insulin only
Explanation:The most appropriate course of action for gestational diabetes with a fasting glucose level of >= 7 mmol/L at diagnosis is to commence insulin. While lifestyle changes and co-prescribing metformin should also be discussed, starting insulin is the priority according to NICE guidelines. Re-checking glucose in 2 weeks, starting exenatide, or relying on lifestyle changes alone would not be appropriate. Metformin alone may not be sufficient for glucose levels above 7 mmol/L, but it can be used in combination with insulin. If glucose levels are below 7 mmol/L, lifestyle changes can be trialed before considering metformin.
Gestational diabetes is a common medical disorder affecting around 4% of pregnancies. Risk factors include a high BMI, previous gestational diabetes, and family history of diabetes. Screening is done through an oral glucose tolerance test, and diagnostic thresholds have recently been updated. Management includes self-monitoring of blood glucose, diet and exercise advice, and medication if necessary. For pre-existing diabetes, weight loss and insulin are recommended, and tight glycemic control is important. Targets for self-monitoring include fasting glucose of 5.3 mmol/l and 1-2 hour post-meal glucose levels.
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This question is part of the following fields:
- Obstetrics
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Question 29
Incorrect
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A 28-year-old primigravida woman is rushed for an emergency caesarean section due to fetal distress and hypoxia detected on cardiotocography. She is currently at 31 weeks gestation.
After delivery, the baby is admitted to the neonatal intensive care unit (NICU) and given oxygen to aid breathing difficulties.
Several weeks later, during an ophthalmological examination, the baby is found to have bilateral absent red reflex and retinal neovascularisation.
What is the probable diagnosis?Your Answer: Retinoblastoma
Correct Answer: Retinopathy of prematurity
Explanation:Risks Associated with Prematurity
Prematurity is a condition that poses several risks to the health of newborns. The risk of mortality increases with decreasing gestational age. Premature babies are at risk of developing respiratory distress syndrome, intraventricular haemorrhage, necrotizing enterocolitis, chronic lung disease, hypothermia, feeding problems, infection, jaundice, and retinopathy of prematurity. Retinopathy of prematurity is a significant cause of visual impairment in babies born before 32 weeks of gestation. The cause of this condition is not fully understood, but it is believed that over oxygenation during ventilation can lead to the proliferation of retinal blood vessels, resulting in neovascularization. Screening for retinopathy of prematurity is done in at-risk groups. Premature babies are also at risk of hearing problems.
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This question is part of the following fields:
- Obstetrics
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Question 30
Incorrect
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A 25-year-old primiparous patient is seen at home by the community midwife for a routine antenatal visit. She is 34 weeks pregnant and has had an uneventful pregnancy to date. On examination, she is well and has a symphysis fundal height of 33 cm. Her blood pressure is 155/92 mmHg and she has 2++ protein in the urine.
What is the most likely diagnosis?Your Answer: Pregnancy-induced hypertension
Correct Answer: Pre-eclampsia
Explanation:Understanding Hypertension in Pregnancy
Hypertension in pregnancy can be a serious condition that requires urgent assessment and management. Pre-eclampsia, characterized by both hypertension and proteinuria, is a common diagnosis. Early detection and management can prevent complications.
Normal blood pressure during pregnancy typically drops slightly in the first and second trimesters and rises back to pre-pregnancy levels in the third trimester. However, some patients may have chronic hypertension that was previously undiagnosed.
White-coat hypertension, where blood pressure is elevated in a clinical setting but normal at home, should be ruled out before a diagnosis of pregnancy-induced hypertension is made. This type of hypertension occurs after week 20 of pregnancy but without proteinuria. Regular screening for proteinuria is necessary in these cases.
In cases of mild to moderate hypertension, patients may be admitted to the hospital and monitored or started on oral labetalol. Severe hypertension requires immediate hospitalization and treatment. Overall, understanding hypertension in pregnancy is crucial for the health and well-being of both the mother and baby.
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This question is part of the following fields:
- Obstetrics
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Question 31
Incorrect
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You are a FY-1 doctor working in obstetrics. For one day a week you are based in the early pregnancy assessment unit (EPAU). You are assessing a 28-year-old female with a suspected threatened miscarriage. How does this condition typically manifest?
Your Answer: Per-vaginal bleeding and an open cervical os
Correct Answer: Painless per-vaginal bleeding and a closed cervical os
Explanation:A threatened miscarriage is characterized by bleeding, but the cervical os remains closed. Miscarriages can be classified as threatened, inevitable, incomplete, complete, or missed. Mild bleeding and little to no pain are typical symptoms of a threatened miscarriage. In contrast, an inevitable miscarriage is marked by heavy bleeding with clots and pain, and the cervical os is open. Inevitable miscarriages will not result in a continued pregnancy and will progress to incomplete or complete miscarriages.
Miscarriage is a common complication that can occur in up to 25% of all pregnancies. There are different types of miscarriage, each with its own set of symptoms and characteristics. Threatened miscarriage is painless vaginal bleeding that occurs before 24 weeks, typically at 6-9 weeks. The bleeding is usually less than menstruation, and the cervical os is closed. Missed or delayed miscarriage is when a gestational sac containing a dead fetus is present before 20 weeks, without the symptoms of expulsion. The mother may experience light vaginal bleeding or discharge, and the symptoms of pregnancy may disappear. Pain is not usually a feature, and the cervical os is closed. Inevitable miscarriage is characterized by heavy bleeding with clots and pain, and the cervical os is open. Incomplete miscarriage occurs when not all products of conception have been expelled, and there is pain and vaginal bleeding. The cervical os is open in this type of miscarriage.
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This question is part of the following fields:
- Obstetrics
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Question 32
Incorrect
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A 28-year-old woman presents one week following delivery with some concerns about breastfeeding. She is exclusively breastfeeding at present, but the baby has lost weight (400 g) and she finds breastfeeding difficult and painful. The baby weighed 3200 grams at the time of birth. There is pain in both nipples, worse at the beginning of the feed, and clicking noises are heard when the baby is feeding. She sometimes has to stop feeding because of the discomfort.
On examination, the breasts are engorged and there is no area of erythema or tenderness. The nipples appear normal, and there is no discharge or erythema.
Which of the following is the most appropriate next step in this patient’s management?Your Answer: Flucloxacillin for 10–14 days
Correct Answer: Refer to a breastfeeding specialist for assessment
Explanation:Management of Breastfeeding Difficulties: Referral to a Specialist for Assessment
Breastfeeding is a crucial process for the health and well-being of both the mother and the infant. However, some mothers may experience difficulties, such as poor latch, which can lead to pain, discomfort, and inadequate feeding. In such cases, it is essential to seek professional help from a breastfeeding specialist who can assess the situation and offer advice and support.
One of the key indicators of poor latch is pain in both nipples, especially at the beginning of the feed, accompanied by clicking noises from the baby, indicating that they are chewing on the nipple. Additionally, if the baby has lost weight, it may be a sign that they are not feeding enough. On the other hand, a good latch is characterized by a wide-open mouth of the baby, with its chin touching the breast and the nose free, less areola seen under the chin than over the nipple, the lips rolled out, and the absence of pain. The mother should also listen for visible and audible swallowing sounds.
In cases where there is no evidence of skin conditions or nipple infection, the patient does not require any treatment at present. However, if there is suspicion of a fungal infection of the nipple, presenting with sharp pain and itching of the nipples, associated with erythema and worsening of the pain after the feeds, topical miconazole may be recommended. Similarly, if there is psoriasis of the nipple and areola, presenting as raised, red plaques with an overlying grey-silver scale, regular emollients may be advised.
It is important to note that flucloxacillin is not recommended in cases where there is no evidence of infection, such as ductal infection or mastitis. Moreover, nipple shields are not recommended as they often exacerbate the poor positioning and symptoms associated with poor latch.
In summary, seeking professional help from a breastfeeding specialist is crucial in managing breastfeeding difficulties, especially poor latch. The specialist can observe the mother breastfeeding, offer advice, and ensure that the method is improved to allow successful feeding.
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This question is part of the following fields:
- Obstetrics
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Question 33
Correct
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A 25-year-old woman had blood tests taken at her 12-week booking appointment with the midwife. This is her first pregnancy and she has no significant medical history. The results of her full blood count (FBC) are as follows:
- Hb: 110 g/L (normal range for females: 115-160 g/L)
- Platelets: 340 x 10^9/L (normal range: 150-400 x 10^9/L)
- WBC: 7.2 x 10^9/L (normal range: 4.0-11.0 x 10^9/L)
What would be the most appropriate course of action based on these results?Your Answer: Start oral iron replacement therapy
Explanation:To determine if iron supplementation is necessary, a cut-off of 110 g/L should be applied during the first trimester.
During pregnancy, women are checked for anaemia twice – once at the initial booking visit (usually around 8-10 weeks) and again at 28 weeks. The National Institute for Health and Care Excellence (NICE) has set specific cut-off levels to determine if a pregnant woman requires oral iron therapy. These levels are less than 110 g/L in the first trimester, less than 105 g/L in the second and third trimesters, and less than 100 g/L postpartum.
If a woman’s iron levels fall below these cut-offs, she will be prescribed oral ferrous sulfate or ferrous fumarate. It is important to continue this treatment for at least three months after the iron deficiency has been corrected to allow the body to replenish its iron stores. By following these guidelines, healthcare professionals can help ensure that pregnant women receive the appropriate care to prevent and manage anaemia during pregnancy.
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This question is part of the following fields:
- Obstetrics
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Question 34
Incorrect
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A 29-year-old woman who is 20-weeks pregnant comes to the emergency department after noticing a vesicular rash on her torso this morning. Upon further questioning, you discover that her 5-year-old daughter developed chickenpox last week and the patient cannot recall if she has had the condition before. She seems at ease while resting.
Serological testing for varicella zoster virus reveals the following results:
Varicella IgM Positive
Varicella IgG Negative
What is the most suitable course of action?Your Answer: Varicella zoster vaccination
Correct Answer: Oral acyclovir
Explanation:Chickenpox exposure in pregnancy can pose risks to both the mother and fetus, including fetal varicella syndrome. Post-exposure prophylaxis (PEP) with varicella-zoster immunoglobulin (VZIG) or antivirals should be given to non-immune pregnant women, with timing dependent on gestational age. If a pregnant woman develops chickenpox, specialist advice should be sought and oral acyclovir may be given if she is ≥ 20 weeks and presents within 24 hours of onset of the rash.
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This question is part of the following fields:
- Obstetrics
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Question 35
Incorrect
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A diabetic woman attends for an ultrasound scan during her third trimester of pregnancy. The physician reporting the scan calculates an amniotic index >95th centile and diagnoses polyhydramnios.
What volume of amniotic fluid is considered to be consistent with polyhydramnios?Your Answer: >1–2 l of amniotic fluid
Correct Answer: >2–3 l of amniotic fluid
Explanation:Understanding Polyhydramnios: Excess Amniotic Fluid in Pregnancy
Polyhydramnios is a condition in which there is an excess of amniotic fluid in the second and third trimesters of pregnancy. This excess fluid is produced by the fetal kidneys and is normally swallowed by the fetus. Diagnosis of polyhydramnios is made by ultrasound assessment of the amount of fluid. If the deepest vertical pool is greater than 8 cm or if the amniotic fluid index (AFI) is greater than the 95th percentile for the corresponding gestational age, polyhydramnios is diagnosed.
Polyhydramnios occurs in approximately 2% of all pregnancies and is associated with maternal diabetes and fetal anomalies resulting in gastrointestinal obstruction, such as esophageal atresia and poor fetal swallowing.
It is important to note that normal amniotic fluid varies and increases with gestational age, peaking at around 1 liter. An excess of 2 liters or more is considered consistent with polyhydramnios. Understanding this condition can help healthcare providers monitor and manage pregnancies for the best possible outcomes.
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This question is part of the following fields:
- Obstetrics
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Question 36
Incorrect
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A 32-year-old woman who is at 16 weeks gestation attends her antenatal appointment and is given the option to undergo the quadruple test for chromosomal disorders. After consenting, she has a blood test and is later informed that the results indicate a higher likelihood of Down's syndrome in the fetus. The patient is now invited to discuss the next course of action. What is the probable outcome of the quadruple test?
Your Answer: Decreased AFP, decreased oestriol, decreased hCG, normal inhibin A
Correct Answer: Decreased AFP, decreased oestriol, increased hCG, increased inhibin A
Explanation:The correct result for the quadruple test in a patient with Down’s syndrome is a decrease in AFP and oestriol, and an increase in hCG and inhibin A. This test is recommended by NICE for pregnant patients between 15-20 weeks gestation. If the screening test shows an increased risk, further diagnostic tests such as NIPT, amniocentesis, or chorionic villous sampling may be offered to confirm the diagnosis. It is important to note that a pattern of decreased AFP, decreased oestriol, decreased hCG, and normal inhibin A is suggestive of an increased risk of Edward’s syndrome. Increased AFP, increased oestriol, decreased hCG, and decreased inhibin A or any other combination of abnormal results may not be indicative of Down’s syndrome.
NICE updated guidelines on antenatal care in 2021, recommending the combined test for screening for Down’s syndrome between 11-13+6 weeks. The test includes nuchal translucency measurement, serum B-HCG, and pregnancy-associated plasma protein A (PAPP-A). The quadruple test is offered between 15-20 weeks for women who book later in pregnancy. Results are interpreted as either a ‘lower chance’ or ‘higher chance’ of chromosomal abnormalities. If a woman receives a ‘higher chance’ result, she may be offered a non-invasive prenatal screening test (NIPT) or a diagnostic test. NIPT analyzes cell-free fetal DNA in the mother’s blood and has high sensitivity and specificity for detecting chromosomal abnormalities. Private companies offer NIPT screening from 10 weeks gestation.
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This question is part of the following fields:
- Obstetrics
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Question 37
Incorrect
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A 29-year-old woman presents with hypertension at 12 weeks into her pregnancy. She has no history of hypertension. She complains of headache and tenderness in the right lower quadrant. An ultrasound of her pelvis reveals multiple cysts in both ovaries. There are no signs of hirsutism or virilism. What is the most probable diagnosis?
Your Answer: Adrenal tumour
Correct Answer: Molar pregnancy
Explanation:Possible Causes of Hirsutism in Women: A Differential Diagnosis
Hirsutism, the excessive growth of hair in women in a male pattern, can be caused by various underlying conditions. Here are some possible causes and their distinguishing features:
Molar Pregnancy: This condition is characterized by hypertension in the first trimester of pregnancy. Excessive stimulation of ovarian follicles by high levels of gonadotrophins or human chorionic gonadotrophin (hCG) can lead to the formation of multiple theca lutein cysts bilaterally.
Congenital Adrenal Hyperplasia: This disease, which is mostly found in women, can present with gradual onset of hirsutism without virilization. It is caused by a deficiency of 21-hydroxylase and is characterized by an elevated serum concentration of 17-hydroxyprogesterone.
Luteoma of Pregnancy: This benign, solid ovarian tumor develops during pregnancy and disappears after delivery. It may be associated with excess androgen production, leading to hirsutism and virilization.
Adrenal Tumor: Androgen-secreting adrenal tumors can cause rapid onset of severe hirsutism, with or without virilization. Amenorrhea is found in almost half of the patients, and testosterone and dihydrotestosterone sulfate concentrations are elevated.
Polycystic Ovary Syndrome: Women with this condition are at higher risk of developing pre-eclampsia. However, the development of hypertension in the first trimester of pregnancy makes it more likely that there is a molar pregnancy present, with theca lutein cysts seen on ultrasound.
In summary, hirsutism in women can be caused by various conditions, and a differential diagnosis is necessary to determine the underlying cause and appropriate treatment.
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This question is part of the following fields:
- Obstetrics
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Question 38
Correct
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A 32-year-old woman who is at 10 weeks’ gestation in her second pregnancy sees her midwife to receive her Booking Clinic blood results. She feels a bit tired at present and appears pale. She denies any infective symptoms, and observations and examination are unremarkable.
Her full blood count is as follows:
Investigation Result Normal value
Haemoglobin 101 g/l 115–155 g/l
Mean corpuscular volume (MCV) 73 fl 76–98 fl
White cell count (WCC) 7 × 109/l 4–11 × 109/l
Platelets 323 × 109/l 150–400 × 109/l
Which of the following statements best describes the management of anaemia in pregnancy?Your Answer: A trial of iron supplementation, followed by a re-check of the full blood count at two weeks, is the standard method for treating anaemia in pregnancy
Explanation:The standard method for treating anaemia in pregnancy is to conduct a full blood count at the booking appointment and at 28 weeks, or when the patient is symptomatic, and to initiate treatment if a normocytic or microcytic anaemia is detected. Iron deficiency is the most common cause of anaemia in pregnancy, and oral iron supplementation is the first-line treatment. A repeat full blood count should be performed two weeks after starting iron supplementation, and if there is an upward trend in haemoglobin levels, iron supplementation should continue. If the trial fails to increase haemoglobin levels, further investigations should be conducted, and referral to a Combined Obstetric/Haematologic Clinic may be necessary. Serum ferritin is the most specific test for iron deficiency anaemia, and a value of < 30 μg/l in pregnancy should prompt iron supplementation. All pregnant women in the UK are not recommended to be offered iron supplementation, but only those with anaemia. Anaemia is defined as a haemoglobin level of < 110 g/dl in the first trimester and < 105 g/l in the second trimester. In an uncomplicated, low-risk pregnancy, the full blood count is assessed twice, at the booking visit and at 28 weeks of gestation. Postpartum anaemia is defined as a haemoglobin level of < 100 g/l, and oral iron supplementation for three months is recommended to replenish iron stores. Ferrous sulfate and ferrous fumarate are commonly used oral preparations of iron.
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This question is part of the following fields:
- Obstetrics
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Question 39
Incorrect
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A 26-year-old woman presents with significant vaginal bleeding and is diagnosed with a hydatidiform mole. The uterus is evacuated, but she continues to feel unwell and her β-human chorionic gonadotrophin (β-HCG) levels continue to increase in the following weeks.
What is the most probable diagnosis?Your Answer: Second, untreated, non-invasive hydatidiform mole
Correct Answer: Choriocarcinoma
Explanation:Gestational trophoblastic disease (GTD) is a rare condition that includes hydatidiform mole, choriocarcinoma, and placental site trophoblastic tumor. GTD occurs when abnormal trophoblastic tissue forms instead of a fetus after fertilization. Hydatidiform moles are the most common form of GTD and are found in about 1 in every 1000 births. They often present with signs of early pregnancy failure, such as heavy vaginal bleeding. Treatment involves removing the abnormal tissue, and close monitoring of beta-HCG levels is necessary post-evacuation. If levels fail to drop, it may indicate an invasive mole or choriocarcinoma, which requires referral to a specialist center for further treatment. Pituitary and adrenal adenomas are other types of tumors that can produce hormones and cause various symptoms. In contrast, ectopic pregnancy is a separate condition that occurs when a fertilized egg implants outside the uterus.
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This question is part of the following fields:
- Obstetrics
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Question 40
Incorrect
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A 25-year-old female patient visits her GP complaining of severe lower abdominal pain that is not relieved by painkillers. She has no significant medical history. During the evaluation, her GP conducts a pregnancy test, which comes back positive. The patient is immediately referred to the hospital, where a transvaginal ultrasound confirms an ectopic pregnancy in the left tube. What is the best course of action for management?
Your Answer: Vaginal misoprostol
Correct Answer: Salpingectomy
Explanation:If a patient has an ectopic pregnancy, the treatment plan will depend on various factors such as the size and location of the pregnancy, the patient’s overall health, and the potential impact on their fertility. If the pregnancy is small and the patient’s health is stable, they may be able to receive medication to dissolve the pregnancy. However, if the pregnancy is larger or causing severe symptoms, surgery may be necessary.
In cases where surgery is required, the surgeon may attempt to preserve the affected fallopian tube if possible. However, if the tube is severely damaged or the patient has other factors that may affect their fertility, such as age or previous fertility issues, the surgeon may opt to remove the tube completely. This decision will also depend on the patient’s desire for future fertility and the likelihood of requiring further treatment with methotrexate or a salpingectomy. If the patient’s contralateral tube is unaffected, complete removal of the affected tube may be the most appropriate course of action.
Ectopic pregnancy is a serious condition that requires prompt investigation and management. Women who are stable are typically investigated and managed in an early pregnancy assessment unit, while those who are unstable should be referred to the emergency department. The investigation of choice for ectopic pregnancy is a transvaginal ultrasound, which will confirm the presence of a positive pregnancy test.
There are three ways to manage ectopic pregnancies: expectant management, medical management, and surgical management. The choice of management will depend on various criteria, such as the size of the ectopic pregnancy, whether it is ruptured or not, and the patient’s symptoms and hCG levels. Expectant management involves closely monitoring the patient over 48 hours, while medical management involves giving the patient methotrexate and requires follow-up. Surgical management can involve salpingectomy or salpingostomy, depending on the patient’s risk factors for infertility.
Salpingectomy is the first-line treatment for women without other risk factors for infertility, while salpingostomy should be considered for women with contralateral tube damage. However, around 1 in 5 women who undergo a salpingostomy require further treatment, such as methotrexate and/or a salpingectomy. It is important to carefully consider the patient’s individual circumstances and make a decision that will provide the best possible outcome.
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This question is part of the following fields:
- Obstetrics
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Question 41
Incorrect
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A 25-year-old woman who is 16 weeks pregnant comes to her GP with concerns of exposure to an infectious disease. Her neighbor's son has a rash and a high temperature. She has no medical history and is unsure if she had chickenpox in childhood. What is the initial step to take?
Your Answer: Immediate administration of varicella-zoster immunoglobulin
Correct Answer: Check varicella antibodies
Explanation:When a pregnant woman is exposed to chickenpox, the first step is to check if she has varicella antibodies. If she is unsure whether she has had chickenpox in the past, the presence or absence of antibodies will determine the next course of action.
If a pregnant woman is over 20 weeks gestation and does not have varicella antibodies, she should be given varicella-zoster immunoglobulin or oral acyclovir within 7-14 days of exposure. Delaying the administration of oral acyclovir can reduce the risk of developing chickenpox.
Oral acyclovir is also recommended if a pregnant woman over 20 weeks gestation develops chickenpox. However, caution should be exercised if the patient is under 20 weeks gestation and does not have any symptoms of chickenpox.
The varicella-zoster vaccine is not recommended for pregnant women as it is a live attenuated vaccine that can cross the placenta and cause foetal varicella syndrome. It can be given to women who have not had chickenpox and are not immune to antibody testing, but they should avoid getting pregnant for three months after receiving the vaccine.
Varicella-zoster immunoglobulin is recommended for pregnant women who are not immune to varicella on antibody testing and can receive it within 10 days of exposure. However, it provides short-lived protection, so patients should be advised to get the varicella-zoster vaccine after their pregnancy.
Chickenpox exposure in pregnancy can pose risks to both the mother and fetus, including fetal varicella syndrome. Post-exposure prophylaxis (PEP) with varicella-zoster immunoglobulin (VZIG) or antivirals should be given to non-immune pregnant women, with timing dependent on gestational age. If a pregnant woman develops chickenpox, specialist advice should be sought and oral acyclovir may be given if she is ≥ 20 weeks and presents within 24 hours of onset of the rash.
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This question is part of the following fields:
- Obstetrics
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Question 42
Correct
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A 23-year-old asthmatic woman has been brought to the emergency department after experiencing seizures during her pregnancy. She is currently 35 weeks pregnant and has been diagnosed with gestational hypertension by her doctor. She is taking oral medication to manage her condition. Upon examination, her urine test shows proteinuria (3+) and her blood pressure is elevated at 170/115 mmHg. As a result, the baby is delivered and the patient's seizures have ceased. What is the most appropriate treatment option for her seizures after delivery, given her probable diagnosis?
Your Answer: Magnesium sulphate for 24 hours after delivery/last seizure
Explanation:The correct answer is that magnesium sulphate treatment should continue for 24 hours after delivery or the last seizure. This treatment is used to prevent and treat seizures in mothers with eclampsia. In this case, the patient is showing signs of eclampsia due to high protein levels in her urine, pregnancy-induced hypertension, and seizures. Therefore, she needs to be admitted and continue magnesium treatment for 24 hours after delivery or the last seizure. Magnesium helps prevent seizures by relaxing smooth muscle tissues and slowing uterine contractions. Labetalol is not the correct answer as it is used for long-term treatment of hypertension, which may not be necessary for this patient after delivery. Nifedipine with hydralazine may be more suitable for her hypertension as she is asthmatic. Magnesium sulphate treatment for 12 or 48 hours after delivery or the last seizure is not recommended according to guidelines, which suggest 24 hours is the appropriate duration.
Understanding Eclampsia and its Treatment
Eclampsia is a condition that occurs when seizures develop in association with pre-eclampsia, a pregnancy-induced hypertension that is characterized by proteinuria and occurs after 20 weeks of gestation. To prevent seizures in patients with severe pre-eclampsia and treat seizures once they develop, magnesium sulphate is commonly used. However, it is important to note that this medication should only be given once a decision to deliver has been made. In cases of eclampsia, an IV bolus of 4g over 5-10 minutes should be given, followed by an infusion of 1g/hour. During treatment, it is crucial to monitor urine output, reflexes, respiratory rate, and oxygen saturations. Respiratory depression can occur, and calcium gluconate is the first-line treatment for magnesium sulphate-induced respiratory depression. Treatment should continue for 24 hours after the last seizure or delivery, as around 40% of seizures occur post-partum. Additionally, fluid restriction is necessary to avoid the potentially serious consequences of fluid overload.
In summary, understanding the development of eclampsia and its treatment is crucial in managing this potentially life-threatening condition. Magnesium sulphate is the primary medication used to prevent and treat seizures, but it should only be given once a decision to deliver has been made. Monitoring vital signs and urine output is essential during treatment, and calcium gluconate should be readily available in case of respiratory depression. Finally, fluid restriction is necessary to avoid complications associated with fluid overload.
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This question is part of the following fields:
- Obstetrics
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Question 43
Incorrect
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A 29-year-old woman in her first pregnancy presents at 30 weeks’ gestation with an episode of antepartum haemorrhage. She noticed fresh red blood on wiping this morning and followed by spotting since. She denies any pain, and the abdomen is soft and non-tender on examination. The baby is moving well. This is the first episode of bleeding in this pregnancy. She is under midwifery-led care but tells you she has a scan booked for 32 weeks. Urinalysis is unremarkable, and her observations are stable.
Which of the following is the most likely cause of this patient’s antepartum haemorrhage?Your Answer: Concealed placental abruption
Correct Answer: Placenta praevia
Explanation:Antepartum Haemorrhage: Causes and Differential Diagnosis
Antepartum haemorrhage can be caused by various conditions, including placenta praevia, placental abruption, genitourinary infection, and premature labour. Placenta praevia occurs when the placenta covers the internal cervical os, leading to painless vaginal bleeding. Risk factors include maternal age, multiparity, and smoking. Diagnosis is made through ultrasound scanning, and close monitoring is necessary to prevent rebleeding. Placental abruption can be revealed or concealed, with the former causing significant abdominal pain and vaginal bleeding, while the latter is confined within the uterus. Genitourinary infection should also be considered, although this patient’s urinalysis is unremarkable. Premature labour, which is associated with cyclical abdominal pain, is another possible cause of antepartum bleeding. However, this patient presents without pain. A thorough differential diagnosis is crucial in managing antepartum haemorrhage.
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This question is part of the following fields:
- Obstetrics
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Question 44
Incorrect
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A 32-year-old woman presents to the Labour Ward at 38 weeks’ gestation for an elective Caesarean section. She has human immunodeficiency virus (HIV), had been taking combined highly active antiretroviral therapy (HAART) during pregnancy, and her viral load today is 60 copies/ml. She is asking about breastfeeding and also wants to know what will happen to the baby once it is born.
Which of the following statements best answers this patient’s questions?Your Answer: Breastfeeding should be avoided and the baby will have a single blood test two days after birth to confirm if they have HIV
Correct Answer: Breastfeeding should be avoided and the baby should have antiretroviral therapy for 4–6 weeks
Explanation:Guidelines for HIV-positive mothers and breastfeeding
Breastfeeding is not recommended for HIV-positive mothers as it increases the risk of transmission to the child. Instead, the baby should receive a first dose of antiretroviral therapy within four hours of delivery and continue treatment for 4-6 weeks. Blood tests are taken at set intervals to check the baby’s status. Hepatitis B vaccination should be offered at birth only if there is co-infection with hepatitis B virus in the mother.
However, if the mother’s viral load is less than 50 copies/ml, breastfeeding may be considered in low-resource settings where the nutritive benefits outweigh the risk of transmission. In high-resource settings, breastfeeding is not advised. The baby will still need to undergo several blood tests to establish their HIV status, with the last one taking place at 18 months of life.
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This question is part of the following fields:
- Obstetrics
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Question 45
Correct
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A 35-year-old woman presents with a two-week history of morning sickness. She is 10 weeks pregnant. She can keep down oral fluid but has vomited twice in the previous 24 hours. There are no acid reflux symptoms, abdominal pain, vaginal bleeding or urinary symptoms.
She takes folic acid and is not on any other medications.
On examination, her temperature is 36.8ºC. Blood pressure is 100/60 mmHg and heart rate is 80/min. Her abdomen is soft and non-tender. Urine B-HCG is positive and urine dipstick shows 1+ ketone only. There is no weight loss.
What is the most appropriate management option for this patient?Your Answer: Commence on oral cyclizine
Explanation:The recommended first-line treatment for nausea and vomiting in pregnancy or hyperemesis gravidarum is antihistamines, specifically oral cyclizine. Second-line options include ondansetron and domperidone. Hospital admission may be necessary if the patient cannot tolerate oral medications or fluids, or if symptoms are not controlled with primary care management. There is no indication for oral omeprazole in this case as the patient has not reported any dyspeptic symptoms.
Hyperemesis gravidarum is an extreme form of nausea and vomiting of pregnancy that occurs in around 1% of pregnancies and is most common between 8 and 12 weeks. It is associated with raised beta hCG levels and can be caused by multiple pregnancies, trophoblastic disease, hyperthyroidism, nulliparity, and obesity. Referral criteria for nausea and vomiting in pregnancy include continued symptoms with ketonuria and/or weight loss, a confirmed or suspected comorbidity, and inability to keep down liquids or oral antiemetics. The diagnosis of hyperemesis gravidarum requires the presence of 5% pre-pregnancy weight loss, dehydration, and electrolyte imbalance. Management includes first-line use of antihistamines and oral cyclizine or promethazine, with second-line options of ondansetron and metoclopramide. Admission may be needed for IV hydration. Complications can include Wernicke’s encephalopathy, Mallory-Weiss tear, central pontine myelinolysis, acute tubular necrosis, and fetal growth issues.
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This question is part of the following fields:
- Obstetrics
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Question 46
Incorrect
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A 25-year-old woman is being assessed in the postpartum unit, 48 hours after a vaginal delivery. The delivery was uncomplicated and she is eager to be discharged. She has initiated breastfeeding and is forming a strong attachment with her newborn.
When inquired about birth control, she reports that she previously used the progesterone-only pill and wishes to resume this method. What is the soonest she can restart this contraception?Your Answer: Six months
Correct Answer: Immediately
Explanation:The progesterone-only pill can be taken by postpartum women (both breastfeeding and non-breastfeeding) at any time after delivery. It is categorized as UKMEC 1, meaning there are no restrictions on its use. Women can start taking it immediately if they choose to do so, and there is no need to wait for three weeks before starting. The combined oral contraceptive pill (COCP) can be taken as UKMEC 2 after three weeks in non-breastfeeding women, and after six weeks in breastfeeding women or as UKMEC 1 in non-breastfeeding women. In breastfeeding women, the COCP can be taken as UKMEC 1 after six months. The progesterone-only pill is safe for breastfeeding women as it has minimal transfer into breast milk, and there is no harm to the baby.
After giving birth, women need to use contraception after 21 days. The progesterone-only pill (POP) can be started at any time postpartum, according to the FSRH. Additional contraception should be used for the first two days after day 21. A small amount of progesterone enters breast milk, but it is not harmful to the infant. On the other hand, the combined oral contraceptive pill (COCP) is absolutely contraindicated (UKMEC 4) if breastfeeding is less than six weeks post-partum. If breastfeeding is between six weeks and six months postpartum, it is a UKMEC 2. The COCP may reduce breast milk production in lactating mothers. It should not be used in the first 21 days due to the increased venous thromboembolism risk post-partum. After day 21, additional contraception should be used for the first seven days. The intrauterine device or intrauterine system can be inserted within 48 hours of childbirth or after four weeks.
The lactational amenorrhoea method (LAM) is 98% effective if the woman is fully breastfeeding (no supplementary feeds), amenorrhoeic, and less than six months post-partum. It is important to note that an inter-pregnancy interval of less than 12 months between childbirth and conceiving again is associated with an increased risk of preterm birth, low birth weight, and small for gestational age babies.
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This question is part of the following fields:
- Obstetrics
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Question 47
Incorrect
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A 32-year-old teacher with type II diabetes is 5-months pregnant with her first child. Following reviewing the patient in prenatal clinic, you are interested to find out more about stages of fetal development.
During the fifth (gestational) month of human development, which organ is the most active site of formation of formed elements of the blood?Your Answer: Yolk sac
Correct Answer: Bone marrow
Explanation:The Sites of Haematopoiesis in the Fetus and Adult
Haematopoiesis, the process of blood cell formation, occurs in various sites throughout fetal development and in adults. The dominant site of haematopoiesis changes as the fetus develops and bones are formed. Here are the different sites of haematopoiesis and their significance:
Bone Marrow: From four months into childhood and adulthood, bone marrow becomes the primary source of hematopoiesis. Red blood cells and immune effector cells are derived from pluripotent haematopoietic cells, which are first noted in blood islands of the yolk sac. By 20 weeks, almost all of these cells are produced by the bone marrow.
Yolk Sac: Haematopoiesis begins in the yolk sac and in angiogenic cell clusters throughout the embryonic body. This involves the formation of nucleated red blood cells, which differentiate from endothelial cells in the walls of blood vessels. Yolk sac haematopoiesis peaks at about one month and becomes insignificant by three months.
Liver: By the sixth week, the fetal liver performs haematopoiesis. This peaks at 12-16 weeks and continues until approximately 36 weeks. Haematopoietic stem cells differentiate in the walls of liver sinusoids. In adults, there is a reserve haematopoietic capacity, especially in the liver.
Spleen: The spleen is a minor site of haematopoiesis, being active between the third and sixth months.
Lymph Nodes: Lymph nodes are not a significant site of haematopoiesis.
In patients with certain conditions, such as haemolytic anaemia or myeloproliferative disease, hepatic haematopoiesis may be reactivated, leading to hepatomegaly. Understanding the different sites of haematopoiesis is important for understanding blood cell formation and certain medical conditions.
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This question is part of the following fields:
- Obstetrics
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Question 48
Correct
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A 32-year-old woman who is 36 weeks pregnant visits her midwife for a routine check-up. She reports feeling generally well, but mentions experiencing constipation and has been taking lactulose for relief. The midwife conducts the following assessments:
- Fundal height: 37cm
- Blood pressure: 140/90 mmHg
- Urine dip: protein 1+
What would be the best course of action for the midwife to take in managing this patient?Your Answer: Urgent obstetrics referral
Explanation:If pre-eclampsia is suspected in a woman, NICE recommends arranging emergency secondary care assessment. This is because pre-eclampsia can be asymptomatic and potentially life-threatening. In this case, the patient has high blood pressure (>=140/90 mmHg) and proteinuria (>= +1), which are features of pre-eclampsia. While a growth scan may be necessary as part of her overall management, it is not the priority at this time. Home BP monitoring is also not indicated now, as she needs further assessment first. Repeating the assessment in 24 hours is not appropriate, as emergency secondary care assessment is necessary. While labetalol may be used to manage her blood pressure, it should not be initiated before obstetric specialist investigation and input.
Pre-eclampsia is a condition that occurs during pregnancy and is characterized by high blood pressure, proteinuria, and edema. It can lead to complications such as eclampsia, neurological issues, fetal growth problems, liver involvement, and cardiac failure. Severe pre-eclampsia is marked by hypertension, proteinuria, headache, visual disturbances, and other symptoms. Risk factors for pre-eclampsia include hypertension in a previous pregnancy, chronic kidney disease, autoimmune disease, diabetes, chronic hypertension, first pregnancy, and age over 40. Aspirin may be recommended for women with high or moderate risk factors. Treatment involves emergency assessment, admission for observation, and medication such as labetalol, nifedipine, or hydralazine. Delivery of the baby is the most important step in management, with timing depending on the individual case.
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This question is part of the following fields:
- Obstetrics
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Question 49
Incorrect
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A 23-year-old woman who is pregnant at 37 weeks gestation develops spontaneous labour. She has a history of pre-eclampsia. Her blood pressure is 170/110 mmHg.
Blood results are as follows:
Hb 110 g/L
Male: (135-180)
Female: (115 - 160)
Platelets 100 * 109/L
(150 - 400)
WBC 15.0 * 109/L
(4.0 - 11.0)
The medical team decides to administer magnesium sulphate to the patient. However, shortly after receiving the medication, the patient experiences respiratory depression with a respiratory rate of 6 breaths per minute.
What is the urgent treatment required for this patient?Your Answer: Bilevel positive airway pressure (BiPAP)
Correct Answer: Calcium gluconate
Explanation:The patient is showing signs of severe pre-eclampsia, including high blood pressure and thrombocytopenia, and requires urgent delivery and magnesium sulphate. While magnesium sulphate is effective in preventing and treating seizures, it can also cause toxicity, which is characterized by loss of deep tendon reflexes, respiratory depression, and cardiac arrest. In this case, the patient is likely experiencing magnesium sulphate toxicity due to respiratory depression. The appropriate treatment is calcium gluconate, which is the first-line option for this condition. BiPAP and CPAP are not suitable in this situation, and intubation and ventilation should only be considered if non-invasive strategies fail.
Understanding Eclampsia and its Treatment
Eclampsia is a condition that occurs when seizures develop in association with pre-eclampsia, a pregnancy-induced hypertension that is characterized by proteinuria and occurs after 20 weeks of gestation. To prevent seizures in patients with severe pre-eclampsia and treat seizures once they develop, magnesium sulphate is commonly used. However, it is important to note that this medication should only be given once a decision to deliver has been made. In cases of eclampsia, an IV bolus of 4g over 5-10 minutes should be given, followed by an infusion of 1g/hour. During treatment, it is crucial to monitor urine output, reflexes, respiratory rate, and oxygen saturations. Respiratory depression can occur, and calcium gluconate is the first-line treatment for magnesium sulphate-induced respiratory depression. Treatment should continue for 24 hours after the last seizure or delivery, as around 40% of seizures occur post-partum. Additionally, fluid restriction is necessary to avoid the potentially serious consequences of fluid overload.
In summary, understanding the development of eclampsia and its treatment is crucial in managing this potentially life-threatening condition. Magnesium sulphate is the primary medication used to prevent and treat seizures, but it should only be given once a decision to deliver has been made. Monitoring vital signs and urine output is essential during treatment, and calcium gluconate should be readily available in case of respiratory depression. Finally, fluid restriction is necessary to avoid complications associated with fluid overload.
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This question is part of the following fields:
- Obstetrics
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Question 50
Correct
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A 28-year-old female patient comes to the rheumatology clinic seeking guidance on starting a family. She and her partner are both diagnosed with rheumatoid arthritis and are currently undergoing weekly methotrexate treatment. The patient was informed about the need for pregnancy advice when she began taking the medication. What recommendations should you provide?
Your Answer: The patient and her partner will both need to wait 6 months after stopping methotrexate before conceiving
Explanation:To avoid teratogenic effects, both men and women must discontinue the use of methotrexate for at least 6 months before attempting to conceive. Methotrexate inhibits dihydrofolate reductase, which affects DNA synthesis and can harm the rapidly dividing cells of the fetus. Additionally, methotrexate can damage various semen parameters. It is not enough for only the patient to stop taking methotrexate; both partners must cease use. Taking folic acid during pregnancy does not counteract the harmful effects of methotrexate on folate metabolism and does not address the partner’s use of the drug. Waiting for 3 months is insufficient; both partners must wait for 6 months to ensure that methotrexate will not cause teratogenic effects.
Managing Rheumatoid Arthritis During Pregnancy
Rheumatoid arthritis (RA) is a condition that commonly affects women of reproductive age, making issues surrounding conception and pregnancy a concern. While there are no official guidelines for managing RA during pregnancy, expert reviews suggest that patients with early or poorly controlled RA should wait until their disease is more stable before attempting to conceive.
During pregnancy, RA symptoms tend to improve for most patients, but only a small minority experience complete resolution. After delivery, patients often experience a flare-up of symptoms. It’s important to note that certain medications used to treat RA are not safe during pregnancy, such as methotrexate and leflunomide. However, sulfasalazine and hydroxychloroquine are considered safe.
Interestingly, studies have shown that the use of TNF-α blockers during pregnancy does not significantly increase adverse outcomes. However, many patients in these studies stopped taking the medication once they found out they were pregnant. Low-dose corticosteroids may also be used to control symptoms during pregnancy.
NSAIDs can be used until 32 weeks, but should be withdrawn after that due to the risk of early closure of the ductus arteriosus. Patients with RA should also be referred to an obstetric anaesthetist due to the risk of Atlantoaxial subluxation. Overall, managing RA during pregnancy requires careful consideration and consultation with healthcare professionals.
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This question is part of the following fields:
- Obstetrics
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Question 51
Incorrect
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A 35-year-old primip is being evaluated on day six postpartum for unilateral breast discomfort. The discomfort began two days ago, and despite continuing to breastfeed, it has not improved. She feels generally fatigued, but she is currently eating and drinking well.
During the examination, you observe an erythematosus, firm, and swollen area in a wedge-shaped distribution on the right breast. There is a small crack in the nipple. The examination is painful.
Her vital signs are stable, and her temperature is 37.5 °C.
What is the most appropriate initial management, given the above information?Your Answer: Reassure the patient, advise her to continue breastfeeding and offer simple analgesia
Correct Answer: Advise her to continue breastfeeding and start empirical antibiotics
Explanation:Management of Lactational Mastitis: Advice for Patients
Lactational mastitis is a common condition that affects breastfeeding women. It is important to manage this condition promptly to prevent complications such as breast abscesses. Here are some management options for lactational mastitis:
1. Advise her to continue breastfeeding and start empirical antibiotics: If the patient presents with lactational mastitis and has a nipple fissure, it is suggestive of an infective cause. In this case, the patient should be reassured, asked to continue breastfeeding, offered adequate analgesia, and started on empirical antibiotics.
2. Reassure the patient, ask her to continue expressing milk and review if there is no improvement in two days: If there is no evidence of infection, reassurance and advice to continue breastfeeding, as well as simple analgesia, are a good first management option. However, if symptoms do not improve in 24 hours, then there is an indication for starting empirical antibiotics.
3. Admit the patient to hospital for intravenous antibiotics and drainage: Admission is advisable for intravenous antibiotics and drainage if oral antibiotics fail to improve symptoms, the patient develops sepsis, or there is evidence of the development of a breast abscess.
4. Advise her to continue breastfeeding and send a breast milk culture and treat if positive: A breast milk culture should be sent before starting antibiotics, but in this case, given the patient fulfils the criteria for starting empirical treatment, you should not delay antibiotic therapy until the breast milk culture is back.
5. Reassure the patient, advise her to continue breastfeeding and offer simple analgesia: Reassurance, advice to continue breastfeeding, and simple analgesia are offered to women who first present with lactational mastitis. If symptoms do not improve after three days, there is an indication to offer empirical antibiotics.
In conclusion, lactational mastitis should be managed promptly to prevent complications. Patients should be advised to continue breastfeeding, offered adequate analgesia, and started on empirical antibiotics if necessary. If symptoms do not improve, further management options should be considered.
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This question is part of the following fields:
- Obstetrics
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Question 52
Incorrect
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A 35-year-old pregnant woman of South Asian descent is in her second pregnancy and is currently 10+0 weeks along. She has previously given birth naturally to a healthy child at 39 weeks and has no other prior pregnancies. Due to her family's history of type 2 diabetes mellitus, she undergoes a fasting glucose test during her booking visit, which reveals a level of 7.2 mmol/L. What is the best initial course of action for managing her fasting glucose level?
Your Answer: Advice on diet and exercise plus daily blood glucose monitoring
Correct Answer: Insulin
Explanation:Immediate insulin (with or without metformin) should be initiated if the fasting glucose level is >= 7 mmol/l at the time of gestational diabetes diagnosis. This is the appropriate course of action, as relying solely on diet and exercise advice would not be sufficient given the patient’s high fasting glucose level. It is important to monitor glucose levels regularly while managing gestational diabetes, but when the fasting glucose level is >7 mmol/L at diagnosis, insulin therapy should be started. Sulfonylureas like gliclazide are not recommended during pregnancy due to the increased risk of fetal macrosomia.
Gestational diabetes is a common medical disorder affecting around 4% of pregnancies. Risk factors include a high BMI, previous gestational diabetes, and family history of diabetes. Screening is done through an oral glucose tolerance test, and diagnostic thresholds have recently been updated. Management includes self-monitoring of blood glucose, diet and exercise advice, and medication if necessary. For pre-existing diabetes, weight loss and insulin are recommended, and tight glycemic control is important. Targets for self-monitoring include fasting glucose of 5.3 mmol/l and 1-2 hour post-meal glucose levels.
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This question is part of the following fields:
- Obstetrics
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Question 53
Incorrect
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A 28-year-old woman who is 35 weeks pregnant presents to the Emergency Department with fever, abdominal pain, and anxiety. She reports experiencing night sweats for the past few days and has a history of uterine fibroids. She has been sexually active throughout her pregnancy. During the examination, there is significant uterine tenderness and a foul-smelling brown vaginal discharge is observed. The patient's blood pressure is 134/93 mmHg, and her heart rate is 110 beats per minute. Her white blood cell count is 18.5 * 109/l. The fetal heart rate is 170 beats per minute. What is the most likely diagnosis?
Your Answer: Acute herpes infection
Correct Answer: Chorioamnionitis
Explanation:The patient’s symptoms suggest an infectious process, as evidenced by her fever, rapid heartbeat, and elevated levels of neutrophils (which are already higher than normal during pregnancy). Chorioamnionitis is a clinical diagnosis that may be indicated by uterine tenderness and a foul-smelling discharge, and the presence of a baseline fetal tachycardia supports this diagnosis. The likely cause of the infection is prolonged premature rupture of membranes. Although the patient has a history of uterine fibroids, this is not relevant to her current condition, as fibroids typically cause symptoms earlier in pregnancy. Acute placental abruption would cause sudden abdominal pain, which is not present in this case. While pyelonephritis is a possible differential diagnosis, the absence of dysuria makes it less likely.
Understanding Chorioamnionitis
Chorioamnionitis is a serious medical condition that can affect both the mother and the foetus during pregnancy. It is caused by a bacterial infection that affects the amniotic fluid, membranes, and placenta. This condition is considered a medical emergency and can be life-threatening if not treated promptly. It is more likely to occur when the membranes rupture prematurely, but it can also happen when the membranes are still intact.
Prompt delivery of the foetus is crucial in treating chorioamnionitis, and a cesarean section may be necessary. Intravenous antibiotics are also administered to help fight the infection. This condition affects up to 5% of all pregnancies, and it is important for pregnant women to be aware of the symptoms and seek medical attention immediately if they suspect they may have chorioamnionitis.
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This question is part of the following fields:
- Obstetrics
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Question 54
Incorrect
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A 35-year-old G1P0 woman is brought to the hospital at 39 weeks of gestation by her husband because she is experiencing strong uterine contractions. She delivers a healthy baby with an Apgar score of 8, 5 min after birth. However, she experiences significant bleeding with an estimated blood loss of six litres and is hypotensive with a BP of 60/24 mmHg despite aggressive resuscitation. The placenta appears to be adherent to the uterine wall and the surgeons are unable to separate it. It is noted that she was treated with ceftriaxone for a gonococcal infection 5 years ago, although she had lower abdominal pain for some time after.
What is the definitive treatment for this patient’s present condition?Your Answer: Oxytocin
Correct Answer: Hysterectomy
Explanation:The patient is suffering from placenta accreta, a pregnancy complication where the placenta attaches to the myometrium wall. This condition is often caused by past Caesarean sections, Asherman syndrome, or pelvic inflammatory disease, which the patient had due to a previous infection with Neisseria gonorrhoeae. To prevent co-transmission with Chlamydia trachomatis, doxycycline is given with a third-generation cephalosporin. The patient’s placenta accreta is likely due to scarring from pelvic inflammatory disease, and a total hysterectomy may be necessary if the patient’s condition worsens. While the patient may require a large blood transfusion, immediate transfusion is not the definitive treatment. Oxytocin may be used as a first-line treatment, but a hysterectomy is the definitive treatment if bleeding persists. Phenylephrine, a vasoconstrictor, may decrease bleeding but is not a definitive treatment for placenta accreta. Dinoprostone, a prostaglandin E2 analogue, is not indicated for placenta accreta.
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This question is part of the following fields:
- Obstetrics
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Question 55
Incorrect
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A 32-year-old woman comes in for a routine antenatal check-up at 15 weeks of pregnancy. During the clinic visit, her blood pressure is measured at 154/94 mmHg, which is confirmed by ambulatory blood pressure monitoring. Four weeks prior, her blood pressure was recorded at 146/88 mmHg. A urine dipstick test shows no abnormalities, and there is no significant medical history to report. What is the probable diagnosis?
Your Answer: Pre-eclampsia
Correct Answer: Pre-existing hypertension
Explanation:It should be noted that the woman already had hypertension before becoming pregnant. Blood pressure issues related to pregnancy, such as pre-eclampsia or pregnancy-induced hypertension, typically do not occur until after 20 weeks of gestation. The elevated blood pressure readings obtained through ambulatory monitoring rule out the possibility of white-coat hypertension. It is important to note that the term pre-existing hypertension is used instead of essential hypertension, as high blood pressure in a woman of this age is uncommon and may indicate secondary hypertension.
Hypertension during pregnancy is a common occurrence that requires careful management. In normal pregnancies, blood pressure tends to decrease in the first trimester and then gradually increase to pre-pregnancy levels by term. However, in cases of hypertension during pregnancy, the systolic blood pressure is usually above 140 mmHg or the diastolic blood pressure is above 90 mmHg. Additionally, an increase of more than 30 mmHg systolic or 15 mmHg diastolic from the initial readings may also indicate hypertension.
There are three categories of hypertension during pregnancy: pre-existing hypertension, pregnancy-induced hypertension (PIH), and pre-eclampsia. Pre-existing hypertension refers to a history of hypertension before pregnancy or elevated blood pressure before 20 weeks gestation. PIH occurs in the second half of pregnancy and resolves after birth. Pre-eclampsia is characterized by hypertension and proteinuria, and may also involve edema.
The management of hypertension during pregnancy involves the use of antihypertensive medications such as labetalol, nifedipine, and hydralazine. In cases of pre-existing hypertension, ACE inhibitors and angiotensin II receptor blockers should be stopped immediately and alternative medications should be prescribed. Women who are at high risk of developing pre-eclampsia should take aspirin from 12 weeks until the birth of the baby. It is important to carefully monitor blood pressure and proteinuria levels during pregnancy to ensure the health of both the mother and the baby.
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This question is part of the following fields:
- Obstetrics
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Question 56
Incorrect
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A 35-year-old woman who is 32 weeks pregnant with twins comes to you complaining of intense pruritus that has been affecting her sleep for the past 4 days. She has multiple excoriations but no visible skin rash. The pregnancy has been uneventful, and foetal movements are normal.
Her blood tests show:
- Bilirubin 38 µmol/L (3 - 17)
- ALP 205 u/L (30 - 100)
- ALT 180 u/L (3 - 40)
An abdominal ultrasound shows no abnormalities.
What is the most likely diagnosis, and what management plan would you recommend?Your Answer: Advise she will likely need a caesarian section
Correct Answer: Plan to induce labour at 37 weeks
Explanation:This patient has intrahepatic cholestasis of pregnancy, which is characterized by abnormal liver function tests and severe itching in the third trimester. This condition increases the risk of stillbirth and maternal complications, particularly after 37 weeks of gestation. Therefore, induction of labor is typically recommended at this point, especially for patients with elevated transaminases and bile acids. While increased fetal monitoring is advised, hospitalization is not necessary unless there are signs of immediate concern for the fetus. A vaginal birth is usually appropriate, and a cesarean section is rarely required unless there are indications of non-reassuring fetal status. Although antihistamines can provide symptomatic relief, they are not sufficient on their own due to the risks associated with this condition. Other options for symptom relief include ursodeoxycholic acid, cholestyramine, and topical emollients. There is no indication for immediate delivery, as fetal movements and ultrasound results are normal.
Intrahepatic Cholestasis of Pregnancy: Symptoms and Management
Intrahepatic cholestasis of pregnancy, also known as obstetric cholestasis, is a condition that affects approximately 1% of pregnancies in the UK. It is characterized by intense itching, particularly on the palms, soles, and abdomen, and may also result in clinically detectable jaundice in around 20% of patients. Raised bilirubin levels are seen in over 90% of cases.
The management of intrahepatic cholestasis of pregnancy typically involves induction of labor at 37-38 weeks, although this practice may not be evidence-based. Ursodeoxycholic acid is also widely used, although the evidence base for its effectiveness is not clear. Additionally, vitamin K supplementation may be recommended.
It is important to note that the recurrence rate of intrahepatic cholestasis of pregnancy in subsequent pregnancies is high, ranging from 45-90%. Therefore, close monitoring and management are necessary for women who have experienced this condition in the past.
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This question is part of the following fields:
- Obstetrics
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Question 57
Incorrect
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A 36-year-old woman presents to you, her primary care physician, with complaints of feeling sad and low since giving birth to her daughter 2 weeks ago. She reports difficulty sleeping and believes that her baby does not like her and that they are not bonding, despite breastfeeding. She has a strong support system, including the baby's father, and has no history of depression. She denies any thoughts of self-harm or substance abuse, and you do not believe the baby is in danger. What is the best course of action for management?
Your Answer: Antidepressant therapy
Correct Answer: Cognitive behavioural therapy (CBT)
Explanation:The recommended first line treatment for moderate to severe depression in pregnancy or post-natal period for women without a history of severe depression is a high intensity psychological intervention, such as CBT, according to the National Institute for Health and Care Excellence. If this is not accepted or symptoms do not improve, an antidepressant such as a selective serotonin re-uptake inhibitor (SSRI) or tricyclic antidepressant (TCA) should be used. Mindfulness may be helpful for women with persistent subclinical depressive symptoms. Social services should only be involved if there is a risk to someone in the household. The British National Formulary (BNF) advises against using zopiclone while breastfeeding as it is present in breast milk.
Understanding Postpartum Mental Health Problems
Postpartum mental health problems can range from mild ‘baby-blues’ to severe puerperal psychosis. To screen for depression, healthcare professionals may use the Edinburgh Postnatal Depression Scale, which is a 10-item questionnaire that indicates how the mother has felt over the previous week. A score of more than 13 indicates a ‘depressive illness of varying severity’, with sensitivity and specificity of more than 90%. The questionnaire also includes a question about self-harm.
‘Baby-blues’ is seen in around 60-70% of women and typically occurs 3-7 days following birth. It is more common in primips, and mothers are characteristically anxious, tearful, and irritable. Reassurance and support from healthcare professionals, particularly health visitors, play a key role in managing this condition. Most women with the baby blues will not require specific treatment other than reassurance.
Postnatal depression affects around 10% of women, with most cases starting within a month and typically peaking at 3 months. The features are similar to depression seen in other circumstances, and cognitive behavioural therapy may be beneficial. Certain SSRIs such as sertraline and paroxetine may be used if symptoms are severe. Although these medications are secreted in breast milk, they are not thought to be harmful to the infant.
Puerperal psychosis affects approximately 0.2% of women and requires admission to hospital, ideally in a Mother & Baby Unit. Onset usually occurs within the first 2-3 weeks following birth, and features include severe swings in mood (similar to bipolar disorder) and disordered perception (e.g. auditory hallucinations). There is around a 25-50% risk of recurrence following future pregnancies. Paroxetine is recommended by SIGN because of the low milk/plasma ratio, while fluoxetine is best avoided due to a long half-life.
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This question is part of the following fields:
- Obstetrics
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Question 58
Incorrect
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Which of these is a possible indication for induction of labour in a 30-year-old woman?
Your Answer: Previous classical Caesarean section
Correct Answer: Uncomplicated pregnancy at 41 weeks gestation
Explanation:1. The Bishop’s score rates the cervix out of 10, with a higher score indicating a more favorable cervix and a greater likelihood of spontaneous birth. A score below 5 suggests that labor is unlikely to begin without induction.
2. This is not a reason to induce labor.
3. It is recommended that women with uncomplicated pregnancies be offered induction between 41-42 weeks to prevent the risks associated with prolonged pregnancy.
4. A previous classical Caesarean section is an absolute contraindication for inducing labor.
5. Inducing labor is not advisable when the fetus is in a breech position.
Reference: NICE guidelines – Inducing labor and Antenatal care for uncomplicated pregnancies.
Induction of labour is a process where labour is artificially started and is required in about 20% of pregnancies. It is indicated in cases of prolonged pregnancy, prelabour premature rupture of the membranes, maternal medical problems, diabetic mother over 38 weeks, pre-eclampsia, obstetric cholestasis, and intrauterine fetal death. The Bishop score is used to assess whether induction of labour is necessary and includes cervical position, consistency, effacement, dilation, and fetal station. A score of less than 5 indicates that labour is unlikely to start without induction, while a score of 8 or more indicates a high chance of spontaneous labour or response to interventions made to induce labour.
Possible methods of induction include membrane sweep, vaginal prostaglandin E2, oral prostaglandin E1, maternal oxytocin infusion, amniotomy, and cervical ripening balloon. The NICE guidelines recommend vaginal prostaglandins or oral misoprostol if the Bishop score is less than or equal to 6, while amniotomy and an intravenous oxytocin infusion are recommended if the score is greater than 6.
The main complication of induction of labour is uterine hyperstimulation, which refers to prolonged and frequent uterine contractions that can interrupt blood flow to the intervillous space and result in fetal hypoxemia and acidemia. Uterine rupture is a rare but serious complication. Management includes removing vaginal prostaglandins and stopping the oxytocin infusion if one has been started, and considering tocolysis.
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This question is part of the following fields:
- Obstetrics
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Question 59
Incorrect
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A 20-year-old primigravida presents to your clinic with a complaint of persistent vomiting. She is currently 12 weeks pregnant and has been experiencing this symptom for the past four days. Upon examination, you note that she has a fast heart rate, low blood pressure upon standing, and her urine test shows the presence of ketones. What is the most significant risk factor for hyperemesis gravidarum?
Your Answer: Increasing maternal age
Correct Answer: Twin pregnancy
Explanation:Hyperemesis gravidarum, a severe form of nausea and vomiting in pregnancy, is associated with multiple pregnancies, molar pregnancies, young maternal age, first pregnancy, and obesity. The condition may be caused by high beta hCG and oestrogen levels, nutritional deficiencies, and gastric dysfunction due to high progesterone levels. Prolonged and frequent vomiting can be problematic.
Hyperemesis gravidarum is an extreme form of nausea and vomiting of pregnancy that occurs in around 1% of pregnancies and is most common between 8 and 12 weeks. It is associated with raised beta hCG levels and can be caused by multiple pregnancies, trophoblastic disease, hyperthyroidism, nulliparity, and obesity. Referral criteria for nausea and vomiting in pregnancy include continued symptoms with ketonuria and/or weight loss, a confirmed or suspected comorbidity, and inability to keep down liquids or oral antiemetics. The diagnosis of hyperemesis gravidarum requires the presence of 5% pre-pregnancy weight loss, dehydration, and electrolyte imbalance. Management includes first-line use of antihistamines and oral cyclizine or promethazine, with second-line options of ondansetron and metoclopramide. Admission may be needed for IV hydration. Complications can include Wernicke’s encephalopathy, Mallory-Weiss tear, central pontine myelinolysis, acute tubular necrosis, and fetal growth issues.
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This question is part of the following fields:
- Obstetrics
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Question 60
Incorrect
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A 28-year-old woman has recently delivered a baby in the labour ward. Following the delivery, an evaluation is conducted to determine the amount of blood loss for recording purposes. The medical records indicate that she experienced a primary postpartum haemorrhage. Can you provide the accurate definition of primary postpartum haemorrhage (PPH)?
Your Answer: The loss of 500 ml or more of blood from the genital tract within 24 hours after delivery of the placenta
Correct Answer: The loss of 500 ml or more of blood from the genital tract within 24 hours of the birth of a baby
Explanation:Maternal mortality rates are still high globally due to obstetric haemorrhage. Postpartum haemorrhage is characterized by blood loss of 500 ml after vaginal delivery, not including the placenta. If blood loss exceeds 1000mls, it is classified as major postpartum haemorrhage. It is crucial to evaluate the severity of the bleeding and seek appropriate management (as outlined below).
Understanding Postpartum Haemorrhage
Postpartum haemorrhage (PPH) is a condition where a woman experiences blood loss of more than 500 ml after giving birth vaginally. It can be classified as primary or secondary. Primary PPH occurs within 24 hours after delivery and is caused by the 4 Ts: tone, trauma, tissue, and thrombin. The most common cause is uterine atony. Risk factors for primary PPH include previous PPH, prolonged labour, pre-eclampsia, increased maternal age, emergency Caesarean section, and placenta praevia.
In managing PPH, it is important to involve senior staff immediately and follow the ABC approach. This includes two peripheral cannulae, lying the woman flat, blood tests, and commencing a warmed crystalloid infusion. Mechanical interventions such as rubbing up the fundus and catheterisation are also done. Medical interventions include IV oxytocin, ergometrine, carboprost, and misoprostol. Surgical options such as intrauterine balloon tamponade, B-Lynch suture, ligation of uterine arteries, and hysterectomy may be considered if medical options fail to control the bleeding.
Secondary PPH occurs between 24 hours to 6 weeks after delivery and is typically due to retained placental tissue or endometritis. It is important to understand the causes and risk factors of PPH to prevent and manage this life-threatening emergency effectively.
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This question is part of the following fields:
- Obstetrics
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Question 61
Incorrect
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A woman presents to the Emergency Department 45 days after giving birth by Caesarean section. She complains of persistent vaginal bleeding. Her temperature is 38.5 ºC, pulse 88 bpm and blood pressure 110/76.
What is the most likely diagnosis?Your Answer: Wound infection
Correct Answer: Endometritis
Explanation:Post-Caesarean Section Complications: Causes and Symptoms
One common complication following a Caesarean section is endometritis, which is characterized by inflammation of the endometrial lining. This condition is usually caused by an infection and can lead to vaginal bleeding. Immediate treatment with antibiotics is necessary to prevent further complications.
Other post-Caesarean section complications that may cause fever include mastitis, wound infections, and haematomas. However, these conditions are not typically associated with prolonged vaginal bleeding.
Retained products of conception are rare following a Caesarean section since the surgical cavity is thoroughly checked during the operation. On the other hand, wound infections and haematomas may cause fever but are not usually accompanied by prolonged vaginal bleeding.
It is important to monitor any symptoms following a Caesarean section and seek medical attention if any complications arise.
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This question is part of the following fields:
- Obstetrics
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Question 62
Correct
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A 35-year-old woman presents with a significant obstetric hemorrhage due to uterine atony. What is the initial medical management after stabilization and general measures?
Your Answer: Syntocinon
Explanation:To treat postpartum haemorrhage caused by uterine atony, medical options include oxytocin, ergometrine, carboprost, and misoprostol.
The leading cause of primary postpartum haemorrhage is uterine atony. The RCOG has issued guidelines (Green-top Guideline No.52) for managing primary PPH due to uterine atony. The first-line treatment recommended is 5U of IV Syntocinon (oxytocin), followed by 0.5 mg of ergometrine.
Understanding Postpartum Haemorrhage
Postpartum haemorrhage (PPH) is a condition where a woman experiences blood loss of more than 500 ml after giving birth vaginally. It can be classified as primary or secondary. Primary PPH occurs within 24 hours after delivery and is caused by the 4 Ts: tone, trauma, tissue, and thrombin. The most common cause is uterine atony. Risk factors for primary PPH include previous PPH, prolonged labour, pre-eclampsia, increased maternal age, emergency Caesarean section, and placenta praevia.
In managing PPH, it is important to involve senior staff immediately and follow the ABC approach. This includes two peripheral cannulae, lying the woman flat, blood tests, and commencing a warmed crystalloid infusion. Mechanical interventions such as rubbing up the fundus and catheterisation are also done. Medical interventions include IV oxytocin, ergometrine, carboprost, and misoprostol. Surgical options such as intrauterine balloon tamponade, B-Lynch suture, ligation of uterine arteries, and hysterectomy may be considered if medical options fail to control the bleeding.
Secondary PPH occurs between 24 hours to 6 weeks after delivery and is typically due to retained placental tissue or endometritis. It is important to understand the causes and risk factors of PPH to prevent and manage this life-threatening emergency effectively.
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This question is part of the following fields:
- Obstetrics
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Question 63
Incorrect
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A 28-year-old woman presents at 16 weeks’ gestation, requesting an abortion. Her relationship has ended; she has moved back in with her parents, and her anxiety has worsened. She feels overwhelmed and states that, at this point, she cannot handle a baby. She has undergone a comprehensive consultation, and her decision remains the same.
What is the most suitable course of action for managing this patient?Your Answer: Oral mifepristone
Correct Answer: Surgical evacuation of products of conception
Explanation:Management Options for Termination of Pregnancy at 16 Weeks’ Gestation
Termination of pregnancy at 16 weeks’ gestation can be managed through surgical evacuation of the products of conception or medical management using oral mifepristone followed by vaginal misoprostol. The decision ultimately lies with the patient, and it is important to explain the potential risks and complications associated with each option.
Surgical Evacuation of Products of Conception
This procedure involves vacuum aspiration before 14 weeks’ gestation or dilation of the cervix and evacuation of the uterine cavity after 14 weeks. Common side-effects include infection, bleeding, cervical trauma, and perforation of the uterus. It is important to inform the patient that the procedure may need to be repeated if the uterus is not emptied completely.No Management Required at Present
While termination of pregnancy is legal in the UK until 24 weeks’ gestation, it is the patient’s right to make the decision. However, if the patient is unsure, it may be appropriate to reassess in two weeks.Oral Mifepristone
Mifepristone is an anti-progesterone medication that is used in combination with misoprostol to induce termination of pregnancy. It is not effective as monotherapy.Oral Mifepristone Followed by Vaginal Misoprostol as an Outpatient
This is the standard medication regime for medical termination of pregnancy. However, after 14 weeks’ gestation, it is recommended that the procedure be performed in a medical setting for appropriate monitoring.Vaginal Misoprostol
Vaginal misoprostol can be used in conjunction with mifepristone for medical termination of pregnancy or as monotherapy in medical management of miscarriage or induction of labour. -
This question is part of the following fields:
- Obstetrics
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Question 64
Incorrect
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A 36-year-old woman has given birth to her first child and was given a dose of intramuscular syntocinon before the placenta was delivered. During the wait for the placenta, she experiences a blood loss of 400ml. Even after the placenta is delivered, the bleeding continues and she loses an additional 500ml of blood. The medical team initiates the necessary resuscitation measures and the major haemorrhage protocol. The cause of the bleeding is identified as uterine atony, and the patient is given boluses of syntocinon, ergometrine, and carboprost. However, the bleeding persists. What is the most appropriate next step?
Your Answer: Lie the patient on her left side
Correct Answer: Intra-uterine Bakri catheter
Explanation:The correct first-line surgical intervention for postpartum haemorrhage is an intra-uterine Bakri catheter. This device is used to tamponade the bleeding caused by uterine atony, which is a failure of the uterine myometrium cells to contract. Hysterectomy is not the first option as it is a last resort and will make the patient infertile. Lying the patient on her left lateral side is not relevant for a woman who has already delivered her baby. Ligation of the internal iliac artery may be used, but it is not the next most appropriate step as it may lead to ischaemic complications. Intra-uterine balloon tamponade is the first-line surgical intervention if other measures fail.
Understanding Postpartum Haemorrhage
Postpartum haemorrhage (PPH) is a condition where a woman experiences blood loss of more than 500 ml after giving birth vaginally. It can be classified as primary or secondary. Primary PPH occurs within 24 hours after delivery and is caused by the 4 Ts: tone, trauma, tissue, and thrombin. The most common cause is uterine atony. Risk factors for primary PPH include previous PPH, prolonged labour, pre-eclampsia, increased maternal age, emergency Caesarean section, and placenta praevia.
In managing PPH, it is important to involve senior staff immediately and follow the ABC approach. This includes two peripheral cannulae, lying the woman flat, blood tests, and commencing a warmed crystalloid infusion. Mechanical interventions such as rubbing up the fundus and catheterisation are also done. Medical interventions include IV oxytocin, ergometrine, carboprost, and misoprostol. Surgical options such as intrauterine balloon tamponade, B-Lynch suture, ligation of uterine arteries, and hysterectomy may be considered if medical options fail to control the bleeding.
Secondary PPH occurs between 24 hours to 6 weeks after delivery and is typically due to retained placental tissue or endometritis. It is important to understand the causes and risk factors of PPH to prevent and manage this life-threatening emergency effectively.
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This question is part of the following fields:
- Obstetrics
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Question 65
Incorrect
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Sarah, a 29-year-old pregnant woman (gravidity 1, parity 0) currently 33+0, visits her obstetrician with a new rash. Sarah attended her 6-year-old nephew's birthday party 2 weeks ago. Today, she woke up feeling unwell with malaise and a loss of appetite. She also noticed a new itchy rash on her back and abdomen. Upon calling her sister, she found out that one of her nephew's friends at the party was recently diagnosed with chickenpox. Sarah has never had chickenpox before. During the examination, Sarah has red papules on her back and abdomen. She is not running a fever. What is the most appropriate course of action?
Your Answer: Intravenous acyclovir
Correct Answer: Oral acyclovir
Explanation:If a pregnant woman who is at least 20 weeks pregnant develops chickenpox, she should receive oral acyclovir treatment if she presents within 24 hours of the rash. Melissa, who is 33 weeks pregnant and has experienced prodromal symptoms, can be treated with oral acyclovir as she presented within the appropriate time frame. IV acyclovir is not typically necessary for pregnant women who have been in contact with chickenpox. To alleviate itchiness, it is reasonable to suggest using calamine lotion and antihistamines, but since Melissa is currently pregnant, she should also begin taking antiviral medications. Pain is not a significant symptom of chickenpox, and Melissa has not reported any pain, so recommending paracetamol is not the most effective course of action.
Chickenpox exposure in pregnancy can pose risks to both the mother and fetus, including fetal varicella syndrome. Post-exposure prophylaxis (PEP) with varicella-zoster immunoglobulin (VZIG) or antivirals should be given to non-immune pregnant women, with timing dependent on gestational age. If a pregnant woman develops chickenpox, specialist advice should be sought and oral acyclovir may be given if she is ≥ 20 weeks and presents within 24 hours of onset of the rash.
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This question is part of the following fields:
- Obstetrics
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Question 66
Incorrect
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A Cardiotocogram (CTG) is performed on a 29-year-old female at 37 weeks gestation who has arrived at labour ward in spontaneous labour. The CTG shows a foetal heart rate of 120 bpm and variable decelerations and accelerations are present. There are no late decelerations. However, the midwife notices a 15 minute period where the foetal heart rate only varies by 2-3bpm. The mum is worried as she has not felt her baby move much for about 15 mins and would like to know what the likely cause is. She starts crying when she tells you that she took some paracetamol earlier as she was in so much pain from the contractions and is concerned this has harmed her baby. What is the most probable reason for this reduced variability?
Your Answer: Foetal tachycardia
Correct Answer: Foetus is sleeping
Explanation:Episodes of decreased variability on CTG that last less than 40 minutes are often attributed to the foetus being asleep. However, if the decreased variability persists for more than 40 minutes, it can be a cause for concern. Other factors that can lead to decreased variability in foetal heart rate on CTG include maternal drug use (such as benzodiazepines, opioids or methyldopa – but not paracetamol), foetal acidosis (usually due to hypoxia), prematurity (which is not applicable in this case), foetal tachycardia (heart rate above 140 bpm, which is also not the case here), and congenital heart abnormalities.
Cardiotocography (CTG) is a medical procedure that measures pressure changes in the uterus using either internal or external pressure transducers. It is used to monitor the fetal heart rate, which normally ranges between 100-160 beats per minute. There are several features that can be observed during a CTG, including baseline bradycardia (heart rate below 100 beats per minute), which can be caused by increased fetal vagal tone or maternal beta-blocker use. Baseline tachycardia (heart rate above 160 beats per minute) can be caused by maternal pyrexia, chorioamnionitis, hypoxia, or prematurity. Loss of baseline variability (less than 5 beats per minute) can be caused by prematurity or hypoxia. Early deceleration, which is a decrease in heart rate that starts with the onset of a contraction and returns to normal after the contraction, is usually harmless and indicates head compression. Late deceleration, on the other hand, is a decrease in heart rate that lags behind the onset of a contraction and does not return to normal until after 30 seconds following the end of the contraction. This can indicate fetal distress, such as asphyxia or placental insufficiency. Variable decelerations, which are independent of contractions, may indicate cord compression.
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This question is part of the following fields:
- Obstetrics
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Question 67
Incorrect
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A 28-year-old female who is 14 weeks in to her first pregnancy comes for a check-up. Her blood pressure today reads 126/82 mmHg. What is the typical trend of blood pressure during pregnancy?
Your Answer: Doesn't change
Correct Answer: Falls in first half of pregnancy before rising to pre-pregnancy levels before term
Explanation:Hypertension during pregnancy is a common occurrence that requires careful management. In normal pregnancies, blood pressure tends to decrease in the first trimester and then gradually increase to pre-pregnancy levels by term. However, in cases of hypertension during pregnancy, the systolic blood pressure is usually above 140 mmHg or the diastolic blood pressure is above 90 mmHg. Additionally, an increase of more than 30 mmHg systolic or 15 mmHg diastolic from the initial readings may also indicate hypertension.
There are three categories of hypertension during pregnancy: pre-existing hypertension, pregnancy-induced hypertension (PIH), and pre-eclampsia. Pre-existing hypertension refers to a history of hypertension before pregnancy or elevated blood pressure before 20 weeks gestation. PIH occurs in the second half of pregnancy and resolves after birth. Pre-eclampsia is characterized by hypertension and proteinuria, and may also involve edema.
The management of hypertension during pregnancy involves the use of antihypertensive medications such as labetalol, nifedipine, and hydralazine. In cases of pre-existing hypertension, ACE inhibitors and angiotensin II receptor blockers should be stopped immediately and alternative medications should be prescribed. Women who are at high risk of developing pre-eclampsia should take aspirin from 12 weeks until the birth of the baby. It is important to carefully monitor blood pressure and proteinuria levels during pregnancy to ensure the health of both the mother and the baby.
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This question is part of the following fields:
- Obstetrics
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Question 68
Correct
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A 28-year-old woman has been diagnosed with gestational diabetes mellitus and is referred to the joint antenatal and diabetic clinic. She is currently 25 weeks pregnant and this is her first pregnancy. Her family has no history of pregnancy-related problems, but her father has type 1 diabetes mellitus. On examination, her BMI is 32 kg/m² and otherwise normal. What diagnostic test would confirm her condition?
Your Answer: Fasting plasma glucose >= 5.6 mmol/L
Explanation:Gestational diabetes can be diagnosed if the patient has a fasting glucose level of 5.6 mmol/L or higher, or a 2-hour glucose level of 7.8 mmol/L or higher. This diagnosis is typically made during an oral glucose tolerance test around 24 weeks into the pregnancy for women with risk factors, such as a high BMI or a first-degree relative with diabetes mellitus. In this patient’s case, she was diagnosed with gestational diabetes mellitus during her first pregnancy due to her risk factors. Therefore, the correct answer is a fasting plasma glucose level above 5.6 mmol/L. It is important to note that a 2-hour glucose level above 5.6 mmol/L is not diagnostic of gestational diabetes mellitus, and random plasma glucose tests are not used for diagnosis. Glucose targets for women with gestational diabetes mellitus include a 2-hour glucose level of 6.4 mmol/L after mealtime and a 1-hour glucose level of 7.8 mmol/L after mealtime.
Gestational diabetes is a common medical disorder affecting around 4% of pregnancies. Risk factors include a high BMI, previous gestational diabetes, and family history of diabetes. Screening is done through an oral glucose tolerance test, and diagnostic thresholds have recently been updated. Management includes self-monitoring of blood glucose, diet and exercise advice, and medication if necessary. For pre-existing diabetes, weight loss and insulin are recommended, and tight glycemic control is important. Targets for self-monitoring include fasting glucose of 5.3 mmol/l and 1-2 hour post-meal glucose levels.
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This question is part of the following fields:
- Obstetrics
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Question 69
Incorrect
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A 35-year-old female presents in the emergency department. She is concerned that her waters broke earlier today and reports a sudden 'gush' that soaked her pants. She is currently 28 weeks pregnant and has had an uneventful pregnancy thus far. What is the initial investigation that should be conducted?
Your Answer: Urinalysis
Correct Answer: Speculum examination
Explanation:To evaluate a patient with suspected premature rupture of membranes, a thorough medical history should be obtained, including the number of pregnancies. A sterile speculum examination is necessary to check for the accumulation of amniotic fluid in the posterior vaginal vault. Digital examination should be avoided to prevent infection. Serum beta-HCG is not recommended, and the patient should have had previous ultrasound scans and have confirmed her pregnancy by this stage. Ultrasound is the appropriate diagnostic tool if there is no evidence of amniotic fluid pooling in the posterior vaginal vault.
Preterm prelabour rupture of the membranes (PPROM) is a condition that occurs in approximately 2% of pregnancies, but it is responsible for around 40% of preterm deliveries. This condition can lead to various complications, including prematurity, infection, and pulmonary hypoplasia in the fetus, as well as chorioamnionitis in the mother. To confirm PPROM, a sterile speculum examination should be performed to check for pooling of amniotic fluid in the posterior vaginal vault. However, digital examination should be avoided due to the risk of infection. If pooling of fluid is not observed, testing the fluid for placental alpha microglobulin-1 protein (PAMG-1) or insulin-like growth factor binding protein-1 is recommended. Ultrasound may also be useful to show oligohydramnios.
The management of PPROM involves admission and regular observations to ensure that chorioamnionitis is not developing. Oral erythromycin should be given for ten days, and antenatal corticosteroids should be administered to reduce the risk of respiratory distress syndrome. Delivery should be considered at 34 weeks of gestation, but there is a trade-off between an increased risk of maternal chorioamnionitis and a decreased risk of respiratory distress syndrome as the pregnancy progresses. PPROM is a serious condition that requires prompt diagnosis and management to minimize the risk of complications for both the mother and the fetus.
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This question is part of the following fields:
- Obstetrics
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Question 70
Correct
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A 32-year-old woman gives birth to her second child. The baby is born via normal vaginal delivery and weighs 3.8 kg. The baby has a normal Newborn and Infant Physical Examination (NIPE) after birth and the mother recovers well following the delivery. The mother wishes to breastfeed her baby and is supported to do so by the midwives on the ward.
They are visited at home by the health visitor two weeks later. The health visitor asks how they have been getting on and the mother explains that she has been experiencing problems with breastfeeding and that her baby often struggles to latch on to her breast. She explains that this has made her very anxious that she is doing something wrong and has made her feel like she is failing as a mother. When her baby does manage to latch on to feed he occasionally gets reflux and vomits afterward. The health visitor weighs the baby who is now 3.4kg.
What is the next most appropriate step?Your Answer: Refer her to a midwife-led breastfeeding clinic
Explanation:If a baby loses more than 10% of its birth weight, it is necessary to refer the mother and baby to a midwife for assistance in increasing the baby’s weight.
Breastfeeding Problems and Their Management
Breastfeeding is a natural process, but it can come with its own set of challenges. Some of the minor problems that breastfeeding mothers may encounter include frequent feeding, nipple pain, blocked ducts, and nipple candidiasis. These issues can be managed by seeking advice on proper positioning, trying breast massage, and using appropriate medication.
Mastitis is a more serious problem that affects around 1 in 10 breastfeeding women. It is characterized by symptoms such as fever, nipple fissure, and persistent pain. Treatment involves the use of antibiotics, such as flucloxacillin, for 10-14 days. Breastfeeding or expressing milk should continue during treatment to prevent complications such as breast abscess.
Breast engorgement is another common problem that causes breast pain in breastfeeding women. It occurs in the first few days after birth and affects both breasts. Hand expression of milk can help relieve the discomfort of engorgement. Raynaud’s disease of the nipple is a less common problem that causes nipple pain and blanching. Treatment involves minimizing exposure to cold, using heat packs, and avoiding caffeine and smoking.
If a breastfed baby loses more than 10% of their birth weight in the first week of life, it may be a sign of poor weight gain. This should prompt consideration of the above breastfeeding problems and an expert review of feeding. Monitoring of weight should continue until weight gain is satisfactory.
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This question is part of the following fields:
- Obstetrics
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Question 71
Correct
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You are working at a prenatal care center. A couple comes in who are 28 weeks pregnant. They had difficulty getting pregnant naturally but were able to conceive through their second attempt at IVF. This is their first child. During their 14 week ultrasound, the sonographer expressed concern about the placement of the placenta and they have returned for a follow-up scan today, which confirms the initial finding. What is the probable anomaly?
Your Answer: Placenta praevia
Explanation:A study conducted in Norway in 2006 revealed that singleton pregnancies conceived through assisted fertilization had a six-fold higher risk of placenta praevia compared to naturally conceived pregnancies. The risk of placenta previa was also nearly three-fold higher in pregnancies following assisted fertilization for mothers who had conceived both naturally and through assisted fertilization. This abnormal placental placement is believed to be linked to the abnormal ovarian stimulation hormones that occur during IVF. Additionally, the incidence of placenta praevia is associated with previous caesarean sections, multiparity, and previous gynaecological surgeries, while the incidence of other options given increases with the number of previous caesarean sections.
Understanding Placenta Praevia
Placenta praevia is a condition where the placenta is located wholly or partially in the lower uterine segment. It is a relatively rare condition, with only 5% of women having a low-lying placenta when scanned at 16-20 weeks gestation. However, the incidence at delivery is only 0.5%, as most placentas tend to rise away from the cervix.
There are several factors associated with placenta praevia, including multiparity, multiple pregnancy, and embryos implanting on a lower segment scar from a previous caesarean section. Clinical features of placenta praevia include shock in proportion to visible loss, no pain, a non-tender uterus, abnormal lie and presentation, and a usually normal fetal heart. Coagulation problems are rare, and small bleeds may occur before larger ones.
Diagnosis of placenta praevia should not involve digital vaginal examination before an ultrasound, as this may provoke severe haemorrhage. The condition is often picked up on routine 20-week abdominal ultrasounds, but the Royal College of Obstetricians and Gynaecologists recommends the use of transvaginal ultrasound for improved accuracy and safety. Placenta praevia is classified into four grades, with grade IV being the most severe, where the placenta completely covers the internal os.
In summary, placenta praevia is a rare condition that can have serious consequences if not diagnosed and managed appropriately. It is important for healthcare professionals to be aware of the associated factors and clinical features, and to use appropriate diagnostic methods for accurate grading and management.
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This question is part of the following fields:
- Obstetrics
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Question 72
Incorrect
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You are asked to assess a woman who has given birth to her third child 2 hours ago. The baby was born at term, weighed 4.2kg, and was in good health. She had a natural delivery that lasted for 7 hours, and opted for a physiological third stage. According to the nurse, she has lost around 750ml of blood, but her vital signs are stable and the bleeding seems to be decreasing. What is the leading reason for her blood loss?
Your Answer: Retained placenta
Correct Answer: Uterine atony
Explanation:PPH, which is the loss of 500ml or more from the genital tract within 24 hours of giving birth, is primarily caused by uterine atony. It can be classified as minor (500-1000ml) or major (>1000ml) and has a mortality rate of 6 deaths/million deliveries. The causes of PPH can be categorized into the ‘four T’s’: tone, tissue (retained placenta), trauma, and thrombin (coagulation abnormalities).
Understanding Postpartum Haemorrhage
Postpartum haemorrhage (PPH) is a condition where a woman experiences blood loss of more than 500 ml after giving birth vaginally. It can be classified as primary or secondary. Primary PPH occurs within 24 hours after delivery and is caused by the 4 Ts: tone, trauma, tissue, and thrombin. The most common cause is uterine atony. Risk factors for primary PPH include previous PPH, prolonged labour, pre-eclampsia, increased maternal age, emergency Caesarean section, and placenta praevia.
In managing PPH, it is important to involve senior staff immediately and follow the ABC approach. This includes two peripheral cannulae, lying the woman flat, blood tests, and commencing a warmed crystalloid infusion. Mechanical interventions such as rubbing up the fundus and catheterisation are also done. Medical interventions include IV oxytocin, ergometrine, carboprost, and misoprostol. Surgical options such as intrauterine balloon tamponade, B-Lynch suture, ligation of uterine arteries, and hysterectomy may be considered if medical options fail to control the bleeding.
Secondary PPH occurs between 24 hours to 6 weeks after delivery and is typically due to retained placental tissue or endometritis. It is important to understand the causes and risk factors of PPH to prevent and manage this life-threatening emergency effectively.
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This question is part of the following fields:
- Obstetrics
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Question 73
Incorrect
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A 30-year-old woman, who recently gave birth, visits her GP for a regular check-up. She expresses her worries about the medications she is taking for different health issues and their potential impact on her breastfeeding baby. Can you advise her on which medications are safe to continue taking?
Your Answer: Isotretinoin
Correct Answer: Lamotrigine
Explanation:Breastfeeding is generally safe with most anti-epileptic drugs, including Lamotrigine which is commonly prescribed for seizures. It is a preferred option for women as it does not affect their ability to bear children. However, Carbimazole and Diazepam active metabolite can be passed on to the baby through breast milk and should be avoided. Isotretinoin effect on breastfed infants is not well studied, but oral retinoids should generally be avoided while breastfeeding.
Pregnancy and breastfeeding can be a concern for women with epilepsy. It is generally recommended that women continue taking their medication during pregnancy, as the risks of uncontrolled seizures outweigh the potential risks to the fetus. However, it is important for women to take folic acid before pregnancy to reduce the risk of neural tube defects. The use of antiepileptic medication during pregnancy can increase the risk of congenital defects, but this risk is still relatively low. It is recommended to aim for monotherapy and there is no need to monitor drug levels. Sodium valproate is associated with neural tube defects, while carbamazepine is considered the least teratogenic of the older antiepileptics. Phenytoin is associated with cleft palate, and lamotrigine may require a dose increase during pregnancy. Breastfeeding is generally safe for mothers taking antiepileptics, except for barbiturates. Pregnant women taking phenytoin should be given vitamin K in the last month of pregnancy to prevent clotting disorders in the newborn.
A warning has been issued about the use of sodium valproate during pregnancy and in women of childbearing age. New evidence suggests a significant risk of neurodevelopmental delay in children following maternal use of this medication. Therefore, it should only be used if clearly necessary and under specialist neurological or psychiatric advice. It is important for women with epilepsy to discuss their options with their healthcare provider and make informed decisions about their treatment during pregnancy and breastfeeding.
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This question is part of the following fields:
- Obstetrics
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Question 74
Incorrect
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A 29-year-old primip is brought in by ambulance at 38+2 weeks’ gestation. She has had an uncomplicated pregnancy so far, and she is a smoker. This morning, she had sudden-onset abdominal pain, which has become very severe. The uterus is hard and contracted. There is no vaginal bleeding, and the os is closed, with a long cervix. She looks clammy and pale.
Her observations are as follows: heart rate (HR) 130 bpm, blood pressure (BP) 98/56 mmHg, respiratory rate (RR) 20 breaths per minute, oxygen saturations 96% on air, and temperature 37.1 °C. The cardiotocogram shows fetal distress, and fetal movements cannot be palpated.
Which of the following is the most appropriate management?Your Answer: Intravenous (iv) fluids, iv paracetamol and reassess
Correct Answer: Emergency Caesarean section
Explanation:Management of Placental Abruption: Emergency Caesarean Section and Other Options
Placental abruption is a serious obstetric emergency that can lead to maternal and fetal mortality. Risk factors include smoking, pre-eclampsia, cocaine use, trauma, and maternal age >35. Symptoms may include sudden-onset, severe pain, a contracted uterus, and fetal distress. In severe cases, an emergency Caesarean section is necessary to reduce the risk of mortality.
If a patient presents with a history suggestive of placental abruption but no maternal or fetal compromise, a transabdominal and/or transvaginal ultrasound scan can confirm the diagnosis and assess fetal wellbeing.
Admission for monitoring and analgesia may be appropriate in cases where there is a concealed or resolved placental abruption and the patient is stable without fetal distress. However, in the presence of maternal and fetal compromise, induction of labor is not appropriate.
In cases where there is no maternal or fetal distress, admitting for intravenous analgesia and fluids can be appropriate to assess the patient and make a timely decision for delivery as required.
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This question is part of the following fields:
- Obstetrics
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Question 75
Incorrect
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A 34-year-old female who is 28 weeks pregnant presents to the emergency department with severe lower abdominal pain. She is tachycardic but is otherwise stable. On examination, her uterus is tender and hard, but fetal lie is normal. Cardiotocography shows no signs of fetal distress.
What is the most appropriate course of action for management?Your Answer: Emergency caesarean section
Correct Answer: Admit her and administer steroids
Explanation:When managing placental abruption in a case where the fetus is alive, less than 36 weeks old, and not displaying any signs of distress, the appropriate course of action is to admit the patient and administer steroids. Admitting the patient is necessary for monitoring and providing necessary care. Steroids are given to aid in the maturation of fetal lungs. It is recommended to deliver the baby at 37-38 weeks due to the increased risk of stillbirth. Tocolytics are not routinely given due to their controversial nature and potential for maternal cardiovascular side effects. Discharging the patient with safety netting is not appropriate as the patient is symptomatic. Activating the major haemorrhage protocol, calling 2222, and performing an emergency caesarean section are not the most suitable options as the patient is not hypotensive and there are no signs of fetal distress.
Placental Abruption: Causes, Management, and Complications
Placental abruption is a condition where the placenta separates from the uterine wall, leading to maternal haemorrhage. The severity of the condition depends on the extent of the separation and the gestational age of the fetus. Management of placental abruption is crucial to prevent maternal and fetal complications.
If the fetus is alive and less than 36 weeks, immediate caesarean delivery is recommended if there is fetal distress. If there is no fetal distress, close observation, administration of steroids, and no tocolysis are recommended. The decision to deliver depends on the gestational age of the fetus. If the fetus is alive and more than 36 weeks, immediate caesarean delivery is recommended if there is fetal distress. If there is no fetal distress, vaginal delivery is recommended. If the fetus is dead, vaginal delivery should be induced.
Placental abruption can lead to various maternal complications, including shock, disseminated intravascular coagulation (DIC), renal failure, and postpartum haemorrhage (PPH). Fetal complications include intrauterine growth restriction (IUGR), hypoxia, and death. The condition is associated with a high perinatal mortality rate and is responsible for 15% of perinatal deaths.
In conclusion, placental abruption is a serious condition that requires prompt management to prevent maternal and fetal complications. Close monitoring and timely intervention can improve the prognosis for both the mother and the baby.
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This question is part of the following fields:
- Obstetrics
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Question 76
Incorrect
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A 35-year-old primigravida, at 39+3 weeks’ gestation, presented to the Labour Ward in spontaneous labour. The midwife has asked you to review the patient, as the latter has only dilated 2 cm in the last six hours. She is now at 4 cm of cervical dilation at 10 hours since onset of labour. Cardiotocography shows no evidence of fetal distress; uterine contractions are palpable, but irregular and not very strong, and the patient’s observations are stable.
What is the next step in managing this patient?Your Answer: No action required at present, reassess in one hour
Correct Answer: Amniotomy and reassess by vaginal examination in two hours
Explanation:Management of Prolonged First Stage of Labour: Interventions and Considerations
When a patient experiences a prolonged first stage of labour, it is important to assess the three categories where problems could arise: Powers, Passage, and Passenger. In the case of a primigravida who is achieving less than 0.5 cm per hour over the past 6 hours, and with irregular, non-powerful contractions, the first step is to perform a vaginal examination to assess cervical dilation, fetal position and presentation, and membrane integrity. If the membranes are intact, an amniotomy or artificial rupture of membranes can be performed to accelerate the first stage of labour. Progress is then reassessed by vaginal examination after two hours. If progress remains suboptimal, an oxytocin infusion can be commenced, with analgesia taken into consideration. However, oxytocin infusion should be avoided in women with a previous Caesarean section due to the risk of uterine rupture.
If there is no indication of fetal distress, uncontrolled haemorrhage, or other maternal complications, there is no need for a Caesarean section or instrumental delivery at present. However, if fetal distress or serious maternal complications arise, an emergency Caesarean section would be the preferred mode of delivery. In the absence of these indications, an intervention such as amniotomy should be offered early to increase the chances of a normal vaginal delivery before the patient tires. Therefore, reassessment should be done in one hour to ensure timely intervention.
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This question is part of the following fields:
- Obstetrics
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Question 77
Incorrect
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A 25-year-old woman visits her GP with complaints of mild abdominal pain and vaginal bleeding. She is currently 6 weeks pregnant and is otherwise feeling well. On examination, she is tender in the right iliac fossa and has a small amount of blood in the vaginal vault with a closed cervical os. There is no cervical excitation. Her vital signs are stable, with a blood pressure of 120/80 mmHg, heart rate of 80 bpm, temperature of 36.5ºC, saturations of 99% on air, and respiratory rate of 14 breaths/minute. A urine dip reveals blood only, and a urinary pregnancy test is positive. What is the most appropriate course of action?
Your Answer: Arrange an outpatient transvaginal ultrasound
Correct Answer: Refer for immediate assessment at the Early Pregnancy Unit
Explanation:A woman with a positive pregnancy test and abdominal, pelvic or cervical motion tenderness should be immediately referred for assessment due to the risk of an ectopic pregnancy. Arranging an outpatient ultrasound or reassuring the patient is not appropriate. Urgent investigation is necessary to prevent the risk of rupture. Expectant management may be appropriate for a woman with vaginal bleeding and no pain or tenderness, but not for this patient who has both.
Bleeding in the First Trimester: Understanding the Causes and Management
Bleeding in the first trimester of pregnancy is a common concern for many women. It can be caused by various factors, including miscarriage, ectopic pregnancy, implantation bleeding, cervical ectropion, vaginitis, trauma, and polyps. However, the most important cause to rule out is ectopic pregnancy, as it can be life-threatening if left untreated.
To manage early bleeding, the National Institute for Health and Care Excellence (NICE) released guidelines in 2019. If a woman has a positive pregnancy test and experiences pain, abdominal tenderness, pelvic tenderness, or cervical motion tenderness, she should be referred immediately to an early pregnancy assessment service. If the pregnancy is over six weeks gestation or of uncertain gestation and the woman has bleeding, she should also be referred to an early pregnancy assessment service.
A transvaginal ultrasound scan is the most important investigation to identify the location of the pregnancy and whether there is a fetal pole and heartbeat. If the pregnancy is less than six weeks gestation and the woman has bleeding but no pain or risk factors for ectopic pregnancy, she can be managed expectantly. However, she should be advised to return if bleeding continues or pain develops and to repeat a urine pregnancy test after 7-10 days and to return if it is positive. A negative pregnancy test means that the pregnancy has miscarried.
In summary, bleeding in the first trimester of pregnancy can be caused by various factors, but ectopic pregnancy is the most important cause to rule out. Early referral to an early pregnancy assessment service and a transvaginal ultrasound scan are crucial in identifying the location of the pregnancy and ensuring appropriate management. Women should also be advised to seek medical attention if they experience any worrying symptoms or if bleeding or pain persists.
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This question is part of the following fields:
- Obstetrics
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Question 78
Incorrect
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A 28-year-old woman comes to the clinic with her worried partner. She has been exhibiting unpredictable mood swings since giving birth to their daughter 10 days ago. During the appointment, she seems restless and agitated. Her partner shares that she has been avoiding sleep due to her fear that something terrible will happen to their baby. The patient has a history of depression but has not taken her fluoxetine medication for 4 months because of concerns about potential complications. What is the best course of action for managing her symptoms?
Your Answer: Restart fluoxetine at a low dose, titrating to control symptoms
Correct Answer: Admit to hospital for urgent assessment
Explanation:The appropriate course of action for a woman exhibiting symptoms of agitation and paranoid delusions after giving birth is to admit her to the hospital for urgent assessment. This is likely a case of postpartum psychosis, which is different from postnatal depression. Postpartum psychosis can include mania, depression, irritability, rapid mood changes, confusion, paranoia, delusions, and/or hallucinations. Prescribing medication to aid in sleep is not appropriate in this case, and reassurance that her low mood will improve with time is also not appropriate due to the risk to herself and her baby. Gradual titration of fluoxetine would not manage her acute symptoms and would not ensure the safety of her or her baby. Ideally, she should be hospitalized in a Mother & Baby Unit.
Understanding Postpartum Mental Health Problems
Postpartum mental health problems can range from mild ‘baby-blues’ to severe puerperal psychosis. To screen for depression, healthcare professionals may use the Edinburgh Postnatal Depression Scale, which is a 10-item questionnaire that indicates how the mother has felt over the previous week. A score of more than 13 indicates a ‘depressive illness of varying severity’, with sensitivity and specificity of more than 90%. The questionnaire also includes a question about self-harm.
‘Baby-blues’ is seen in around 60-70% of women and typically occurs 3-7 days following birth. It is more common in primips, and mothers are characteristically anxious, tearful, and irritable. Reassurance and support from healthcare professionals, particularly health visitors, play a key role in managing this condition. Most women with the baby blues will not require specific treatment other than reassurance.
Postnatal depression affects around 10% of women, with most cases starting within a month and typically peaking at 3 months. The features are similar to depression seen in other circumstances, and cognitive behavioural therapy may be beneficial. Certain SSRIs such as sertraline and paroxetine may be used if symptoms are severe. Although these medications are secreted in breast milk, they are not thought to be harmful to the infant.
Puerperal psychosis affects approximately 0.2% of women and requires admission to hospital, ideally in a Mother & Baby Unit. Onset usually occurs within the first 2-3 weeks following birth, and features include severe swings in mood (similar to bipolar disorder) and disordered perception (e.g. auditory hallucinations). There is around a 25-50% risk of recurrence following future pregnancies. Paroxetine is recommended by SIGN because of the low milk/plasma ratio, while fluoxetine is best avoided due to a long half-life.
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This question is part of the following fields:
- Obstetrics
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Question 79
Incorrect
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A 28-year-old woman who is 30+2 weeks pregnant, G3 P2+0, arrives at the maternity triage unit due to an episode of vaginal bleeding. Her previous deliveries were both elective Caesarean sections. She has had an uncomplicated pregnancy so far and reports that the bleeding was about a tablespoon in amount without accompanying pain. What is the next step in establishing a diagnosis?
Your Answer: Fetal blood monitoring to check for fetal distress
Correct Answer: Ultrasound scan
Explanation:This individual is suspected to have placenta praevia, a significant cause of antepartum haemorrhage. Due to her history of multiple Caesarean sections, multiparity, and symptoms (minimal bleeding, no pain), it is more likely that she has a low-lying placenta. An ultrasound scan is necessary to accurately determine the location of the placenta, as previous scans may have missed or misinterpreted it. Placenta praevia can be diagnosed and graded through an ultrasound scan. It is important to avoid any internal examinations initially, as they may cause the placenta to bleed. According to the RCOG Green Top guidelines, digital vaginal examination should not be performed until an ultrasound has excluded placenta praevia if it is suspected. While some clinicians may consider a speculum examination to check for polyps/ectropion, this is not a diagnostic option for placenta praevia. A full blood count would not aid in the diagnosis, and any amount of blood loss during pregnancy should be investigated.
Management and Prognosis of Placenta Praevia
Placenta praevia is a condition where the placenta is located wholly or partially in the lower uterine segment. If a low-lying placenta is detected at the 20-week scan, a rescan is recommended at 32 weeks. There is no need to limit activity or intercourse unless there is bleeding. If the placenta is still present at 32 weeks and is grade I/II, then a scan every two weeks is recommended. A final ultrasound at 36-37 weeks is necessary to determine the method of delivery. For grades III/IV, an elective caesarean section is recommended between 37-38 weeks. However, if the placenta is grade I, a trial of vaginal delivery may be offered. If a woman with known placenta praevia goes into labour before the elective caesarean section, an emergency caesarean section should be performed due to the risk of post-partum haemorrhage.
In cases where placenta praevia is accompanied by bleeding, the woman should be admitted and an ABC approach should be taken to stabilise her. If stabilisation is not possible, an emergency caesarean section should be performed. If the woman is in labour or has reached term, an emergency caesarean section is also necessary.
The prognosis for placenta praevia has improved significantly, and death is now extremely rare. The major cause of death in women with placenta praevia is post-partum haemorrhage.
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This question is part of the following fields:
- Obstetrics
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Question 80
Incorrect
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A 30-year-old Caucasian woman who is 26 weeks pregnant with her first child presents to antenatal clinic. She had been invited to attend screening for gestational diabetes on account of her booking BMI, which was 32kg/m². Prior to her pregnancy, she had been healthy and had no personal or family history of diabetes mellitus. She takes no regular medications and has no known allergies.
During her antenatal visit, she undergoes an oral glucose tolerance test (OGTT), which reveals the following results:
- Fasting glucose 6.9mmol/L
- 2-hour glucose 7.8 mmol/L
An ultrasound scan shows no fetal abnormalities or hydramnios. She is advised on diet and exercise and undergoes a repeat OGTT two weeks later. Due to persistent impaired fasting glucose, she is started on metformin.
After taking metformin for two weeks, she undergoes another OGTT, with the following results:
- Fasting glucose 5.8 mmol/L
- 2-hour glucose 7.2mmol/L
What is the most appropriate next step in managing her glycaemic control?Your Answer: Add a sulfonylurea
Correct Answer: Add insulin
Explanation:If blood glucose targets are not achieved through diet and metformin in gestational diabetes, insulin should be introduced. This patient was diagnosed with gestational diabetes at 25 weeks due to a fasting glucose level above 5.6mmol/L. Despite lifestyle changes and the addition of metformin, her glycaemic control has not improved, and her fasting glucose level remains above the target range. Therefore, NICE recommends adding short-acting insulin to her current treatment. Switching to modified-release metformin may help patients who experience side effects, but it would not improve glycaemic control in this case. Insulin should be added in conjunction with metformin for persistent impaired glycaemic control, rather than replacing it. Sulfonylureas like glibenclamide should only be used for patients who cannot tolerate metformin or as an adjunct for those who refuse insulin treatment, and they are not the best option for this patient.
Gestational diabetes is a common medical disorder affecting around 4% of pregnancies. Risk factors include a high BMI, previous gestational diabetes, and family history of diabetes. Screening is done through an oral glucose tolerance test, and diagnostic thresholds have recently been updated. Management includes self-monitoring of blood glucose, diet and exercise advice, and medication if necessary. For pre-existing diabetes, weight loss and insulin are recommended, and tight glycemic control is important. Targets for self-monitoring include fasting glucose of 5.3 mmol/l and 1-2 hour post-meal glucose levels.
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This question is part of the following fields:
- Obstetrics
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Question 81
Incorrect
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A 35-year-old woman who is 8 weeks pregnant with twins presents to the early pregnancy unit with a 3-day history of vomiting and postural dizziness. The patient is gravida 2, parity 0, and never had such severe sickness in her previous pregnancy. No one else in the family is sick.
She has a past medical history of hypothyroidism and takes levothyroxine.
During examination, her BMI is 16 kg/m² and she has lost >5% of her body weight in the last 3 days. She is visibly dehydrated and her blood pressure is 98/75 mmHg.
What aspect of the patient's history poses the highest risk for the development of this condition?Your Answer: Hypothyroidism
Correct Answer: Pregnant with twins
Explanation:The risk of hyperemesis gravidarum is higher in women who are pregnant with twins. This is because each twin produces hCG, which can increase the levels of hCG in the body and lead to hyperemesis gravidarum. Hypothyroidism is not a risk factor, but hyperthyroidism is because it can increase levels of TSH, which is chemically similar to hCG. Age and previous pregnancies do not increase the risk of hyperemesis gravidarum, but a history of hyperemesis gravidarum in a previous pregnancy can increase the likelihood of developing it in future pregnancies.
Hyperemesis gravidarum is an extreme form of nausea and vomiting of pregnancy that occurs in around 1% of pregnancies and is most common between 8 and 12 weeks. It is associated with raised beta hCG levels and can be caused by multiple pregnancies, trophoblastic disease, hyperthyroidism, nulliparity, and obesity. Referral criteria for nausea and vomiting in pregnancy include continued symptoms with ketonuria and/or weight loss, a confirmed or suspected comorbidity, and inability to keep down liquids or oral antiemetics. The diagnosis of hyperemesis gravidarum requires the presence of 5% pre-pregnancy weight loss, dehydration, and electrolyte imbalance. Management includes first-line use of antihistamines and oral cyclizine or promethazine, with second-line options of ondansetron and metoclopramide. Admission may be needed for IV hydration. Complications can include Wernicke’s encephalopathy, Mallory-Weiss tear, central pontine myelinolysis, acute tubular necrosis, and fetal growth issues.
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This question is part of the following fields:
- Obstetrics
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Question 82
Incorrect
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An obstetrician is getting ready to perform an emergency lower segmental caesarian section for a 26-year-old woman who is experiencing complications of pre-eclampsia. Once the incision is made through the skin and superficial and deep fascia, what layers will the obstetrician need to traverse/cut through to access the fetus?
Your Answer: Linea alba - rectus abdominis muscle - transversalis fascia - extraperitoneal connective tissue - peritoneum - uterus
Correct Answer: Anterior rectus sheath - rectus abdominis muscle - transversalis fascia - extraperitoneal connective tissue - peritoneum - uterus
Explanation:In obstetric operating theatres or surgical vivas, a frequently asked question pertains to the structures that lie between the skin and the fetus during a lower segment Caesarian section. A confident and clear response indicates a sound understanding of local anatomy and the necessary incisions to reach the fetus. The layers between the skin and the fetus include the superficial fascia, deep fascia, anterior rectus sheath, rectus abdominis muscle (which is not cut but rather pushed laterally after incising the linea alba), transversalis fascia, extraperitoneal connective tissue, peritoneum, and uterus.
Caesarean Section: Types, Indications, and Risks
Caesarean section, also known as C-section, is a surgical procedure that involves delivering a baby through an incision in the mother’s abdomen and uterus. In recent years, the rate of C-section has increased significantly due to an increased fear of litigation. There are two main types of C-section: lower segment C-section, which comprises 99% of cases, and classic C-section, which involves a longitudinal incision in the upper segment of the uterus.
C-section may be indicated for various reasons, including absolute cephalopelvic disproportion, placenta praevia grades 3/4, pre-eclampsia, post-maturity, IUGR, fetal distress in labor/prolapsed cord, failure of labor to progress, malpresentations, placental abruption, vaginal infection, and cervical cancer. The urgency of C-section may be categorized into four categories, with Category 1 being the most urgent and Category 4 being elective.
It is important for clinicians to inform women of the serious and frequent risks associated with C-section, including emergency hysterectomy, need for further surgery, admission to intensive care unit, thromboembolic disease, bladder injury, ureteric injury, and death. C-section may also increase the risk of uterine rupture, antepartum stillbirth, placenta praevia, and placenta accreta in subsequent pregnancies. Other complications may include persistent wound and abdominal discomfort, increased risk of repeat C-section, readmission to hospital, haemorrhage, infection, and fetal lacerations.
Vaginal birth after C-section (VBAC) may be an appropriate method of delivery for pregnant women with a single previous C-section delivery, except for those with previous uterine rupture or classical C-section scar. The success rate of VBAC is around 70-75%.
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This question is part of the following fields:
- Obstetrics
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Question 83
Incorrect
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As a junior doctor in the neonatal unit, you receive a call from a nurse regarding a delivery where the baby's head has been delivered, but the shoulders are not descending with normal downward traction. What is your initial step in managing this situation?
Your Answer: Symphysiotomy
Correct Answer: Ask the mother to hyperflex their legs and apply suprapubic pressure
Explanation:In cases where the previous method is unsuccessful, an episiotomy may be necessary to facilitate internal maneuvers. Various alternatives may be considered, such as…
Shoulder dystocia is a complication that can occur during vaginal delivery when the body of the fetus cannot be delivered after the head has already been delivered. This is usually due to the anterior shoulder of the fetus becoming stuck on the mother’s pubic bone. Shoulder dystocia can cause harm to both the mother and the fetus. Risk factors for shoulder dystocia include fetal macrosomia, high maternal body mass index, diabetes mellitus, and prolonged labor.
If shoulder dystocia is identified, it is important to call for senior help immediately. The McRoberts’ maneuver is often performed, which involves flexing and abducting the mother’s hips to increase the angle of the pelvis and facilitate delivery. An episiotomy may be performed to provide better access for internal maneuvers, but it will not relieve the bony obstruction. Symphysiotomy and the Zavanelli maneuver are not recommended as they can cause significant maternal morbidity. Oxytocin administration is not indicated for shoulder dystocia.
Complications of shoulder dystocia can include postpartum hemorrhage and perineal tears for the mother, and brachial plexus injury and neonatal death for the fetus. It is important to manage shoulder dystocia promptly and appropriately to minimize the risk of these complications.
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This question is part of the following fields:
- Obstetrics
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Question 84
Incorrect
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You are a male FY1 working in obstetrics. A 35-year-old female is on the ward in labour, 10 minutes ago she suffered a placental abruption and is in need of emergency care. Her midwife comes to see you, informing you that she is requesting to only be seen and cared for by female doctors. How do you respond?
Your Answer: Tell the patient you will see what you can arrange and that you will see her in 1 hour with any news on a female doctor
Correct Answer: Ask the midwife to immediately summon senior medical support, regardless of gender
Explanation:Placental abruption is a critical obstetric emergency that requires immediate attention to prevent severe blood loss and potential harm to both the mother and baby. While patients have the right to choose their doctor, this right does not apply in emergency situations where prompt treatment is necessary to save the patient’s life. Therefore, suggesting that the patient wait for a female doctor or return in an hour is inappropriate and could result in a dangerous delay in medical care. It is also unnecessary to label the comment as sexist and document it in the patient’s notes. While it is important to respect the patient’s preferences, the priority in this situation is to provide urgent medical attention. Similarly, asking a midwife to take on the role of a doctor is not a safe or appropriate solution, as their training and responsibilities differ. Ultimately, if a female doctor is not available, the patient must be treated by a male doctor to address the emergency as quickly and effectively as possible.
Placental Abruption: Causes, Symptoms, and Risk Factors
Placental abruption is a condition that occurs when the placenta separates from the uterine wall, leading to maternal bleeding into the space between them. Although the exact cause of this condition is unknown, certain factors have been associated with it, including proteinuric hypertension, cocaine use, multiparity, maternal trauma, and increasing maternal age. Placental abruption is not a common occurrence, affecting approximately 1 in 200 pregnancies.
The clinical features of placental abruption include shock that is disproportionate to the visible blood loss, constant pain, a tender and tense uterus, and a normal lie and presentation of the fetus. The fetal heart may be absent or distressed, and there may be coagulation problems. It is important to be aware of other conditions that may present with similar symptoms, such as pre-eclampsia, disseminated intravascular coagulation (DIC), and anuria.
In summary, placental abruption is a serious condition that can have significant consequences for both the mother and the fetus. Understanding the risk factors and symptoms of this condition is important for early detection and appropriate management.
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This question is part of the following fields:
- Obstetrics
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Question 85
Incorrect
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You are an FY2 doctor in General Practice and have been asked to examine a lady who is 28 weeks pregnant as part of a routine antenatal check-up. She appears comfortable and her pregnancy has been uneventful so far.
Which of these should be part of a routine antenatal examination?Your Answer: Fetal heart rate with hand-held doppler ultrasound
Correct Answer: Symphysis-fundal height
Explanation:Antenatal Examinations: What to Expect and When
During pregnancy, regular antenatal examinations are important to monitor the health and development of both the mother and the fetus. Here are some key points to keep in mind:
Symphysis-fundal height: This measurement should be taken at every antenatal appointment from 24 weeks of gestation onwards.
Blood pressure and urine dipstick: These should be checked at every antenatal examination, especially in late pregnancy when pre-eclampsia is more common.
Abdominal palpation for fetal presentation: This should only be done at or after 36 weeks of gestation, as it is more accurate and can influence management of delivery. If an abnormal presentation is suspected, an ultrasound scan should be performed.
Ultrasound scan: Routine scanning after 24 weeks of gestation is not recommended.
Fetal movement counting: This is not routinely offered.
Fetal heart rate with hand-held doppler ultrasound: Routine auscultation is not recommended, but may be done to reassure the mother if requested.
By following these guidelines, healthcare providers can ensure that antenatal examinations are conducted safely and effectively.
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This question is part of the following fields:
- Obstetrics
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Question 86
Incorrect
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A 31-year-old primiparous woman, who is 34 weeks pregnant, presents to the emergency department with abdominal pain and vaginal bleeding. She reports that the bleeding has stopped after about a teaspoon of blood. Her pregnancy has been uncomplicated, and she has been attending antenatal care regularly. She confirms that her waters have not broken.
Upon examination, her vital signs are stable, and the foetal heart rate is reassuring. However, she has a tense and tender abdomen. A transvaginal ultrasound reveals a small retroplacental haemorrhage and an apically located placenta.
What is the most appropriate next step in managing this patient?Your Answer: Admit for 24-hour cardiotocography monitoring
Correct Answer: Admit for IV corticosteroids and monitoring
Explanation:The patient has presented with antepartum haemorrhage and ultrasound shows retroplacental haemorrhage, indicating placental abruption. Conservative management is appropriate due to stable vital signs and gestation of 33 weeks. IV corticosteroids are recommended to develop fetal lungs. Tocolysis, category 2 caesarean section, 24-hour cardiotocography monitoring, and planned induction are not indicated. Admission and monitoring are necessary in case of maternal or fetal compromise. Delivery may be required sooner than 3 weeks.
Placental Abruption: Causes, Symptoms, and Risk Factors
Placental abruption is a condition that occurs when the placenta separates from the uterine wall, leading to maternal bleeding into the space between them. Although the exact cause of this condition is unknown, certain factors have been associated with it, including proteinuric hypertension, cocaine use, multiparity, maternal trauma, and increasing maternal age. Placental abruption is not a common occurrence, affecting approximately 1 in 200 pregnancies.
The clinical features of placental abruption include shock that is disproportionate to the visible blood loss, constant pain, a tender and tense uterus, and a normal lie and presentation of the fetus. The fetal heart may be absent or distressed, and there may be coagulation problems. It is important to be aware of other conditions that may present with similar symptoms, such as pre-eclampsia, disseminated intravascular coagulation (DIC), and anuria.
In summary, placental abruption is a serious condition that can have significant consequences for both the mother and the fetus. Understanding the risk factors and symptoms of this condition is important for early detection and appropriate management.
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This question is part of the following fields:
- Obstetrics
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Question 87
Incorrect
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A 28-year-old primigravid woman is rushed to the hospital due to preterm premature rupture of membranes. During assessment, it is observed that the cord is protruding below the level of the introitus. What is the most suitable immediate course of action to take while preparing for a caesarian section?
Your Answer: Give IV oxytocin
Correct Answer: Insert a urinary catheter and fill the bladder with saline
Explanation:The most appropriate action for managing umbilical cord prolapse is to insert a urinary catheter and fill the bladder with saline, which can help lift the presenting part off the cord. Alternatively, the presenting part can be manually lifted to prevent cord compression. Applying suprapubic pressure is not the correct management for cord prolapse, as it is used for shoulder dystocia. Administering IV oxytocin is not recommended, as it can induce contractions. Tocolytics such as terbutaline or nifedipine can be used to relax the uterus and delay delivery while transferring the patient to theatre for a caesarian section. Episiotomy may be used in the management of shoulder dystocia, but it is not appropriate for cord prolapse. Pushing the cord back inside the vagina is not recommended, as it can cause vasospasm and lead to foetal hypoxia.
Understanding Umbilical Cord Prolapse
Umbilical cord prolapse is a rare but serious complication that can occur during delivery. It happens when the umbilical cord descends ahead of the presenting part of the fetus, which can lead to compression or spasm of the cord. This can cause fetal hypoxia and potentially irreversible damage or death. Certain factors increase the risk of cord prolapse, such as prematurity, multiparity, polyhydramnios, twin pregnancy, cephalopelvic disproportion, and abnormal presentations like breech or transverse lie.
Around half of all cord prolapses occur when the membranes are artificially ruptured. Diagnosis is usually made when the fetal heart rate becomes abnormal and the cord is palpable vaginally or visible beyond the introitus. Cord prolapse is an obstetric emergency that requires immediate management. The presenting part of the fetus may be pushed back into the uterus to avoid compression, and the cord should be kept warm and moist to prevent vasospasm. The patient may be asked to go on all fours or assume the left lateral position until preparations for an immediate caesarian section have been carried out. Tocolytics may be used to reduce uterine contractions, and retrofilling the bladder with saline can help elevate the presenting part. Although caesarian section is the usual first-line method of delivery, an instrumental vaginal delivery may be possible if the cervix is fully dilated and the head is low.
In conclusion, umbilical cord prolapse is a rare but serious complication that requires prompt recognition and management. Understanding the risk factors and appropriate interventions can help reduce the incidence of fetal mortality associated with this condition.
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This question is part of the following fields:
- Obstetrics
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Question 88
Incorrect
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A woman gives birth via normal vaginal delivery. The midwife notices the baby has an umbilical hernia, a large, protruding tongue, flattened face, and low muscle tone. What is the most probable outcome of this woman's combined screening test at 13-weeks-pregnant with this child?
Your Answer: ↓ HCG, ↓ PAPP-A, thickened nuchal translucency
Correct Answer: ↑ HCG, ↓ PAPP-A, thickened nuchal translucency
Explanation:NICE updated guidelines on antenatal care in 2021, recommending the combined test for screening for Down’s syndrome between 11-13+6 weeks. The test includes nuchal translucency measurement, serum B-HCG, and pregnancy-associated plasma protein A (PAPP-A). The quadruple test is offered between 15-20 weeks for women who book later in pregnancy. Results are interpreted as either a ‘lower chance’ or ‘higher chance’ of chromosomal abnormalities. If a woman receives a ‘higher chance’ result, she may be offered a non-invasive prenatal screening test (NIPT) or a diagnostic test. NIPT analyzes cell-free fetal DNA in the mother’s blood and has high sensitivity and specificity for detecting chromosomal abnormalities. Private companies offer NIPT screening from 10 weeks gestation.
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This question is part of the following fields:
- Obstetrics
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Question 89
Correct
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A 32-year-old woman from Chad complains of continuous dribbling incontinence following the birth of her second child. She reports no other issues related to her pregnancies and is generally healthy. What is the probable diagnosis?
Your Answer: Vesicovaginal fistula
Explanation:If a patient has continuous dribbling incontinence after prolonged labor and comes from an area with limited obstetric services, it is important to consider the possibility of vesicovaginal fistulae.
Understanding Urinary Incontinence: Causes, Classification, and Management
Urinary incontinence (UI) is a common condition that affects around 4-5% of the population, with elderly females being more susceptible. Several risk factors contribute to UI, including advancing age, previous pregnancy and childbirth, high body mass index, hysterectomy, and family history. UI can be classified into different types, such as overactive bladder (OAB)/urge incontinence, stress incontinence, mixed incontinence, overflow incontinence, and functional incontinence.
Initial investigation of UI involves completing bladder diaries for at least three days, vaginal examination, urine dipstick and culture, and urodynamic studies. Management of UI depends on the predominant type of incontinence. For urge incontinence, bladder retraining and bladder stabilizing drugs such as antimuscarinics are recommended. For stress incontinence, pelvic floor muscle training and surgical procedures such as retropubic mid-urethral tape procedures may be offered. Duloxetine, a combined noradrenaline and serotonin reuptake inhibitor, may also be used as an alternative to surgery.
In summary, understanding the causes, classification, and management of UI is crucial in providing appropriate care for patients. Early diagnosis and intervention can significantly improve the quality of life for those affected by this condition.
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This question is part of the following fields:
- Obstetrics
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Question 90
Incorrect
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A 32-year-old G3P0 attends the practice for review, following a miscarriage at 16 weeks’ gestation. She reports that in her other two pregnancies, she miscarried at 15 weeks’ and 18 weeks’ gestation, respectively. In all three pregnancies, she had ultrasound scans that were consistent with her dates.
What could be a potential factor that contributed to her recurrent miscarriages?Your Answer: Paternal Robertsonian translocation
Correct Answer: Incomplete fusion of paramesonephric ducts
Explanation:Causes of Second-Trimester Miscarriage: Incomplete Fusion of Paramesonephric Ducts and Other Factors
Second-trimester miscarriage can have various causes, including a septate or bicornuate uterus, cervical incompetence, and antiphospholipid syndrome or systemic lupus erythematosus. One possible reason for a septate or bicornuate uterus is incomplete fusion of the paramesonephric ducts. However, other factors such as low maternal serum progesterone or a failure of migration of gonadotropin-releasing hormone (GnRH)-secreting neurones from the olfactory placode can also contribute to second-trimester miscarriage. It is important to consider all possible causes when investigating recurrent pregnancy loss.
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This question is part of the following fields:
- Obstetrics
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Question 91
Incorrect
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A 28-year-old woman with her first pregnancy comes to you at 32-weeks gestation complaining of itchiness. Upon examination, there is no rash present. After being referred to an obstetrician, she is diagnosed with intrahepatic cholestasis of pregnancy and prescribed ursodeoxycholic acid. During her visit, the patient mentions that her obstetrician mentioned something about her labor, but she didn't quite understand.
What plans need to be made for this patient's labor?Your Answer: Caesarean section at 40 weeks gestation
Correct Answer: Induction of labour at 37-38 weeks gestation
Explanation:Due to the increased risk of stillbirth associated with intrahepatic cholestasis of pregnancy, induction of labour is typically recommended at 37-38 weeks gestation. Therefore, a normal labour is not appropriate for this patient. Ursodeoxycholic acid is used to treat the intense pruritus associated with this condition. While a caesarean section may be necessary on an emergency basis, it is not necessarily indicated at 37-38 weeks. Similarly, a caesarean section at 40 weeks is not currently warranted, as complications or emergencies may arise later in pregnancy. Induction of labour at 40 weeks is also not recommended, as it is later than the suggested timeline for minimising the risk of stillbirth.
Intrahepatic Cholestasis of Pregnancy: Symptoms and Management
Intrahepatic cholestasis of pregnancy, also known as obstetric cholestasis, is a condition that affects approximately 1% of pregnancies in the UK. It is characterized by intense itching, particularly on the palms, soles, and abdomen, and may also result in clinically detectable jaundice in around 20% of patients. Raised bilirubin levels are seen in over 90% of cases.
The management of intrahepatic cholestasis of pregnancy typically involves induction of labor at 37-38 weeks, although this practice may not be evidence-based. Ursodeoxycholic acid is also widely used, although the evidence base for its effectiveness is not clear. Additionally, vitamin K supplementation may be recommended.
It is important to note that the recurrence rate of intrahepatic cholestasis of pregnancy in subsequent pregnancies is high, ranging from 45-90%. Therefore, close monitoring and management are necessary for women who have experienced this condition in the past.
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This question is part of the following fields:
- Obstetrics
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Question 92
Incorrect
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You are a healthcare professional in obstetrics & gynaecology. A 27-year-old female patient has come to the early pregnancy assessment clinic complaining of light vaginal spotting and lower abdominal pain that has been present for 48 hours. She had taken a home pregnancy test 6 weeks ago, which was positive, and her last menstrual period was 8 weeks ago. A transvaginal ultrasound was performed, but no intrauterine pregnancy was detected. The serum βHCG results show a level of 3,662 IU per ml. What is the most likely diagnosis for this patient?
Your Answer: Early viable pregnancy
Correct Answer: Ectopic pregnancy
Explanation:Understanding Ectopic Pregnancy
Ectopic pregnancy occurs when a fertilized egg implants outside the uterus. This condition is characterized by lower abdominal pain and vaginal bleeding, typically occurring 6-8 weeks after the start of the last period. The pain is usually constant and may be felt on one side of the abdomen due to tubal spasm. Vaginal bleeding is usually less than a normal period and may be dark brown in color. Other symptoms may include shoulder tip pain, pain on defecation/urination, dizziness, fainting, or syncope. Breast tenderness may also be reported.
During examination, abdominal tenderness and cervical excitation may be observed. However, it is not recommended to examine for an adnexal mass due to the risk of rupturing the pregnancy. Instead, a pelvic examination to check for cervical excitation is recommended. In cases of pregnancy of unknown location, serum bHCG levels >1,500 may indicate an ectopic pregnancy. It is important to seek medical attention immediately if ectopic pregnancy is suspected as it can be life-threatening.
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This question is part of the following fields:
- Obstetrics
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Question 93
Incorrect
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A 35-year-old woman complains of lower abdominal pain during her 8th week of pregnancy. A transvaginal ultrasound reveals the presence of a simple ovarian cyst alongside an 8-week intrauterine pregnancy. What is the best course of action for managing the cyst?
Your Answer: Termination of pregnancy
Correct Answer: Reassure patient that this is normal and leave the cyst alone
Explanation:During the initial stages of pregnancy, ovarian cysts are typically physiological and referred to as corpus luteum. These cysts typically disappear during the second trimester. It is crucial to provide reassurance in such situations as expecting mothers are likely to experience high levels of anxiety. It is important to avoid anxiety during pregnancy to prevent any negative consequences for both the mother and the developing fetus.
Understanding the Different Types of Ovarian Cysts
Ovarian cysts are a common occurrence in women, and they can be classified into different types. The most common type of ovarian cyst is the physiological cyst, which includes follicular cysts and corpus luteum cysts. Follicular cysts occur when the dominant follicle fails to rupture or when a non-dominant follicle fails to undergo atresia. These cysts usually regress after a few menstrual cycles. Corpus luteum cysts, on the other hand, occur when the corpus luteum fails to break down and disappear after the menstrual cycle. These cysts may fill with blood or fluid and are more likely to cause intraperitoneal bleeding than follicular cysts.
Another type of ovarian cyst is the benign germ cell tumour, which includes dermoid cysts. Dermoid cysts are also known as mature cystic teratomas and are usually lined with epithelial tissue. They may contain skin appendages, hair, and teeth. Dermoid cysts are the most common benign ovarian tumour in women under the age of 30, and they are usually asymptomatic. However, torsion is more likely to occur with dermoid cysts than with other ovarian tumours.
Lastly, there are benign epithelial tumours, which arise from the ovarian surface epithelium. The most common benign epithelial tumour is the serous cystadenoma, which bears a resemblance to the most common type of ovarian cancer (serous carcinoma). Serous cystadenomas are bilateral in around 20% of cases. The second most common benign epithelial tumour is the mucinous cystadenoma, which is typically large and may become massive. If it ruptures, it may cause pseudomyxoma peritonei.
In conclusion, understanding the different types of ovarian cysts is important for proper diagnosis and treatment. Complex ovarian cysts should be biopsied to exclude malignancy, while benign cysts may require monitoring or surgical removal depending on their size and symptoms.
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This question is part of the following fields:
- Obstetrics
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Question 94
Incorrect
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A 36-year-old pregnant woman has a vaginal swab taken at 34 weeks gestation despite being asymptomatic. She informs you that during her previous pregnancy a bacteria which can cause sepsis in babies was detected on one of her swabs, which is why she needs to be tested again.
The microbiology report reads as follows:
Sample: Positive (awaiting sensitivities)
Gram stain: Positive
Morphology: Cocci in chains
Growth requirements: Facultative anaerobe
What is the most likely organism present based on this report?Your Answer: Staphylococcus aureus
Correct Answer: Streptococcus agalactiae
Explanation:Mothers who have previously tested positive for Group B Streptococcus during pregnancy should be given intravenous antibiotics as a preventative measure during labor or offered testing in late pregnancy and given antibiotics if the test is positive. Group B Streptococcus is a bacterium that can cause severe infections in newborns, including pneumonia and meningitis. It is a Gram-positive coccus that forms chains and is a facultative anaerobe. In contrast, Neisseria gonorrhoeae is a Gram-negative, diplococcus that requires oxygen to grow and is associated with conjunctivitis in newborns. Clostridium difficile is a Gram-positive, anaerobic bacillus that causes diarrheal illness, not neonatal sepsis.
Group B Streptococcus (GBS) is a common cause of severe infection in newborns. It is estimated that 20-40% of mothers carry GBS in their bowel flora, which can be passed on to their infants during labor and lead to serious infections. Prematurity, prolonged rupture of membranes, previous sibling GBS infection, and maternal pyrexia are all risk factors for GBS infection. The Royal College of Obstetricians and Gynaecologists (RCOG) has published guidelines on GBS management, which include not offering universal screening for GBS to all women and not offering screening based on maternal request. Women who have had GBS detected in a previous pregnancy should be offered intrapartum antibiotic prophylaxis (IAP) or testing in late pregnancy and antibiotics if still positive. IAP should also be offered to women with a previous baby with GBS disease, women in preterm labor, and women with a fever during labor. Benzylpenicillin is the preferred antibiotic for GBS prophylaxis.
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This question is part of the following fields:
- Obstetrics
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Question 95
Incorrect
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A 26-year-old primigravida woman is admitted to the hospital with a headache, fever, vomiting, and three episodes of convulsions. These were tonic-clonic movements lasting one to two minutes. She has no history of hypertension or epilepsy. On admission, her blood pressure was 186/136 mmHg, heart rate 115 beats per minute, and temperature 36.9ºC. The patient is started on intravenous magnesium sulfate due to the suspected diagnosis. The evening senior house officer is responsible for performing a neurological examination to monitor her reflexes. What other parameters should be monitored during this treatment?
Your Answer: Blood ketones
Correct Answer: Respiratory rate
Explanation:It is recommended to monitor reflexes and respiratory rate when administering magnesium sulphate.
Understanding Eclampsia and its Treatment
Eclampsia is a condition that occurs when seizures develop in association with pre-eclampsia, a pregnancy-induced hypertension that is characterized by proteinuria and occurs after 20 weeks of gestation. To prevent seizures in patients with severe pre-eclampsia and treat seizures once they develop, magnesium sulphate is commonly used. However, it is important to note that this medication should only be given once a decision to deliver has been made. In cases of eclampsia, an IV bolus of 4g over 5-10 minutes should be given, followed by an infusion of 1g/hour. During treatment, it is crucial to monitor urine output, reflexes, respiratory rate, and oxygen saturations. Respiratory depression can occur, and calcium gluconate is the first-line treatment for magnesium sulphate-induced respiratory depression. Treatment should continue for 24 hours after the last seizure or delivery, as around 40% of seizures occur post-partum. Additionally, fluid restriction is necessary to avoid the potentially serious consequences of fluid overload.
In summary, understanding the development of eclampsia and its treatment is crucial in managing this potentially life-threatening condition. Magnesium sulphate is the primary medication used to prevent and treat seizures, but it should only be given once a decision to deliver has been made. Monitoring vital signs and urine output is essential during treatment, and calcium gluconate should be readily available in case of respiratory depression. Finally, fluid restriction is necessary to avoid complications associated with fluid overload.
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This question is part of the following fields:
- Obstetrics
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Question 96
Correct
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A 35-year-old woman, who is exclusively breastfeeding, presents six months postpartum with burning pains and itching of the nipples. She has occasional sharp pains behind the areolae and reports that symptoms are worse after feeding.
On examination, both nipples appear erythematosus and inflamed, with small fissures. On further questioning, she reports no history of atopy. She also tells you that last night, she noticed some white patches in her infant’s mouth that she tried to wipe off but were stuck on the mucosa.
Which of the following is the most likely diagnosis?Your Answer: Nipple thrush
Explanation:Breastfeeding-Related Nipple Conditions: Symptoms and Treatments
Breastfeeding can lead to various nipple conditions that can cause discomfort and pain for both the mother and the infant. Here are some common nipple conditions and their symptoms:
1. Nipple Thrush: This fungal infection is transmitted from the mother to the infant through breastfeeding. Symptoms include bilateral sharp burning pains in the nipple and retroareolar tissue, red and swollen areas, severe itching, nipple inflammation, and fissuring. Both the mother and the baby should be treated with topical miconazole and oral miconazole gel, respectively.
2. Psoriasis: Psoriasis of the nipple and breast presents with raised red plaques that are well demarcated and easily separated from adjacent skin, with an overlying lacy scale.
3. Blocked Duct: This common problem presents with unilateral nipple pain and a small, round white area at the end of the nipple.
4. Nipple Eczema: Eczema of the nipple can cause a red, scaly rash with thickened lichenoid areas, usually sparing the base of the nipple. It is less likely in this scenario, given the white patches found in the infant’s mouth, suggesting transmission of infection from the mother.
5. Paget’s Disease of the Nipple: Symptoms include erythema, inflammation, burning pain, ulceration, erosions of the skin, and bleeding, usually affecting one side only.
It is important to seek medical attention if any of these symptoms persist or worsen.
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This question is part of the following fields:
- Obstetrics
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Question 97
Incorrect
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A 28-year-old woman is in labor with her first baby. In the second stage, fetal distress is detected, and instrumental delivery is being considered. What would be a contraindication to this procedure?
Your Answer: Ruptured membranes
Correct Answer: Head palpable abdominally
Explanation:Instrumental delivery is a method used to expedite delivery during the second stage of labor in order to prevent fetal and maternal morbidity. It involves the use of traction and is indicated in cases of prolonged active second stage, maternal exhaustion, fetal distress, breech presentation, and prophylactic use in medical conditions such as cardiovascular disease and hypertension. It can also be used to rotate a malpositioned fetal head.
To be eligible for instrumental delivery, the following requirements must be met, which can be remembered using the acronym FORCEPS:
– Fully dilated cervix, indicating that the second stage of labor has been reached
– Occiput anterior (OA) position, preferably with the head in the occiput posterior (OP) position, as delivery is possible with Kielland’s forceps and ventouse. The position of the head must be known to avoid maternal or fetal trauma and failure.
– Ruptured membranes
– Cephalic presentation
– Engaged presenting part, meaning that the head is at or below the ischial spines and cannot be palpated abdominally
– Pain relief
– Sphincter (bladder) empty, which usually requires catheterizationIt is important to note that there must be a clear indication for instrumental delivery.
When is a Forceps Delivery Necessary?
A forceps delivery may be necessary in certain situations during childbirth. These situations include fetal distress, maternal distress, failure to progress, and the need to control the head in a breech delivery. Fetal distress occurs when the baby is not receiving enough oxygen and can be detected through changes in the baby’s heart rate. Maternal distress can occur when the mother is exhausted or experiencing complications such as high blood pressure. Failure to progress refers to a situation where the mother has been pushing for an extended period of time without making progress. In a breech delivery, the baby’s head may need to be controlled to prevent injury. In these situations, a forceps delivery may be recommended by the healthcare provider to safely deliver the baby.
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This question is part of the following fields:
- Obstetrics
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Question 98
Incorrect
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A 28-year-old gravid 3, para 2 at 24 weeks gestation comes to the antenatal clinic to discuss delivery options for her pregnancy. She has a history of delivering her previous pregnancies through vaginal and elective caesarean section, respectively. What is the definite reason for not allowing vaginal delivery after a previous caesarean section?
Your Answer: Post-term dates
Correct Answer: Vertical (classic) caesarean scar
Explanation:VBAC is not recommended for patients who have had previous vertical (classical) caesarean scars, experienced uterine rupture in the past, or have other contraindications to vaginal birth such as placenta praevia. However, women who have had two or more previous caesarean sections may still be considered for VBAC. The remaining options in this question do not necessarily rule out VBAC.
Caesarean Section: Types, Indications, and Risks
Caesarean section, also known as C-section, is a surgical procedure that involves delivering a baby through an incision in the mother’s abdomen and uterus. In recent years, the rate of C-section has increased significantly due to an increased fear of litigation. There are two main types of C-section: lower segment C-section, which comprises 99% of cases, and classic C-section, which involves a longitudinal incision in the upper segment of the uterus.
C-section may be indicated for various reasons, including absolute cephalopelvic disproportion, placenta praevia grades 3/4, pre-eclampsia, post-maturity, IUGR, fetal distress in labor/prolapsed cord, failure of labor to progress, malpresentations, placental abruption, vaginal infection, and cervical cancer. The urgency of C-section may be categorized into four categories, with Category 1 being the most urgent and Category 4 being elective.
It is important for clinicians to inform women of the serious and frequent risks associated with C-section, including emergency hysterectomy, need for further surgery, admission to intensive care unit, thromboembolic disease, bladder injury, ureteric injury, and death. C-section may also increase the risk of uterine rupture, antepartum stillbirth, placenta praevia, and placenta accreta in subsequent pregnancies. Other complications may include persistent wound and abdominal discomfort, increased risk of repeat C-section, readmission to hospital, haemorrhage, infection, and fetal lacerations.
Vaginal birth after C-section (VBAC) may be an appropriate method of delivery for pregnant women with a single previous C-section delivery, except for those with previous uterine rupture or classical C-section scar. The success rate of VBAC is around 70-75%.
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This question is part of the following fields:
- Obstetrics
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Question 99
Incorrect
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A fit and well 36-week pregnant patient is admitted for a planned Caesarean section. Blood tests show the following:
Investigation Result Normal value
Haemoglobin 102 g/l 115–155 g/l
Mean corpuscular volume (MCV) 89 fl 82–98 fl
Platelets 156 × 109/l 150–400 × 109/l
White cell count (WCC) 11 × 109/l 4–11 × 109/l
With which of the following are these findings consistent?Your Answer: Iron deficiency anaemia
Correct Answer: Dilutional anaemia of pregnancy
Explanation:Understanding Dilutional Anaemia of Pregnancy
Dilutional anaemia of pregnancy is a common condition that occurs during pregnancy. It is characterized by a normal mean cell volume (MCV) and is caused by a disproportional rise in plasma volume, which dilutes the red blood cells. This condition is the most likely option for a patient with a normal MCV.
Iron deficiency anaemia, on the other hand, is microcytic and gives a low MCV. Pancytopenia, which is the term for low haemoglobin, white cells, and platelets, is not applicable in this case as the patient’s white cells and platelets are in the normal range.
Folic acid or B12 deficiency would give rise to macrocytic anaemia with raised MCV, which is not the case for this patient. Myelodysplasia, an uncommon malignant condition that usually occurs in patients over 60, is also unlikely.
In conclusion, understanding dilutional anaemia of pregnancy is important for healthcare professionals to provide appropriate care and management for pregnant patients.
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This question is part of the following fields:
- Obstetrics
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Question 100
Incorrect
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A 19-year-old primiparous woman is being monitored on the labour ward after a midwife raised concerns about her CTG tracing. She is currently in active second stage labour for 2 hours and is using gas and air for pain relief. At 39 weeks gestation, her CTG shows a foetal heart rate of 90 bpm (110 - 160), variability of 15 bpm (5 - 25), and no decelerations. She is experiencing 6-7 contractions per 10 minutes (3 - 4) for the past 7 minutes. What is the most appropriate immediate next step?
Your Answer: Place foetal scalp electrode
Correct Answer: Arrange a caesarean section within 30 minutes
Explanation:In the case of persistent foetal bradycardia with a higher than expected frequency of contractions, a category 1 caesarean section is necessary due to foetal compromise. This procedure should occur within 30 minutes. Therefore, the correct course of action is to arrange a caesarean section within this time frame. It is important to note that a category 2 caesarean section, which should occur within 75 minutes, is not appropriate in this situation as it is reserved for non-immediately life-threatening maternal or foetal compromise. Foetal blood sampling, placing a foetal scalp electrode, and taking an ECG of the mother are also not necessary in this scenario as urgent delivery is the priority.
Caesarean Section: Types, Indications, and Risks
Caesarean section, also known as C-section, is a surgical procedure that involves delivering a baby through an incision in the mother’s abdomen and uterus. In recent years, the rate of C-section has increased significantly due to an increased fear of litigation. There are two main types of C-section: lower segment C-section, which comprises 99% of cases, and classic C-section, which involves a longitudinal incision in the upper segment of the uterus.
C-section may be indicated for various reasons, including absolute cephalopelvic disproportion, placenta praevia grades 3/4, pre-eclampsia, post-maturity, IUGR, fetal distress in labor/prolapsed cord, failure of labor to progress, malpresentations, placental abruption, vaginal infection, and cervical cancer. The urgency of C-section may be categorized into four categories, with Category 1 being the most urgent and Category 4 being elective.
It is important for clinicians to inform women of the serious and frequent risks associated with C-section, including emergency hysterectomy, need for further surgery, admission to intensive care unit, thromboembolic disease, bladder injury, ureteric injury, and death. C-section may also increase the risk of uterine rupture, antepartum stillbirth, placenta praevia, and placenta accreta in subsequent pregnancies. Other complications may include persistent wound and abdominal discomfort, increased risk of repeat C-section, readmission to hospital, haemorrhage, infection, and fetal lacerations.
Vaginal birth after C-section (VBAC) may be an appropriate method of delivery for pregnant women with a single previous C-section delivery, except for those with previous uterine rupture or classical C-section scar. The success rate of VBAC is around 70-75%.
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This question is part of the following fields:
- Obstetrics
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Question 101
Incorrect
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You are evaluating a 23-year-old female who is 8 weeks pregnant and experiencing severe vomiting, making it difficult for her to retain fluids. What is the best method to determine the severity of her symptoms?
Your Answer: 24-hour recording of vomitus volume
Correct Answer: Pregnancy-Unique Quantification of Emesis (PUQE) scoring system
Explanation:Hyperemesis gravidarum is an extreme form of nausea and vomiting of pregnancy that occurs in around 1% of pregnancies and is most common between 8 and 12 weeks. It is associated with raised beta hCG levels and can be caused by multiple pregnancies, trophoblastic disease, hyperthyroidism, nulliparity, and obesity. Referral criteria for nausea and vomiting in pregnancy include continued symptoms with ketonuria and/or weight loss, a confirmed or suspected comorbidity, and inability to keep down liquids or oral antiemetics. The diagnosis of hyperemesis gravidarum requires the presence of 5% pre-pregnancy weight loss, dehydration, and electrolyte imbalance. Management includes first-line use of antihistamines and oral cyclizine or promethazine, with second-line options of ondansetron and metoclopramide. Admission may be needed for IV hydration. Complications can include Wernicke’s encephalopathy, Mallory-Weiss tear, central pontine myelinolysis, acute tubular necrosis, and fetal growth issues.
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This question is part of the following fields:
- Obstetrics
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Question 102
Incorrect
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A patient with known human immunodeficiency virus (HIV) presents at her booking visit at 38 weeks’ gestation. Her booking blood tests include a CD4 count of 480 and a viral load of 40 copies/ml. She is not currently on any antiretrovirals. She wishes to have a vaginal delivery if possible.
Which of the following best describes this patient’s HIV management during her pregnancy?Your Answer: Zidovudine monotherapy starting by 24 weeks until delivery
Correct Answer: Combined antiretroviral therapy starting by 24 weeks and continuing lifelong
Explanation:Antiretroviral Therapy Options for Pregnant Women with HIV
The British HIV Association recommends that all pregnant women who are HIV-positive should be started on combined antiretroviral therapy in the second trimester and continue it lifelong. This therapy consists of three agents. Even if the viral load is low, antiretroviral therapy is still recommended.
For women who refuse combined antiretroviral therapy, zidovudine monotherapy can be offered if the patient has a CD4 count of > 350 and a viral load of < 10 000 copies/ml and agrees to a Caesarean section. This option is less effective than combined therapy but can still be considered. If zidovudine monotherapy is chosen, it should be started in the second trimester and continued until delivery. During delivery, a zidovudine infusion should be running. If the viral load remains < 50 copies/ml, a planned vaginal delivery can be considered.
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This question is part of the following fields:
- Obstetrics
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Question 103
Incorrect
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A 27-year-old woman visits her GP worried about not feeling any fetal movements yet. She is currently 22 weeks pregnant and this is her first pregnancy. She is anxious because her peers who have been pregnant had already experienced their baby's movements by this stage. When should a referral to an obstetrician be made for absence of fetal movements?
Your Answer: 21 weeks
Correct Answer: 24 weeks
Explanation:Referral to a maternal fetal medicine unit is recommended if there are no fetal movements felt by 24 weeks. While most women feel their baby moving around 18-20 weeks, it can range from 16-24 weeks. If there is a lack of fetal movement, it could be due to various reasons, including miscarriages and stillbirth, which can be distressing. Therefore, it is important to check the fetal heartbeat and consider an ultrasound to detect any abnormalities if no fetal movements are felt by 24 weeks.
Understanding Reduced Fetal Movements
Introduction:
Reduced fetal movements can indicate fetal distress and are a response to chronic hypoxia in utero. This can lead to stillbirth and fetal growth restriction. It is believed that placental insufficiency may also be linked to reduced fetal movements.Physiology:
Quickening is the first onset of fetal movements, which usually occurs between 18-20 weeks gestation and increases until 32 weeks gestation. Multiparous women may experience fetal movements sooner. Fetal movements should not reduce towards the end of pregnancy. There is no established definition for what constitutes reduced fetal movements, but less than 10 movements within 2 hours (in pregnancies past 28 weeks gestation) is an indication for further assessment.Epidemiology:
Reduced fetal movements affect up to 15% of pregnancies, with 3-5% of pregnant women having recurrent presentations with RFM. Fetal movements should be established by 24 weeks gestation.Risk factors for reduced fetal movements:
Posture, distraction, placental position, medication, fetal position, body habitus, amniotic fluid volume, and fetal size can all affect fetal movement awareness.Investigations:
Fetal movements are usually based on maternal perception, but can also be objectively assessed using handheld Doppler or ultrasonography. Investigations are dependent on gestation at onset of RFM. If concern remains, despite normal CTG, urgent (within 24 hours) ultrasound can be used.Prognosis:
Reduced fetal movements can represent fetal distress, but in 70% of pregnancies with a single episode of reduced fetal movement, there is no onward complication. However, between 40-55% of women who suffer from stillbirth experience reduced fetal movements prior to diagnosis. Recurrent RFM requires further investigations to consider structural or genetic fetal abnormalities. -
This question is part of the following fields:
- Obstetrics
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Question 104
Incorrect
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A 30-year-old woman, mother of three, presents on day eight postpartum with difficulties breastfeeding. She has exclusively breastfed her other two children. She tells you her baby has problems latching, is feeding for a long time and is always hungry. She has sore nipples as a result of the poor latch.
On examination, you notice that the baby cannot bring his tongue past the lower lip and there is restriction in movement. On lifting the tongue, it acquires a heart shape with a central notch, but you cannot visualise the frenulum.
Which of the following is the most likely diagnosis?Your Answer: Cleft lip
Correct Answer: Posterior tongue tie
Explanation:Common Oral Abnormalities in Infants: Tongue Tie, Upper Lip Tie, Cleft Lip, and Cleft Palate
Tongue tie, also known as ankyloglossia, is a condition that affects up to 10% of live births, more commonly in boys than girls. It is characterized by a short, thickened frenulum attaching the tongue to the floor of the mouth, limiting tongue movements and causing difficulties with breastfeeding. Mothers may report that their infant takes a long time to feed, is irritable, and experiences nipple injury. Examination findings include limited tongue movements, inability to lift the tongue high or move it past the lower lip, and a characteristic heart-shaped notch when attempting to lift the tongue. Tongue tie can be anterior or posterior, with the latter being deeper in the mouth and more difficult to see.
Upper lip tie is a similar condition, with a frenulum attaching the upper lip to the gum line. This can also cause difficulties with breastfeeding due to limited movement of the upper lip.
Cleft lip and cleft palate are congenital malformations that occur when the facial structures fail to fuse properly during development. Cleft lip presents as a gap in the upper lip, while cleft palate is a gap in the roof of the mouth. Both can cause difficulties with feeding and require surgical intervention.
It is important for healthcare providers to be aware of these common oral abnormalities in infants and provide appropriate management and referrals to ensure optimal feeding and development.
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This question is part of the following fields:
- Obstetrics
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Question 105
Correct
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A new father who is 5 weeks post-partum comes in for a check-up. He has noticed a warm, red tender patch on his left breast just lateral to the areola. This has been worsening over the past four days and feeding is now painful. He saw the midwife yesterday who assisted with positioning but there has been no improvement. Upon examination, he has mastitis of the left breast without visible abscess. What is the best course of action for management?
Your Answer: Flucloxacillin, continue Breastfeeding
Explanation:Breastfeeding Problems and Their Management
Breastfeeding is a natural process, but it can come with its own set of challenges. Some of the minor problems that breastfeeding mothers may encounter include frequent feeding, nipple pain, blocked ducts, and nipple candidiasis. These issues can be managed by seeking advice on proper positioning, trying breast massage, and using appropriate medication.
Mastitis is a more serious problem that affects around 1 in 10 breastfeeding women. It is characterized by symptoms such as fever, nipple fissure, and persistent pain. Treatment involves the use of antibiotics, such as flucloxacillin, for 10-14 days. Breastfeeding or expressing milk should continue during treatment to prevent complications such as breast abscess.
Breast engorgement is another common problem that causes breast pain in breastfeeding women. It occurs in the first few days after birth and affects both breasts. Hand expression of milk can help relieve the discomfort of engorgement. Raynaud’s disease of the nipple is a less common problem that causes nipple pain and blanching. Treatment involves minimizing exposure to cold, using heat packs, and avoiding caffeine and smoking.
If a breastfed baby loses more than 10% of their birth weight in the first week of life, it may be a sign of poor weight gain. This should prompt consideration of the above breastfeeding problems and an expert review of feeding. Monitoring of weight should continue until weight gain is satisfactory.
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This question is part of the following fields:
- Obstetrics
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Question 106
Correct
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A 35-year-old woman in her second pregnancy has been diagnosed with pre-eclampsia and is taking labetalol twice daily. She presents to the Antenatal Assessment Unit with abdominal pain that began earlier this morning, followed by a brown discharge. The pain is constant and radiates to the back. During the examination, the uterus is hard and tender, and there is a small amount of dark red blood on the pad she presents to you. Which investigation is more likely to diagnose the cause of this patient's antepartum bleeding?
Your Answer: Transabdominal ultrasound scan
Explanation:When a patient presents with symptoms that suggest placental abruption, a transabdominal ultrasound scan is the most appropriate first-line investigation. This is especially true if the patient has risk factors such as pre-eclampsia and age over 35. The ultrasound scan can serve a dual purpose by assessing the position of the placenta and excluding placenta praevia, as well as assessing the integrity of the placenta and detecting any blood collection or haematoma that may indicate placental abruption. However, in some cases, the ultrasound scan may be normal even in the presence of placental abruption. In such cases, a magnetic resonance imaging (MRI) scan may be necessary for a more accurate diagnosis.
Before performing a bimanual pelvic examination, it is essential to rule out placenta praevia, as this can lead to significant haemorrhage and fetal and maternal compromise. A full blood count is also necessary to assess the extent of bleeding and anaemia, but it is not diagnostic of placental abruption.
An abdominal CT scan is not used as a first-line investigation for all women with antepartum haemorrhage, as it exposes the fetus to a significant radiation dose. It is only used in the assessment of pregnant women who have suffered traumatic injuries. Urinalysis is important in the assessment of women with antepartum haemorrhage, as it can detect genitourinary infections, but it does not aid in the diagnosis of placental abruption.
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This question is part of the following fields:
- Obstetrics
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Question 107
Incorrect
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A 25-year-old primiparous woman attends her booking visit where she is given an appointment for her first scan at 12+4 weeks’ gestation. She wants to know what the appointment will involve.
Regarding the 11–13 week appointment, which of the following is correct?Your Answer: If the patient has booked late, then screening can be performed at 15 weeks
Correct Answer: It can also include the ‘combined test’
Explanation:Understanding Down Syndrome Screening Tests
Down syndrome screening tests are important for pregnant women to determine the likelihood of their baby having the condition. One of the most common tests is the combined test, which is performed between 11+0 and 13+6 weeks’ gestation. This test involves a blood test and an ultrasound scan to measure serum pregnancy-associated plasma protein A (PAPP-A) and β-hCG, as well as nuchal translucency. The results are combined to give an individual risk of having a baby with Down syndrome.
If a woman misses the window for the combined test, she can opt for the quadruple test, which is performed between weeks 15 and 16 of gestation. This test measures four serum markers: inhibin, aFP, unconjugated oestriol, and total serum hCG. Low aFP and unconjugated oestriol, as well as raised inhibin and hCG, are associated with Down syndrome.
It is important to note that these tests are not diagnostic, but rather provide a risk assessment. Women who are classified as high risk may opt for a diagnostic test, such as amniocentesis or chorionic villous sampling, to confirm the presence of an extra chromosome. All pregnant women in the UK should be offered Down syndrome screening and given the opportunity to make an informed decision about participating in the test.
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This question is part of the following fields:
- Obstetrics
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Question 108
Incorrect
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A 27-year-old woman is in the second stage of labour. The fetal head is not descending, and the obstetrician decides to perform a ventouse extraction. He injects local anaesthetic into a nerve that crosses the ischial spine. This nerve then passes along the lateral wall of the ischiorectal fossa embedded in the obturator internus fascia in Alcock’s canal.
Which of the following is this nerve?Your Answer: Perineal branch of S4
Correct Answer: Pudendal nerve
Explanation:Nerve Pathways in the Pelvic Region
The pelvic region contains several important nerves that play a crucial role in the functioning of the lower body. Here are some of the key nerve pathways in this area:
Pudendal Nerve: This nerve exits the pelvis through the greater sciatic foramen and re-enters via the lesser sciatic foramen. It passes through Alcock’s canal and is responsible for the sensation and movement of the perineum.
Sciatic Nerve: The sciatic nerve emerges from the pelvis through the greater sciatic foramen and descends between the femur and ischial tuberosity. It is prone to injury during deep intramuscular injections.
Perineal Branch of S4: This nerve passes between the levator ani and coccygeus muscles and supplies the perianal skin.
Genital Branch of the Genitofemoral Nerve: This nerve descends on the psoas major muscle and supplies the cremaster muscle and labial or scrotal skin.
Obturator Nerve: The obturator nerve emerges from the psoas major muscle and runs along the lateral wall of the true pelvis. It exits the pelvis through the superior aspect of the obturator foramen to enter the thigh.
Understanding these nerve pathways is important for medical professionals who work in the pelvic region, as it can help them diagnose and treat various conditions related to these nerves.
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This question is part of the following fields:
- Obstetrics
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Question 109
Incorrect
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A 28-year-old female patient presents to the clinic at 36 weeks of pregnancy. She reports a decrease in fetal movement over the past few days and is concerned. She has no significant medical history or family history and has had two uncomplicated pregnancies in the past. Physical examination is normal, and vital signs are stable. A handheld Doppler scan reveals no fetal heartbeat.
What is the next course of action in managing this patient?Your Answer: Cardiotocography for 20 minutes
Correct Answer: Ultrasound scan
Explanation:If a woman reports reduced fetal movements and no heartbeat is detected with a handheld Doppler after 28 weeks of gestation, an immediate ultrasound should be offered according to RCOG guidelines. Repeating Doppler after an hour is not recommended. If a heartbeat is detected, cardiotocography should be used to monitor the heart rate for at least 20 minutes. Fetal blood sampling is not necessary in this situation.
Understanding Reduced Fetal Movements
Introduction:
Reduced fetal movements can indicate fetal distress and are a response to chronic hypoxia in utero. This can lead to stillbirth and fetal growth restriction. It is believed that placental insufficiency may also be linked to reduced fetal movements.Physiology:
Quickening is the first onset of fetal movements, which usually occurs between 18-20 weeks gestation and increases until 32 weeks gestation. Multiparous women may experience fetal movements sooner. Fetal movements should not reduce towards the end of pregnancy. There is no established definition for what constitutes reduced fetal movements, but less than 10 movements within 2 hours (in pregnancies past 28 weeks gestation) is an indication for further assessment.Epidemiology:
Reduced fetal movements affect up to 15% of pregnancies, with 3-5% of pregnant women having recurrent presentations with RFM. Fetal movements should be established by 24 weeks gestation.Risk factors for reduced fetal movements:
Posture, distraction, placental position, medication, fetal position, body habitus, amniotic fluid volume, and fetal size can all affect fetal movement awareness.Investigations:
Fetal movements are usually based on maternal perception, but can also be objectively assessed using handheld Doppler or ultrasonography. Investigations are dependent on gestation at onset of RFM. If concern remains, despite normal CTG, urgent (within 24 hours) ultrasound can be used.Prognosis:
Reduced fetal movements can represent fetal distress, but in 70% of pregnancies with a single episode of reduced fetal movement, there is no onward complication. However, between 40-55% of women who suffer from stillbirth experience reduced fetal movements prior to diagnosis. Recurrent RFM requires further investigations to consider structural or genetic fetal abnormalities. -
This question is part of the following fields:
- Obstetrics
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Question 110
Incorrect
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A 28-year-old woman comes in for her regular prenatal check-up at 16 weeks. This is her first pregnancy and she is feeling fine, but is worried because her sister was recently diagnosed with diabetes. She has no other complaints and her uterus is consistent with her gestational age. Blood pressure is within normal limits and urinalysis reveals negative nitrites, negative leukocytes, and negative protein. What is your next course of action?
Your Answer: Fasting plasma glucose
Correct Answer: Arrange oral glucose tolerance test for the 24-28 weeks stage
Explanation:The Importance of Oral Glucose Tolerance Test for Pregnant Women
Pregnant women with risk factors for gestational diabetes should undergo an oral glucose tolerance test at 24-28 weeks, according to National Institute for Health and Care Excellence (NICE) guidelines. Risk factors include a BMI over 30, previous macrosomia, high-risk ethnicity, and family history of diabetes. Women without risk factors do not require the test, while those with one risk factor should undergo the test. If a woman has previously had gestational diabetes, she can monitor her glucose levels or undergo an oral glucose tolerance test as soon as possible after her booking appointment and another test at 24-28 weeks if the first one is normal. HbA1c is not recommended for assessing the risk of gestational diabetes, and fasting blood glucose and random blood glucose tests are not indicated. While a healthy diet is important for all pregnant women, it is insufficient for preventing the development of gestational diabetes. A glucose tolerance test is necessary for diagnosis.
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This question is part of the following fields:
- Obstetrics
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Question 111
Incorrect
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A 23-year-old pregnant woman from Sudan visits her GP with concerns about her upcoming vaginal delivery. She is currently 30 weeks pregnant and has undergone type 3 female genital mutilation. She expresses her preference to have her vagina reinfibulated after delivery, as this is what she is accustomed to. What is the recommended course of action?
Your Answer: Advise her that reinfibulation can only be performed under exceptional circumstances and she will need to be further assessed
Correct Answer: Advise her that reinfibulation is illegal and cannot be done under any circumstances
Explanation:Performing any form of female genital cutting/modification for non-medical reasons, including reinfibulation of a woman with type 3 FGM after vaginal delivery, is illegal according to the Female Genital Mutilation Act 2003. It is strictly prohibited to carry out such procedures under any circumstances. However, discussing the topic is not illegal.
Understanding Female Genital Mutilation
Female genital mutilation (FGM) is a term used to describe any procedure that involves the partial or complete removal of the external female genitalia or any other injury to the female genital organs for non-medical reasons. The World Health Organization (WHO) has classified FGM into four types. Type 1 involves the partial or total removal of the clitoris and/or the prepuce, while type 2 involves the partial or total removal of the clitoris and the labia minora, with or without excision of the labia majora. Type 3 involves the narrowing of the vaginal orifice with the creation of a covering seal by cutting and appositioning the labia minora and/or the labia majora, with or without excision of the clitoris. Finally, type 4 includes all other harmful procedures to the female genitalia for non-medical purposes, such as pricking, piercing, incising, scraping, and cauterization. It is important to understand the different types of FGM to raise awareness and prevent this harmful practice.
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This question is part of the following fields:
- Obstetrics
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Question 112
Incorrect
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A 27-year-old woman (G1P1) gives birth vaginally at 38 weeks gestation and experiences a physiological third stage of labor. She notices some brown mucousy vaginal discharge with blood, which amounts to around 120ml of blood. Upon examination, her abdomen is soft but tender, and she has a GCS of 15, blood pressure of 130/80 mmHg, pulse rate of 88 bpm, and temperature of 36.6C. What is the most appropriate course of action for her management?
Your Answer: Abdominal ultrasound
Correct Answer: Provide sanitary pads
Explanation:After a vaginal delivery, the loss of blood exceeding 500 ml is referred to as postpartum haemorrhage.
Understanding Postpartum Haemorrhage
Postpartum haemorrhage (PPH) is a condition where a woman experiences blood loss of more than 500 ml after giving birth vaginally. It can be classified as primary or secondary. Primary PPH occurs within 24 hours after delivery and is caused by the 4 Ts: tone, trauma, tissue, and thrombin. The most common cause is uterine atony. Risk factors for primary PPH include previous PPH, prolonged labour, pre-eclampsia, increased maternal age, emergency Caesarean section, and placenta praevia.
In managing PPH, it is important to involve senior staff immediately and follow the ABC approach. This includes two peripheral cannulae, lying the woman flat, blood tests, and commencing a warmed crystalloid infusion. Mechanical interventions such as rubbing up the fundus and catheterisation are also done. Medical interventions include IV oxytocin, ergometrine, carboprost, and misoprostol. Surgical options such as intrauterine balloon tamponade, B-Lynch suture, ligation of uterine arteries, and hysterectomy may be considered if medical options fail to control the bleeding.
Secondary PPH occurs between 24 hours to 6 weeks after delivery and is typically due to retained placental tissue or endometritis. It is important to understand the causes and risk factors of PPH to prevent and manage this life-threatening emergency effectively.
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This question is part of the following fields:
- Obstetrics
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Question 113
Correct
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A 35-year-old primigravida woman, at 10 weeks gestation, presents to the emergency department with heavy vaginal bleeding. She reports passing large clots and experiencing cramping for the past 2 hours.
Upon examination, her blood pressure is 85/60 mmHg and her heart rate is 120 beats/minute. Pelvic examination reveals blood clots in the vaginal canal. A speculum exam shows active vaginal bleeding, a dilated cervical os, and a uterus consistent in size with a 9-week gestation. Pelvic ultrasonography reveals small amounts of fluid in the endometrium with an intrauterine sac measuring 22mm in crown-rump length, but no fetal cardiac activity is detected.
What is the most appropriate next step in management?Your Answer: Dilation and curettage
Explanation:If there is evidence of infection or an increased risk of hemorrhage, expectant management is not appropriate for a miscarriage. A patient with first-trimester vaginal bleeding, a dilated cervical os, and an intrauterine sac without fetal cardiac activity is experiencing an inevitable miscarriage. Miscarriages can be managed through expectant, pharmacological, or surgical means. Expectant management involves bed rest, avoiding strenuous physical activity, and weekly follow-up pelvic ultrasounds. This approach is typically recommended for patients with a threatened miscarriage that presents as vaginal bleeding. The threatened miscarriage may resolve on its own or progress to an inevitable, incomplete, or complete miscarriage. However, in this case, the open cervical os and absent fetal cardiac activity indicate that the miscarriage is inevitable, and the fetus is no longer viable. Medical management involves using drugs like misoprostol or methotrexate to medically evacuate retained products of conception in inevitable or incomplete miscarriages. Nevertheless, this patient is experiencing heavy vaginal bleeding, which has caused hypotension and tachycardia, making her hemodynamically unstable. In all cases of early pregnancy loss with hemodynamic instability, urgent surgical evacuation of products of conception is necessary to minimize further blood loss. Dilation and curettage is a common and controlled method of uterine evacuation.
Management Options for Miscarriage
Miscarriage can be a difficult and emotional experience for women. In the 2019 NICE guidelines, three types of management for miscarriage were discussed: expectant, medical, and surgical. Expectant management involves waiting for a spontaneous miscarriage and is considered the first-line option. However, if it is unsuccessful, medical or surgical management may be offered.
Medical management involves using tablets to expedite the miscarriage. Vaginal misoprostol, a prostaglandin analogue, is used to cause strong myometrial contractions leading to the expulsion of tissue. It is important to advise patients to contact their doctor if bleeding does not start within 24 hours. Antiemetics and pain relief should also be given.
Surgical management involves undergoing a surgical procedure under local or general anaesthetic. The two main options are vacuum aspiration (suction curettage) or surgical management in theatre. Vacuum aspiration is done under local anaesthetic as an outpatient, while surgical management is done in theatre under general anaesthetic. This was previously referred to as ‘Evacuation of retained products of conception’.
It is important to note that some situations are better managed with medical or surgical management, such as an increased risk of haemorrhage, being in the late first trimester, having coagulopathies or being unable to have a blood transfusion, previous adverse and/or traumatic experience associated with pregnancy, evidence of infection, and more. Ultimately, the management option chosen should be based on the individual patient’s needs and preferences.
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This question is part of the following fields:
- Obstetrics
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Question 114
Incorrect
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A 36-year-old woman at 38 weeks gestation is in the labour suite and undergoing a cardiotocography (CTG) review. Her waters broke 10 hours ago and she has been in labour for 6 hours. This is her first pregnancy and it has been uncomplicated so far. Her Bishop score is 6.
The CTG findings are as follows:
- Foetal heart rate 120 bpm (110 - 160)
- Variability 10 bpm (5 - 25)
- Decelerations Late, with 50% of contractions absent
- Contractions 3 per 10 minutes (3 - 4)
These findings have been consistent for the past 30 minutes. What is the most appropriate management?Your Answer: Commence syntocinon infusion
Correct Answer: Prepare for category 2 caesarean section
Explanation:Non-reassuring CTG findings during labour can indicate maternal or foetal compromise and require prompt action. Examples of abnormal findings include bradycardia, tachycardia, reduced variability, or prolonged deceleration. If these findings persist, the best course of action is to prepare for a category 2 caesarean section, which is for non-life-threatening maternal or foetal compromise. Augmenting contractions with syntocinon infusion is not recommended, as there is no evidence of its benefit. Increasing the frequency of CTG checks is not the best action, as the definitive action needed is to plan delivery. Tocolysis and a category 3 caesarean section are also not recommended, as they do not resolve the issue quickly enough. Foetal blood sampling is not routinely performed for non-reassuring CTG findings, but may be indicated for abnormal CTG findings to determine the health of the foetus.
Caesarean Section: Types, Indications, and Risks
Caesarean section, also known as C-section, is a surgical procedure that involves delivering a baby through an incision in the mother’s abdomen and uterus. In recent years, the rate of C-section has increased significantly due to an increased fear of litigation. There are two main types of C-section: lower segment C-section, which comprises 99% of cases, and classic C-section, which involves a longitudinal incision in the upper segment of the uterus.
C-section may be indicated for various reasons, including absolute cephalopelvic disproportion, placenta praevia grades 3/4, pre-eclampsia, post-maturity, IUGR, fetal distress in labor/prolapsed cord, failure of labor to progress, malpresentations, placental abruption, vaginal infection, and cervical cancer. The urgency of C-section may be categorized into four categories, with Category 1 being the most urgent and Category 4 being elective.
It is important for clinicians to inform women of the serious and frequent risks associated with C-section, including emergency hysterectomy, need for further surgery, admission to intensive care unit, thromboembolic disease, bladder injury, ureteric injury, and death. C-section may also increase the risk of uterine rupture, antepartum stillbirth, placenta praevia, and placenta accreta in subsequent pregnancies. Other complications may include persistent wound and abdominal discomfort, increased risk of repeat C-section, readmission to hospital, haemorrhage, infection, and fetal lacerations.
Vaginal birth after C-section (VBAC) may be an appropriate method of delivery for pregnant women with a single previous C-section delivery, except for those with previous uterine rupture or classical C-section scar. The success rate of VBAC is around 70-75%.
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This question is part of the following fields:
- Obstetrics
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Question 115
Correct
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A 29-year-old woman who is 39-weeks pregnant presents to the labour suite with sporadic contractions. She had noticed a mucous plug in her underwear earlier in the day. Upon examination, she appears to be breathing heavily and experiencing some discomfort. The cardiotocography is normal and progressing smoothly. During a vaginal examination, her cervix is estimated to be dilated at 2 cm. What phase of labour is she currently in?
Your Answer: Latent 1st stage
Explanation:The correct stage of labour for a woman with a cervix that is just beginning to ripen and dilate is the latent phase of the 1st stage. This stage is characterized by a cervix dilation of 0-3 cm. The active phase of the 1st stage, which is characterized by a cervix dilation of 3-10 cm and more regular contractions, is not applicable in this scenario. The active 2nd stage is also not a descriptive stage of labour, as it only refers to the general stage that ends with the expulsion of the foetus.
Labour is divided into three stages, with the first stage beginning from the onset of true labour until the cervix is fully dilated. This stage is further divided into two phases: the latent phase and the active phase. The latent phase involves dilation of the cervix from 0-3 cm and typically lasts around 6 hours. The active phase involves dilation from 3-10 cm and progresses at a rate of approximately 1 cm per hour. In primigravidas, this stage can last between 10-16 hours.
During this stage, the baby’s presentation is important to note. Approximately 90% of babies present in the vertex position, with the head entering the pelvis in an occipito-lateral position. The head typically delivers in an occipito-anterior position.
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This question is part of the following fields:
- Obstetrics
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Question 116
Incorrect
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A 25-year-old primigravida presents for her 36-week gestation check-up with her midwife in the community. She has had an uneventful pregnancy and is feeling well. Her birth plan is for a water birth at her local midwife-led birth center. During her assessment, her vital signs are as follows: temperature of 36.7ºC, heart rate of 90 beats/min, blood pressure of 161/112 mmHg, oxygen saturation of 98% in room air with a respiratory rate of 21/min. Urinalysis reveals nitrites + and a pH of 6.0, but negative for leucocytes, protein, and blood. What is the most appropriate management plan for this patient?
Your Answer:
Correct Answer: Admit to local maternity unit for observation and consideration of medication
Explanation:Pregnant women whose blood pressure is equal to or greater than 160/110 mmHg are likely to be admitted and monitored. In this case, the patient is hypertensive at 35 weeks of gestation. While pre-eclampsia was previously defined as hypertension and proteinuria during pregnancy, the current diagnosis includes hypertension and any end-organ damage. Although the patient feels well, she should be admitted to the local maternity unit for further investigation as her blood pressure exceeds the threshold. Urgent delivery of the infant should not be arranged unless the mother is unstable or there is fetal distress. The presence of nitrites in the urine dipstick is not a significant concern, and delaying further investigation for a week is not appropriate. Prescribing antibiotics for asymptomatic patients with positive nitrites and no leukocytes in the urine is incorrect management and does not address the hypertension. Continuing with midwife-led care without further investigation for two weeks could lead to the development of pre-eclampsia or eclamptic seizure, which is dangerous for both mother and fetus.
Pre-eclampsia is a condition that occurs during pregnancy and is characterized by high blood pressure, proteinuria, and edema. It can lead to complications such as eclampsia, neurological issues, fetal growth problems, liver involvement, and cardiac failure. Severe pre-eclampsia is marked by hypertension, proteinuria, headache, visual disturbances, and other symptoms. Risk factors for pre-eclampsia include hypertension in a previous pregnancy, chronic kidney disease, autoimmune disease, diabetes, chronic hypertension, first pregnancy, and age over 40. Aspirin may be recommended for women with high or moderate risk factors. Treatment involves emergency assessment, admission for observation, and medication such as labetalol, nifedipine, or hydralazine. Delivery of the baby is the most important step in management, with timing depending on the individual case.
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This question is part of the following fields:
- Obstetrics
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Question 117
Incorrect
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A 32-year-old woman presents at 35 weeks’ gestation in clinic. She had a primary infection with genital herpes at 24 weeks’ gestation, which was treated with acyclovir. She has attended clinic to discuss birth and management options.
What is the recommended management plan for this patient?Your Answer:
Correct Answer: acyclovir daily from 36 weeks and expectant delivery
Explanation:Genital herpes is caused by herpes simplex type 1 or 2 and can harm newborns, leading to neonatal herpes. Pregnant women who contract herpes and remain untreated have a higher risk of premature delivery and membrane rupture. Therefore, it is crucial to promptly treat women with herpes simplex infection. acyclovir is a safe treatment option, which speeds up the healing process and suppresses viral shedding. Women with primary herpes infection in the first and second trimesters should be treated with oral acyclovir and offered treatment-dose acyclovir from the 36th week of gestation until delivery to prevent recurrence and reduce the risk of neonatal herpes. Expectant delivery is acceptable in these cases. Women who acquire herpes in the third trimester should be treated with acyclovir until delivery and offered an elective Caesarean section to reduce the risk of neonatal transmission. Women who have acquired a primary genital herpes infection in the first and second trimesters that was treated should be offered acyclovir from 36 weeks onwards to reduce the risk of recurrence, lesion eruption, and viral shedding. Women with primary herpes simplex virus infection in labor who opt for vaginal delivery should receive intravenous acyclovir infusion to reduce the risk of neonatal herpes infection. Invasive procedures should be avoided in these cases.
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This question is part of the following fields:
- Obstetrics
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Question 118
Incorrect
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A 35-year-old woman, para 2+0, is currently in the second stage of labour and has successfully delivered the anterior shoulder. She has chosen active management for the third stage of labour. During her pregnancy, she experienced mild gestational hypertension and her most recent blood pressure reading was 140/90 mmHg. What medication should be given at this point?
Your Answer:
Correct Answer: Oxytocin
Explanation:The third stage of labor begins with the birth of the baby and ends with the expulsion of the placenta and membranes. To reduce the risk of post-partum hemorrhage and the need for blood transfusion after delivery, active management of this stage is recommended. This involves administering uterotonic drugs, delaying clamping and cutting of the cord for over a minute but less than five minutes, and using controlled cord traction after signs of placental separation. Guidelines recommend the use of 10 IU oxytocin by IM injection after delivery of the anterior shoulder. Ergometrine should not be given to patients with hypertension, and oxytocin is preferred as it causes less nausea and vomiting. The active management process should take less than 30 minutes.
Understanding Labour and its Stages
Labour is the process of giving birth, which is characterized by the onset of regular and painful contractions that are associated with cervical dilation and descent of the presenting part. Signs of labour include regular and painful uterine contractions, a show (shedding of mucous plug), rupture of the membranes (not always), and shortening and dilation of the cervix.
Labour can be divided into three stages. The first stage starts from the onset of true labour to when the cervix is fully dilated. The second stage is from full dilation to delivery of the fetus, while the third stage is from delivery of the fetus to when the placenta and membranes have been completely delivered.
Monitoring is an essential aspect of labour. Fetal heart rate (FHR) should be monitored every 15 minutes (or continuously via CTG), contractions should be assessed every 30 minutes, maternal pulse rate should be assessed every 60 minutes, and maternal blood pressure and temperature should be checked every 4 hours. Vaginal examination (VE) should be offered every 4 hours to check the progression of labour, and maternal urine should be checked for ketones and protein every 4 hours.
In summary, understanding the stages of labour and the importance of monitoring can help ensure a safe and successful delivery.
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This question is part of the following fields:
- Obstetrics
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Question 119
Incorrect
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A 28-year-old woman presents to the antenatal clinic at 12 weeks gestation for Down's syndrome screening. She undergoes a screening test and the results show an increased b-hCG, decreased PAPP-A, and thickened nuchal translucency on ultrasound. The chance of Down's syndrome is calculated to be 1/80. The patient expresses her concern about the safety of the testing options for her and her baby. She has no significant medical history. What is the most appropriate next step in managing this patient?
Your Answer:
Correct Answer: Offer non-invasive prenatal screening test (NIPT)
Explanation:NICE updated guidelines on antenatal care in 2021, recommending the combined test for screening for Down’s syndrome between 11-13+6 weeks. The test includes nuchal translucency measurement, serum B-HCG, and pregnancy-associated plasma protein A (PAPP-A). The quadruple test is offered between 15-20 weeks for women who book later in pregnancy. Results are interpreted as either a ‘lower chance’ or ‘higher chance’ of chromosomal abnormalities. If a woman receives a ‘higher chance’ result, she may be offered a non-invasive prenatal screening test (NIPT) or a diagnostic test. NIPT analyzes cell-free fetal DNA in the mother’s blood and has high sensitivity and specificity for detecting chromosomal abnormalities. Private companies offer NIPT screening from 10 weeks gestation.
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This question is part of the following fields:
- Obstetrics
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Question 120
Incorrect
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A 35-year-old primigravida woman at 30 weeks gestation arrives at the Emergency Department with premature rupture of membranes. She has had an uncomplicated pregnancy and is in good health. What is the optimal approach to managing her condition?
Your Answer:
Correct Answer: Admit her for at least 48 hours and prescribe antibiotics and steroids
Explanation:At 32 weeks gestation, this woman may be experiencing labor with ruptured membranes. It is important to admit her and administer steroids to promote the baby’s lung development. Antibiotics, such as erythromycin, should also be given to prevent sepsis and post-natal infection. Hospital guidelines should always be consulted, especially if Group B streptococcus is present, in which case penicillin and clindamycin may be used. If labor does not progress, the woman may be able to manage at home with temperature checks every 4-8 hours and returning to the hospital if a fever occurs. Delivery at 34 weeks may be considered if the risk of infection outweighs the risk of prematurity now that the baby’s lungs have matured.
Preterm prelabour rupture of the membranes (PPROM) is a condition that occurs in approximately 2% of pregnancies, but it is responsible for around 40% of preterm deliveries. This condition can lead to various complications, including prematurity, infection, and pulmonary hypoplasia in the fetus, as well as chorioamnionitis in the mother. To confirm PPROM, a sterile speculum examination should be performed to check for pooling of amniotic fluid in the posterior vaginal vault. However, digital examination should be avoided due to the risk of infection. If pooling of fluid is not observed, testing the fluid for placental alpha microglobulin-1 protein (PAMG-1) or insulin-like growth factor binding protein-1 is recommended. Ultrasound may also be useful to show oligohydramnios.
The management of PPROM involves admission and regular observations to ensure that chorioamnionitis is not developing. Oral erythromycin should be given for ten days, and antenatal corticosteroids should be administered to reduce the risk of respiratory distress syndrome. Delivery should be considered at 34 weeks of gestation, but there is a trade-off between an increased risk of maternal chorioamnionitis and a decreased risk of respiratory distress syndrome as the pregnancy progresses. PPROM is a serious condition that requires prompt diagnosis and management to minimize the risk of complications for both the mother and the fetus.
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This question is part of the following fields:
- Obstetrics
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Question 121
Incorrect
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A 32-year-old pregnant woman with pre-eclampsia experienced an eclamptic seizure at 11 am today. Magnesium was administered, and the baby was delivered an hour later at midday. However, she had another eclamptic seizure at 2 pm. Both the mother and baby have been stable since then. What is the appropriate time to discontinue the magnesium infusion?
Your Answer:
Correct Answer: 24 hours after last seizure
Explanation:The administration of magnesium should be initiated in women who are at high risk of severe pre-eclampsia or those who have eclampsia. It is important to continue the treatment for 24 hours after delivery or the last seizure, whichever occurs later. Therefore, the correct answer is 24 hours after the last seizure.
Understanding Eclampsia and its Treatment
Eclampsia is a condition that occurs when seizures develop in association with pre-eclampsia, a pregnancy-induced hypertension that is characterized by proteinuria and occurs after 20 weeks of gestation. To prevent seizures in patients with severe pre-eclampsia and treat seizures once they develop, magnesium sulphate is commonly used. However, it is important to note that this medication should only be given once a decision to deliver has been made. In cases of eclampsia, an IV bolus of 4g over 5-10 minutes should be given, followed by an infusion of 1g/hour. During treatment, it is crucial to monitor urine output, reflexes, respiratory rate, and oxygen saturations. Respiratory depression can occur, and calcium gluconate is the first-line treatment for magnesium sulphate-induced respiratory depression. Treatment should continue for 24 hours after the last seizure or delivery, as around 40% of seizures occur post-partum. Additionally, fluid restriction is necessary to avoid the potentially serious consequences of fluid overload.
In summary, understanding the development of eclampsia and its treatment is crucial in managing this potentially life-threatening condition. Magnesium sulphate is the primary medication used to prevent and treat seizures, but it should only be given once a decision to deliver has been made. Monitoring vital signs and urine output is essential during treatment, and calcium gluconate should be readily available in case of respiratory depression. Finally, fluid restriction is necessary to avoid complications associated with fluid overload.
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This question is part of the following fields:
- Obstetrics
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Question 122
Incorrect
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You are a Foundation Year 2 in general practice and a 32-year-old lady comes in who is pregnant with her first child. She feels unwell, has upper abdominal pain near her epigastrium, and thinks that her ankle swelling has been much worse over the last few days. You assess her and your findings are as follows:
Symphysis–fundal height (SFH): 39 cm
Presentation: breech
Lie: longitudinal
Blood pressure (BP): 152/93
Fetal movements: not palpable
Which of these investigations is most likely to lead you to a diagnosis?Your Answer:
Correct Answer: Urine dipstick
Explanation:Diagnosis and Management of Pre-eclampsia in Pregnancy
Pre-eclampsia is a serious condition that can occur during pregnancy, characterized by hypertension, proteinuria, and edema. It can lead to various complications and is a leading cause of maternal death. Risk factors include nulliparity, previous history of pre-eclampsia, family history, and certain medical conditions. Diagnosis is made by testing for proteinuria and monitoring blood pressure. Treatment involves close monitoring, medication, and delivery of the baby. Complications can include HELLP syndrome and eclampsia. Testing for liver function and performing a CTG can aid in management, but will not lead to the diagnosis. Early identification and management are crucial in preventing adverse outcomes.
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This question is part of the following fields:
- Obstetrics
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Question 123
Incorrect
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A 32-year-old woman presents to the antenatal clinic at 40-weeks gestation for her first pregnancy. She reports no contractions yet. Upon examination, her abdomen is soft and a palpable uterus indicates a term pregnancy. The cervix is firm and dilated to 1 cm, with the foetal head stationed 1 cm below the ischial spines. The obstetrician performs a membrane sweep and decides to initiate treatment with vaginal prostaglandins. What is the most probable complication of this procedure?
Your Answer:
Correct Answer: Uterine hyperstimulation
Explanation:When inducing labour in a patient who is past her due date, the main complication to watch out for is uterine hyperstimulation. The recommended method for inducing labour according to NICE guidelines is vaginal prostaglandins, which can be administered as a gel, tablet or slow-release pessary. A membrane sweep may also be performed alongside this. Vaginal prostaglandins work by ripening the cervix and stimulating uterine contractions. If uterine hyperstimulation occurs, tocolytic agents can be given to relax the uterus and slow contractions. It’s important to note that a breech presentation is not a complication of induction of labour, especially in cases where the foetus is stationed in the pelvis below the ischial spines. Chorioamnionitis, which is inflammation of the foetal membranes due to bacterial infection, is a risk during prolonged labour and repeated vaginal examinations, but it is not the main complication of induction of labour. Cord prolapse is also a possible complication, but it is more common when the presenting part of the foetus is high, which is not the case in this pregnancy where the foetal head is stationed 1 cm below the ischial spine.
Induction of labour is a process where labour is artificially started and is required in about 20% of pregnancies. It is indicated in cases of prolonged pregnancy, prelabour premature rupture of the membranes, maternal medical problems, diabetic mother over 38 weeks, pre-eclampsia, obstetric cholestasis, and intrauterine fetal death. The Bishop score is used to assess whether induction of labour is necessary and includes cervical position, consistency, effacement, dilation, and fetal station. A score of less than 5 indicates that labour is unlikely to start without induction, while a score of 8 or more indicates a high chance of spontaneous labour or response to interventions made to induce labour.
Possible methods of induction include membrane sweep, vaginal prostaglandin E2, oral prostaglandin E1, maternal oxytocin infusion, amniotomy, and cervical ripening balloon. The NICE guidelines recommend vaginal prostaglandins or oral misoprostol if the Bishop score is less than or equal to 6, while amniotomy and an intravenous oxytocin infusion are recommended if the score is greater than 6.
The main complication of induction of labour is uterine hyperstimulation, which refers to prolonged and frequent uterine contractions that can interrupt blood flow to the intervillous space and result in fetal hypoxemia and acidemia. Uterine rupture is a rare but serious complication. Management includes removing vaginal prostaglandins and stopping the oxytocin infusion if one has been started, and considering tocolysis.
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This question is part of the following fields:
- Obstetrics
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Question 124
Incorrect
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A 30-year-old woman, para 2+ 0, has given birth to a healthy baby. The third stage of labor was actively managed with Syntocinon, cord clamping, and controlled cord traction. The midwives examined the placenta, which appeared complete. However, the woman is experiencing postpartum bleeding and has lost an estimated 1,500 ml of blood. She has no prior medical history. What is the initial pharmacological treatment of choice to stop the bleeding?
Your Answer:
Correct Answer: IV syntocinon
Explanation:Postpartum haemorrhage (PPH) caused by uterine atony can be treated with various medical options including oxytocin, ergometrine, carboprost, and misoprostol. Initially, non-pharmacological methods such as bimanual uterine compression and catheter insertion should be used. RCOG guidelines recommend starting with Syntocinon 5 Units by slow IV injection, followed by ergometrine (avoid in hypertension), and then a Syntocinon infusion. Carboprost (avoid in asthma) and misoprostol 1000 micrograms rectally are then recommended. If pharmacological management fails, surgical haemostasis should be initiated. In a major PPH, ABCD management should be initiated, including fluids while waiting for appropriate cross-matched blood. Primary PPH is defined as a loss of greater than 500 ml of blood within 24 hours of delivery, with minor PPH being a loss of 500-1000 ml of blood and major PPH being over 1000 ml of blood. The causes of primary PPH can be categorized into the 4 T’s: Tone, Tissue, Trauma, and Thrombin. Uterine atony is the most common cause of primary PPH.
Understanding Postpartum Haemorrhage
Postpartum haemorrhage (PPH) is a condition where a woman experiences blood loss of more than 500 ml after giving birth vaginally. It can be classified as primary or secondary. Primary PPH occurs within 24 hours after delivery and is caused by the 4 Ts: tone, trauma, tissue, and thrombin. The most common cause is uterine atony. Risk factors for primary PPH include previous PPH, prolonged labour, pre-eclampsia, increased maternal age, emergency Caesarean section, and placenta praevia.
In managing PPH, it is important to involve senior staff immediately and follow the ABC approach. This includes two peripheral cannulae, lying the woman flat, blood tests, and commencing a warmed crystalloid infusion. Mechanical interventions such as rubbing up the fundus and catheterisation are also done. Medical interventions include IV oxytocin, ergometrine, carboprost, and misoprostol. Surgical options such as intrauterine balloon tamponade, B-Lynch suture, ligation of uterine arteries, and hysterectomy may be considered if medical options fail to control the bleeding.
Secondary PPH occurs between 24 hours to 6 weeks after delivery and is typically due to retained placental tissue or endometritis. It is important to understand the causes and risk factors of PPH to prevent and manage this life-threatening emergency effectively.
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This question is part of the following fields:
- Obstetrics
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Question 125
Incorrect
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A 26-year-old woman with type 1 diabetes becomes pregnant.
Which of the following statements is correct?Your Answer:
Correct Answer: There is an increased risk of polyhydramnios
Explanation:Misconceptions about Diabetes in Pregnancy
During pregnancy, diabetic patients are at an increased risk of developing polyhydramnios, which is diagnosed when the amniotic fluid index is >25 cm or if the deepest vertical pool is >8 cm. Contrary to popular belief, fetal macrosomia is a risk of a diabetic pregnancy, rather than microsomia. All patients should be treated with insulin because this has no teratogenic effects, in contrast to oral hypoglycaemics. The mortality rate from DKA in pregnant patients approaches 50%, so very close monitoring and counselling about the importance of good diabetic control are essential. Hypertension in pregnancy may be treated with other anti-hypertensives, eg labetalol or methyldopa, as ACE inhibitors are contraindicated in pregnancy because they are associated with oligohydramnios.
Debunking Common Myths about Diabetes in Pregnancy
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This question is part of the following fields:
- Obstetrics
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Question 126
Incorrect
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A 32-year-old woman who is 32 weeks pregnant visits her local antenatal unit for a midwife check-up. She has been diagnosed with intrahepatic cholestasis of pregnancy and is taking ursodeoxycholic acid. Additionally, she is being treated with lamotrigine for epilepsy. This is her first pregnancy, and she has not experienced any previous miscarriages. During her appointment, she expresses concern about her step-sister's recent stillbirth, as her step-sister has already had two prior stillbirths. Based on her medical history, which factor puts her at the highest risk for a similar outcome?
Your Answer:
Correct Answer: Intrahepatic cholestasis of pregnancy
Explanation:Intrahepatic cholestasis of pregnancy is known to increase the risk of stillbirth, which is why doctors usually recommend inducing labor at 37-38 weeks of gestation. Although some studies suggest that this may no longer be the case, the general consensus is that the risk of stillbirth is still relatively high. Therefore, early induction of labor is still advised.
While advanced maternal age is a risk factor for stillbirth, being 34 years old is not considered to be in the category of older maternal age, which is defined as 35 years old or older.
Although there may be a genetic component to stillbirths, having a step-sister with a history of stillbirth does not constitute a family history of the condition. This is because step-siblings are not biologically related, but rather connected through marriage.
Lamotrigine is considered the safest anti-epileptic medication to use during pregnancy, and there is no evidence to suggest that it increases the risk of stillbirth.
Intrahepatic Cholestasis of Pregnancy: Symptoms and Management
Intrahepatic cholestasis of pregnancy, also known as obstetric cholestasis, is a condition that affects approximately 1% of pregnancies in the UK. It is characterized by intense itching, particularly on the palms, soles, and abdomen, and may also result in clinically detectable jaundice in around 20% of patients. Raised bilirubin levels are seen in over 90% of cases.
The management of intrahepatic cholestasis of pregnancy typically involves induction of labor at 37-38 weeks, although this practice may not be evidence-based. Ursodeoxycholic acid is also widely used, although the evidence base for its effectiveness is not clear. Additionally, vitamin K supplementation may be recommended.
It is important to note that the recurrence rate of intrahepatic cholestasis of pregnancy in subsequent pregnancies is high, ranging from 45-90%. Therefore, close monitoring and management are necessary for women who have experienced this condition in the past.
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This question is part of the following fields:
- Obstetrics
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Question 127
Incorrect
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A 28-year-old primigravida arrives at 39 weeks with ruptured membranes and bleeding. She reports a rush of cloudy fluid followed by persistent vaginal bleeding. Despite feeling anxious, she denies experiencing any localized pain or tenderness. Although her pregnancy has been uneventful, she has not attended her prenatal scans. The cardiotocography reveals late decelerations and bradycardia. What is the probable diagnosis?
Your Answer:
Correct Answer: Vasa praevia
Explanation:Vasa praevia is a complication where the blood vessels of the fetus are located near or cross the internal opening of the uterus. If the supporting membranes rupture, the vessels can easily be damaged, resulting in bleeding. The classic symptoms of vasa praevia include painless vaginal bleeding and fetal bradycardia following the rupture of membranes. While there is no significant risk to the mother, fetal mortality rates are high. It can be challenging to differentiate vasa praevia from placenta praevia in emergency situations, but a preceding rupture of membranes is usually highlighted in exams. Although ultrasound scans can identify vasa praevia, some cases may go undetected during pregnancy.
Understanding Bleeding During Pregnancy
Bleeding during pregnancy can be a cause for concern and should be promptly evaluated by a healthcare professional. There are various causes of bleeding during pregnancy, which can be categorized based on the trimester in which they occur. In the first trimester, the major causes of bleeding include spontaneous abortion, ectopic pregnancy, and hydatidiform mole. In the second trimester, bleeding may be due to spontaneous abortion, hydatidiform mole, or placental abruption. In the third trimester, bleeding may be caused by placental abruption, placenta praevia, or vasa praevia.
It is important to note that conditions such as sexually transmitted infections and cervical polyps should also be ruled out as potential causes of bleeding during pregnancy. Each condition has its own unique features that can help in diagnosis. For instance, spontaneous abortion may present as threatened miscarriage, missed miscarriage, or inevitable miscarriage, depending on the extent of fetal and placental tissue expulsion. Ectopic pregnancy is typically characterized by lower abdominal pain and vaginal bleeding, while hydatidiform mole may present with exaggerated pregnancy symptoms and high serum hCG levels.
Placental abruption is usually accompanied by constant lower abdominal pain and a tender, tense uterus, while placenta praevia may present with painless vaginal bleeding and an abnormal lie and presentation. Vasa praevia is characterized by rupture of membranes followed immediately by vaginal bleeding and fetal bradycardia.
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This question is part of the following fields:
- Obstetrics
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Question 128
Incorrect
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A 30-year-old healthy pregnant woman is scheduled for a Caesarean section to deliver her first child at 9 months’ gestation. What type of abdominal surgical incision is the obstetrician likely to use for the procedure?
Your Answer:
Correct Answer: Suprapubic incision
Explanation:Different Types of Incisions for Surgical Procedures
When it comes to surgical procedures, there are various types of incisions that can be made depending on the specific operation being performed. Here are some common types of incisions and their uses:
1. Suprapubic Incision: This is the most common incision site for Gynaecological and obstetric operations like Caesarean sections. It is made at the pubic hairline and is also known as the bikini (Pfannenstiel) incision.
2. Transverse Incision just below the Umbilicus: This type of incision is usually too superior for a Caesarean section because the scar would be visible.
3. Right Subcostal Incision: This incision is used to access the gallbladder and biliary tree. It is commonly used for operations such as an open cholecystectomy.
4. Median Longitudinal Incision: This type of incision is not commonly used because of cosmetic scarring, as well as the fact that the linea alba is relatively avascular and can undergo necrosis if the edges are not aligned and stitched properly.
5. McBurney’s Point Incision: This incision is made at the McBurney’s point, which is approximately one-third of the distance of a line starting at the right anterior superior iliac spine and ending at the umbilicus. It is used to access the vermiform appendix.
In conclusion, the type of incision used in a surgical procedure depends on the specific operation being performed and the location of the area that needs to be accessed.
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This question is part of the following fields:
- Obstetrics
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Question 129
Incorrect
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You receive a call from a 27-year-old woman who is 8-weeks pregnant with twins. Last week she had severe nausea and vomiting despite a combination of oral cyclizine and promethazine. She continued to vomit and was admitted to the hospital briefly where she was started on metoclopramide and ondansetron which helped control her symptoms.
Today she tells you she read a pregnancy forum article warning about the potential risks of ondansetron use in pregnancy. She is concerned and wants advice on whether she should continue taking it.
How would you counsel this woman regarding the use of ondansetron during pregnancy?Your Answer:
Correct Answer: There is a small increased risk of cleft lip/palate in the newborn if used in the first trimester
Explanation:The use of ondansetron during pregnancy has been associated with an increased risk of 3 oral clefts per 10,000 births, according to a study. However, this risk is not included in the RCOG guideline on nausea and vomiting of pregnancy, and there is currently no official NICE guidance on the matter. A draft of NICE antenatal care guidance, published in August 2021, acknowledges the increased risk of cleft lip or palate with ondansetron use, but notes that there is conflicting evidence regarding the drug’s potential to cause heart problems in babies. It is important to note that the risk of spontaneous miscarriage in twin pregnancies is not supported by evidence, and there is no established risk of severe congenital heart defects in newborns associated with ondansetron use.
Hyperemesis gravidarum is an extreme form of nausea and vomiting of pregnancy that occurs in around 1% of pregnancies and is most common between 8 and 12 weeks. It is associated with raised beta hCG levels and can be caused by multiple pregnancies, trophoblastic disease, hyperthyroidism, nulliparity, and obesity. Referral criteria for nausea and vomiting in pregnancy include continued symptoms with ketonuria and/or weight loss, a confirmed or suspected comorbidity, and inability to keep down liquids or oral antiemetics. The diagnosis of hyperemesis gravidarum requires the presence of 5% pre-pregnancy weight loss, dehydration, and electrolyte imbalance. Management includes first-line use of antihistamines and oral cyclizine or promethazine, with second-line options of ondansetron and metoclopramide. Admission may be needed for IV hydration. Complications can include Wernicke’s encephalopathy, Mallory-Weiss tear, central pontine myelinolysis, acute tubular necrosis, and fetal growth issues.
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This question is part of the following fields:
- Obstetrics
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Question 130
Incorrect
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A 34-year-old woman delivers twin girls without any complications. What medication is commonly administered after delivery to aid in the delivery of the placenta and prevent excessive bleeding?
Your Answer:
Correct Answer: Oxytocin / ergometrine
Explanation:Medical treatments that can be used for postpartum haemorrhage caused by uterine atony include oxytocin, ergometrine, carboprost, and misoprostol. However, only oxytocin/ergometrine is commonly used to promote smooth muscle contraction in uterine blood vessels, which can help reduce the risk of postpartum haemorrhage. Prostaglandin E2 is typically used to initiate labour, while indomethacin and salbutamol can be used as tocolytics. Mifepristone is commonly used in medical abortion.
Understanding Postpartum Haemorrhage
Postpartum haemorrhage (PPH) is a condition where a woman experiences blood loss of more than 500 ml after giving birth vaginally. It can be classified as primary or secondary. Primary PPH occurs within 24 hours after delivery and is caused by the 4 Ts: tone, trauma, tissue, and thrombin. The most common cause is uterine atony. Risk factors for primary PPH include previous PPH, prolonged labour, pre-eclampsia, increased maternal age, emergency Caesarean section, and placenta praevia.
In managing PPH, it is important to involve senior staff immediately and follow the ABC approach. This includes two peripheral cannulae, lying the woman flat, blood tests, and commencing a warmed crystalloid infusion. Mechanical interventions such as rubbing up the fundus and catheterisation are also done. Medical interventions include IV oxytocin, ergometrine, carboprost, and misoprostol. Surgical options such as intrauterine balloon tamponade, B-Lynch suture, ligation of uterine arteries, and hysterectomy may be considered if medical options fail to control the bleeding.
Secondary PPH occurs between 24 hours to 6 weeks after delivery and is typically due to retained placental tissue or endometritis. It is important to understand the causes and risk factors of PPH to prevent and manage this life-threatening emergency effectively.
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This question is part of the following fields:
- Obstetrics
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Question 131
Incorrect
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A 35-year-old woman is referred to hospital by her midwife 5 days after giving birth to a healthy baby boy by vaginal delivery. She has reported increasing lochia and has had an increase in lower abdominal cramping over the last few days. On examination, she is hot and sweaty with temperature 38 °C, heart rate 120 bpm and capillary refill time (CRT) 3 s, and her abdomen is firm and tender, with the uterus still palpable just below the umbilicus. There is mild perineal swelling but no tears, and lochia is offensive. The rest of the examination is normal. She is keen to get home to her baby as she is breastfeeding.
What would you do next?Your Answer:
Correct Answer: Admit, send vaginal swabs and blood cultures, start intravenous (iv) antibiotics and arrange a pelvic ultrasound scan
Explanation:This patient is suspected to have a post-partum infection and sepsis in the puerperium, which can be fatal. A thorough examination is necessary to identify the source of infection, which is most likely to be the genital tract. Other potential sources include urinary tract infection, mastitis, skin infections, pharyngitis, pneumonia, and meningitis. The patient is experiencing abdominal pain, fever, and tachycardia, indicating the need for iv antibiotics and senior review. Regular observations, lactate measurement, and iv fluid support should be provided as per sepsis pathways. Blood cultures and vaginal swabs should be taken, and iv antibiotics should be administered within an hour of presentation. The patient is not a candidate for ambulatory treatment and needs to be admitted for further investigation and treatment.
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This question is part of the following fields:
- Obstetrics
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Question 132
Incorrect
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A 27-year-old primigravida female comes in for a 36-week ultrasound scan and it is found that her baby is in the breech position. What should be done in this situation?
Your Answer:
Correct Answer: Offer external cephalic version if still breech at 36 weeks
Explanation:If the foetus is in a breech position at 36 weeks, it is recommended to undergo external cephalic version. However, before 36 weeks, the foetus may naturally move into the correct position, making the procedure unnecessary. It is not necessary to schedule a Caesarean section immediately, but if ECV is unsuccessful, a decision must be made regarding the risks of a vaginal delivery with a breech presentation or a Caesarean section.
Breech presentation occurs when the caudal end of the fetus is in the lower segment, and it is more common at 28 weeks than near term. Risk factors include uterine malformations, placenta praevia, and fetal abnormalities. Management options include spontaneous turning, external cephalic version (ECV), planned caesarean section, or vaginal delivery. The RCOG recommends informing women that planned caesarean section reduces perinatal mortality and early neonatal morbidity, but there is no evidence that the long-term health of babies is influenced by how they are born. ECV is contraindicated in certain cases, such as where caesarean delivery is required or there is an abnormal cardiotocography.
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This question is part of the following fields:
- Obstetrics
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Question 133
Incorrect
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A 28-year-old G2P1 attends the clinic at 37 weeks’ gestation, complaining of ongoing nausea and vomiting for most of the pregnancy. Blood tests show abnormal results for sodium, alkaline phosphatase, and creatinine. What is the most appropriate management?
Your Answer:
Correct Answer: Reassure the patient and follow up in 1 week
Explanation:Management of Abnormal Alkaline Phosphatase in Pregnancy
Alkaline phosphatase is an enzyme produced by the placenta during pregnancy. If a pregnant patient presents with elevated levels of alkaline phosphatase, it can be concerning. However, in the absence of other abnormal blood results and symptoms, further work-up is not indicated. The most appropriate management in this situation is to reassure the patient and follow up in one week.
It is important to note that dehydration and severe electrolyte abnormalities can cause elevated alkaline phosphatase levels. However, if there is no evidence of these issues, there is no need for admission for intravenous hydration.
Additionally, an urgent ultrasound of the liver is not necessary if the rest of the liver enzymes are normal. Induction of labor is not indicated in this situation either.
If the patient has cholestasis of pregnancy, cholestyramine may be used to bind bile acids. However, if the patient has normal bile acids and no evidence of cholestasis, cholestyramine is not necessary.
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This question is part of the following fields:
- Obstetrics
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Question 134
Incorrect
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A 23-year-old female presents to the Emergency Department with her partner, complaining of severe abdominal pain that has worsened over the past few hours. She has vomited twice and feels lightheaded. Upon examination, she experiences tenderness in the left iliac fossa. Her vital signs are stable, except for a mild tachycardia. A urine pregnancy test confirms her pregnancy. An ultrasound performed by the Obstetrics SHO reveals an empty uterus but shows a 40mm pregnancy in her left fallopian tube. What is the appropriate management for this patient?
Your Answer:
Correct Answer: She should be taken to theatre for surgical management
Explanation:If an ectopic pregnancy is larger than 35mm or has a serum B-hCG level exceeding 5,000 IU/L, surgical intervention is necessary. The patient in this scenario is experiencing symptoms such as pain and dizziness, and her tachycardia indicates a risk of instability. While she is currently stable, surgical management should be performed promptly. A laparotomy is not immediately necessary, but the procedure should be carried out as soon as possible. Waiting for a blood hCG is unnecessary, and medical management is not appropriate.
Ectopic pregnancy is a serious condition that requires prompt investigation and management. Women who are stable are typically investigated and managed in an early pregnancy assessment unit, while those who are unstable should be referred to the emergency department. The investigation of choice for ectopic pregnancy is a transvaginal ultrasound, which will confirm the presence of a positive pregnancy test.
There are three ways to manage ectopic pregnancies: expectant management, medical management, and surgical management. The choice of management will depend on various criteria, such as the size of the ectopic pregnancy, whether it is ruptured or not, and the patient’s symptoms and hCG levels. Expectant management involves closely monitoring the patient over 48 hours, while medical management involves giving the patient methotrexate and requires follow-up. Surgical management can involve salpingectomy or salpingostomy, depending on the patient’s risk factors for infertility.
Salpingectomy is the first-line treatment for women without other risk factors for infertility, while salpingostomy should be considered for women with contralateral tube damage. However, around 1 in 5 women who undergo a salpingostomy require further treatment, such as methotrexate and/or a salpingectomy. It is important to carefully consider the patient’s individual circumstances and make a decision that will provide the best possible outcome.
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This question is part of the following fields:
- Obstetrics
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Question 135
Incorrect
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A 25-year-old woman has experienced difficulty with lactation during the first week after giving birth to her second child. She successfully breastfed her first child for nine months. She delivered at full term and suffered from a significant postpartum hemorrhage six hours after delivery. She received an IV oxytocin infusion and a blood transfusion. What is the most probable location of the lesion?
Your Answer:
Correct Answer: Anterior pituitary
Explanation:Understanding Pituitary Lesions and their Symptoms
The pituitary gland is a small gland located at the base of the brain that produces and releases hormones that regulate various bodily functions. Lesions in different parts of the pituitary gland can cause a range of symptoms.
Anterior Pituitary: Ischaemic necrosis of the anterior pituitary can occur following post-partum haemorrhage, leading to varying symptoms of hypopituitarism. The most common initial symptom is low or absent prolactin, resulting in failure to commence lactation. Other symptoms may include amenorrhoea, hypothyroidism, glucocorticoid deficiency, and loss of genital and axillary hair. Treatment requires hormone supplementation and involvement of an endocrinologist.
Hypothalamus: Lesions in the hypothalamus can cause hyperthermia/hypothermia, aggressive behaviour, somnolence, and Horner syndrome.
Cerebral Cortex: Lesions in the cerebral cortex are associated with stroke or multiple sclerosis and affect different functions such as speech, movement, hearing, and sight.
Posterior Pituitary: Lesions in the posterior pituitary are associated with central diabetes insipidus.
Pituitary Stalk: Lesions in the pituitary stalk are associated with diabetes insipidus, hypopituitarism, and hyperprolactinaemia. The patient presents with galactorrhoea, irregular menstrual periods, and other symptoms related to hyperprolactinaemia due to the lifting of dopamine neurotransmitter release inhibition.
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This question is part of the following fields:
- Obstetrics
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Question 136
Incorrect
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A 29-year-old G1P0 woman is brought to the Emergency Department by her husband at 12 weeks’ gestation because she has been experiencing severe morning sickness, palpitations and heat intolerance. Ultrasound of her uterus reveals a ‘snow storm’ appearance and complete absence of fetal tissue.
What is the most suitable parameter to monitor for effective treatment of this patient’s condition?Your Answer:
Correct Answer: Beta human chorionic gonadotropin (β-HCG)
Explanation:Common Tumor Markers and their Clinical Significance
Beta human chorionic gonadotropin (β-HCG)
β-HCG levels are monitored in cases of molar pregnancy, which can present with morning sickness and symptoms of hyperthyroidism due to high levels of HCG. Monitoring levels of β-HCG is important to ensure that no fetal tissue remains after treatment to minimise the risk of developing choriocarcinoma or a persistent mole.Alpha fetoprotein (AFP)
AFP is a marker used to screen for neural tube defects, hepatocellular carcinoma and endodermal sinus tumours.CA-125
CA-125 is a marker of ovarian malignancy. Although it is used to monitor response to chemotherapy and tumour recurrence, it has not been widely used as a screening tool.Lactate dehydrogenase (LDH)
Increased LDH is strongly associated with dysgerminomas.Oestriol
Urine unconjugated oestriol is measured as part of the quadruple screen for trisomy 21. Low levels of oestriol are suggestive of Down syndrome.Understanding Tumor Markers and their Clinical Implications
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This question is part of the following fields:
- Obstetrics
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Question 137
Incorrect
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A 27-year-old woman presents at 18 weeks’ gestation, seeking advice. She was collecting her son from school the other day when the teacher alerted the parents that a few children had developed ‘slapped cheek syndrome’. One of those children was at her house with his parents for dinner over the weekend.
She is concerned she may have been infected and is worried about her baby. She had all her paediatric vaccinations, as per the National Health Service (NHS) schedule.
Which of the following should be the next step in the investigation of this patient?Your Answer:
Correct Answer: Parvovirus B19 immunoglobulin G (IgG) and immunoglobulin M (IgM) serology
Explanation:Serology Testing for Parvovirus B19 and Rubella During Pregnancy
During pregnancy, it is important to investigate exposure to certain viruses, such as parvovirus B19 and rubella, as they can have detrimental effects on the fetus. Serology testing for immunoglobulin G (IgG) and immunoglobulin M (IgM) antibodies is used to determine if a patient has had a previous infection or if there is a recent or acute infection.
Parvovirus B19 is a DNA virus that commonly affects children and can cause slapped cheek syndrome. If a patient has had significant exposure to parvovirus B19, IgG and IgM serology testing is performed. A positive IgG and negative IgM result indicates an old infection, while a negative IgG and IgM result requires repeat testing in one month. A positive IgM result indicates a recent infection, which requires further confirmation and referral to a specialist center for fetal monitoring.
Varicella IgG serology is performed if there was exposure to chickenpox during pregnancy. A positive result indicates immunity to the virus, and no further investigation is required.
Rubella IgG and IgM serology is used to investigate exposure to rubella during pregnancy. A positive IgG indicates previous exposure or immunity from vaccination, while a positive IgM indicates a recent or acute infection.
In conclusion, serology testing is an important tool in investigating viral exposure during pregnancy and can help guide appropriate management and monitoring.
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This question is part of the following fields:
- Obstetrics
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Question 138
Incorrect
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A 16-year-old female who is 23 weeks pregnant (G1PO) arrives at the emergency department complaining of severe lower abdominal pain. She has a history of multiple sexual partners and was recently treated for gonorrhoeae with ceftriaxone. Although she does not take any regular medications, she admits to using illicit drugs such as marijuana and cocaine. During the physical examination, you notice that her uterus is hard and tender. What risk factor in her medical history is likely to contribute to her diagnosis?
Your Answer:
Correct Answer: Cocaine use
Explanation:The risk of placental abruption is increased by cocaine abuse due to its ability to cause vasospasm in the placental blood vessels. Ceftriaxone use, which is the treatment of choice for gonorrhoeae, is not a known risk factor for placental abruption and is therefore a distractor. Although gonorrhoeae can lead to chorioamnionitis, which is a known risk factor for placental abruption, there is no evidence to suggest that this is the case and it is less likely than cocaine use. Primiparity is an incorrect answer as it is actually multiparity that is a risk factor for placental abruption.
Placental Abruption: Causes, Symptoms, and Risk Factors
Placental abruption is a condition that occurs when the placenta separates from the uterine wall, leading to maternal bleeding into the space between them. Although the exact cause of this condition is unknown, certain factors have been associated with it, including proteinuric hypertension, cocaine use, multiparity, maternal trauma, and increasing maternal age. Placental abruption is not a common occurrence, affecting approximately 1 in 200 pregnancies.
The clinical features of placental abruption include shock that is disproportionate to the visible blood loss, constant pain, a tender and tense uterus, and a normal lie and presentation of the fetus. The fetal heart may be absent or distressed, and there may be coagulation problems. It is important to be aware of other conditions that may present with similar symptoms, such as pre-eclampsia, disseminated intravascular coagulation (DIC), and anuria.
In summary, placental abruption is a serious condition that can have significant consequences for both the mother and the fetus. Understanding the risk factors and symptoms of this condition is important for early detection and appropriate management.
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This question is part of the following fields:
- Obstetrics
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Question 139
Incorrect
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A 27-year-old woman presents to the GP clinic with complaints of abdominal pain. She missed her last menstrual period and had unprotected sexual intercourse 8 weeks ago. She denies any vaginal discharge or bleeding and has no urinary symptoms. On examination, her abdomen is soft with mild suprapubic tenderness. Her vital signs are stable with a heart rate of 72 beats per minute and blood pressure of 118/78 mmHg. A pregnancy test is performed and comes back positive. As per the current NICE CKS guidelines, what is the next appropriate step in management?
Your Answer:
Correct Answer: Arrange immediate referral to the early pregnancy assessment unit
Explanation:Women with a positive pregnancy test and abdominal, pelvic or cervical motion tenderness should be referred for immediate assessment to exclude ectopic pregnancy, which could be fatal. Referral should be made even if an ultrasound cannot be arranged immediately, as the patient may require monitoring in hospital before their scan. Serial hCG measurements should not be done in secondary care, and referral to a sexual health clinic alone is not appropriate.
Bleeding in the First Trimester: Understanding the Causes and Management
Bleeding in the first trimester of pregnancy is a common concern for many women. It can be caused by various factors, including miscarriage, ectopic pregnancy, implantation bleeding, cervical ectropion, vaginitis, trauma, and polyps. However, the most important cause to rule out is ectopic pregnancy, as it can be life-threatening if left untreated.
To manage early bleeding, the National Institute for Health and Care Excellence (NICE) released guidelines in 2019. If a woman has a positive pregnancy test and experiences pain, abdominal tenderness, pelvic tenderness, or cervical motion tenderness, she should be referred immediately to an early pregnancy assessment service. If the pregnancy is over six weeks gestation or of uncertain gestation and the woman has bleeding, she should also be referred to an early pregnancy assessment service.
A transvaginal ultrasound scan is the most important investigation to identify the location of the pregnancy and whether there is a fetal pole and heartbeat. If the pregnancy is less than six weeks gestation and the woman has bleeding but no pain or risk factors for ectopic pregnancy, she can be managed expectantly. However, she should be advised to return if bleeding continues or pain develops and to repeat a urine pregnancy test after 7-10 days and to return if it is positive. A negative pregnancy test means that the pregnancy has miscarried.
In summary, bleeding in the first trimester of pregnancy can be caused by various factors, but ectopic pregnancy is the most important cause to rule out. Early referral to an early pregnancy assessment service and a transvaginal ultrasound scan are crucial in identifying the location of the pregnancy and ensuring appropriate management. Women should also be advised to seek medical attention if they experience any worrying symptoms or if bleeding or pain persists.
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This question is part of the following fields:
- Obstetrics
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Question 140
Incorrect
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A 25-year-old primigravida woman at 36 weeks gestation comes in with mild irregular labor pains in the lower abdomen. Upon examination, her cervix is firm, posterior, and closed, and fetal heart tones are present. However, the pain subsides during the consultation. What would be the most suitable course of action?
Your Answer:
Correct Answer: Reassure and discharge
Explanation:False labor typically happens during the final month of pregnancy. It is characterized by contractions felt in the lower abdomen that are irregular and spaced out every 20 minutes. However, there are no progressive changes in the cervix.
Labour is divided into three stages, with the first stage beginning from the onset of true labour until the cervix is fully dilated. This stage is further divided into two phases: the latent phase and the active phase. The latent phase involves dilation of the cervix from 0-3 cm and typically lasts around 6 hours. The active phase involves dilation from 3-10 cm and progresses at a rate of approximately 1 cm per hour. In primigravidas, this stage can last between 10-16 hours.
During this stage, the baby’s presentation is important to note. Approximately 90% of babies present in the vertex position, with the head entering the pelvis in an occipito-lateral position. The head typically delivers in an occipito-anterior position.
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This question is part of the following fields:
- Obstetrics
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Question 141
Incorrect
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A 25-year-old woman who is 9 weeks pregnant presents for a review of her booking bloods. Her haemoglobin level is 105 g/L and the mean cell volume (MCV) is 70 fL, which is below the normal range of 77-95 fL. What is the best course of action in this situation?
Your Answer:
Correct Answer: Oral iron tablets
Explanation:The management of anaemia in pregnancy involves different cut off values for Hb levels depending on the trimester. For first trimester anaemia with Hb less than 110 g/L, the recommended first step is a trial of oral iron tablets. Further investigations are only necessary if there is no rise in Hb after 2 weeks. Parenteral iron is only used if oral iron is not effective or tolerated. Blood transfusion is not appropriate at this level of Hb without active bleeding.
During pregnancy, women are checked for anaemia twice – once at the initial booking visit (usually around 8-10 weeks) and again at 28 weeks. The National Institute for Health and Care Excellence (NICE) has set specific cut-off levels to determine if a pregnant woman requires oral iron therapy. These levels are less than 110 g/L in the first trimester, less than 105 g/L in the second and third trimesters, and less than 100 g/L postpartum.
If a woman’s iron levels fall below these cut-offs, she will be prescribed oral ferrous sulfate or ferrous fumarate. It is important to continue this treatment for at least three months after the iron deficiency has been corrected to allow the body to replenish its iron stores. By following these guidelines, healthcare professionals can help ensure that pregnant women receive the appropriate care to prevent and manage anaemia during pregnancy.
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This question is part of the following fields:
- Obstetrics
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Question 142
Incorrect
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A 25-year-old woman has a vaginal delivery of her first child. Although the birth was uncomplicated, she suffers a tear which extends from the vaginal mucosa into the submucosal tissue, but not into the external anal sphincter. Which degree tear is this classed as?
Your Answer:
Correct Answer: Second degree
Explanation:– First degree: a tear that only affects the vaginal mucosa
– Second degree: a tear that extends into the subcutaneous tissue
– Third degree: a laceration that reaches the external anal sphincter
– Fourth degree: a laceration that goes through the external anal sphincter and reaches the rectal mucosaPerineal tears are a common occurrence during childbirth, and the Royal College of Obstetricians and Gynaecologists (RCOG) has developed guidelines to classify them based on their severity. First-degree tears are superficial and do not require any repair, while second-degree tears involve the perineal muscle and require suturing by a midwife or clinician. Third-degree tears involve the anal sphincter complex and require repair in theatre by a trained clinician, with subcategories based on the extent of the tear. Fourth-degree tears involve the anal sphincter complex and rectal mucosa and also require repair in theatre by a trained clinician.
There are several risk factors for perineal tears, including being a first-time mother, having a large baby, experiencing a precipitant labour, and having a shoulder dystocia or forceps delivery. It is important for healthcare providers to be aware of these risk factors and to provide appropriate care and management during childbirth to minimize the risk of perineal tears. By following the RCOG guidelines and providing timely and effective treatment, healthcare providers can help ensure the best possible outcomes for both mother and baby.
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This question is part of the following fields:
- Obstetrics
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Question 143
Incorrect
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A 32-year-old pregnant woman at 14 weeks gestation presents with a three-week history of severe nausea and vomiting. During examination, her pulse is 110 beats/min and blood pressure is 110/80 mmHg. The patient is also experiencing ataxia and diplopia. Urinalysis shows an increased specific gravity and 3+ ketones. The diagnosis of hyperemesis gravidarum is made, and the patient responds well to fluid resuscitation with 0.9% saline. What other treatment options should be considered for this patient?
Your Answer:
Correct Answer: Intravenous vitamins B and C (Pabrinex)
Explanation:Hyperemesis gravidarum is a pregnancy complication that can lead to severe dehydration, metabolic imbalances, and deficiencies in essential vitamins and minerals. If left untreated, it can also cause Wernicke’s encephalopathy, as evidenced by the patient’s diplopia and ataxia. To address this, it is recommended to supplement with thiamine (Vitamin B1) and a complex of vitamins B and C, such as Pabrinex.
Hyperemesis gravidarum is an extreme form of nausea and vomiting of pregnancy that occurs in around 1% of pregnancies and is most common between 8 and 12 weeks. It is associated with raised beta hCG levels and can be caused by multiple pregnancies, trophoblastic disease, hyperthyroidism, nulliparity, and obesity. Referral criteria for nausea and vomiting in pregnancy include continued symptoms with ketonuria and/or weight loss, a confirmed or suspected comorbidity, and inability to keep down liquids or oral antiemetics. The diagnosis of hyperemesis gravidarum requires the presence of 5% pre-pregnancy weight loss, dehydration, and electrolyte imbalance. Management includes first-line use of antihistamines and oral cyclizine or promethazine, with second-line options of ondansetron and metoclopramide. Admission may be needed for IV hydration. Complications can include Wernicke’s encephalopathy, Mallory-Weiss tear, central pontine myelinolysis, acute tubular necrosis, and fetal growth issues.
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This question is part of the following fields:
- Obstetrics
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Question 144
Incorrect
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A 27-year-old woman, who is 30 weeks pregnant, reports feeling breathless during a routine prenatal appointment. Upon examination, you observe that everything appears normal except for mild hyperventilation. What is the probable discovery during pregnancy?
Your Answer:
Correct Answer: Decrease in total lung capacity
Explanation:Changes in Physiological Parameters during Pregnancy
During pregnancy, various physiological changes occur in a woman’s body to support the growing fetus. One of these changes is a decrease in total lung capacity by approximately 200 ml. This reduction is due to a decrease in residual volume caused by the fetus. However, the basal metabolic rate increases during pregnancy. Additionally, cardiac output can increase by up to 40%, while the glomerular filtration rate (GFR) normally increases. Maternal oxygen consumption also rises during pregnancy to meet the oxygen demands of the fetus, leading to an increase in minute volume. These changes in physiological parameters are essential for the healthy development of the fetus and the mother’s well-being during pregnancy.
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This question is part of the following fields:
- Obstetrics
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Question 145
Incorrect
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You are seeing a G3P1 14-weeks pregnant woman in the GP surgery. She is concerned about the possibility of developing postpartum psychosis again, as she had experienced it in her previous pregnancy and was hospitalized. What is the likelihood of her developing this condition once more?
Your Answer:
Correct Answer: 25-50 %
Explanation:To monitor her throughout her pregnancy and postnatal period, this woman requires a referral to a perinatal mental health team due to her increased risk of postpartum psychosis. It would have been preferable for her to receive preconception advice before becoming pregnant. The recurrence rate is not influenced by the baby’s gender.
Understanding Postpartum Mental Health Problems
Postpartum mental health problems can range from mild ‘baby-blues’ to severe puerperal psychosis. To screen for depression, healthcare professionals may use the Edinburgh Postnatal Depression Scale, which is a 10-item questionnaire that indicates how the mother has felt over the previous week. A score of more than 13 indicates a ‘depressive illness of varying severity’, with sensitivity and specificity of more than 90%. The questionnaire also includes a question about self-harm.
‘Baby-blues’ is seen in around 60-70% of women and typically occurs 3-7 days following birth. It is more common in primips, and mothers are characteristically anxious, tearful, and irritable. Reassurance and support from healthcare professionals, particularly health visitors, play a key role in managing this condition. Most women with the baby blues will not require specific treatment other than reassurance.
Postnatal depression affects around 10% of women, with most cases starting within a month and typically peaking at 3 months. The features are similar to depression seen in other circumstances, and cognitive behavioural therapy may be beneficial. Certain SSRIs such as sertraline and paroxetine may be used if symptoms are severe. Although these medications are secreted in breast milk, they are not thought to be harmful to the infant.
Puerperal psychosis affects approximately 0.2% of women and requires admission to hospital, ideally in a Mother & Baby Unit. Onset usually occurs within the first 2-3 weeks following birth, and features include severe swings in mood (similar to bipolar disorder) and disordered perception (e.g. auditory hallucinations). There is around a 25-50% risk of recurrence following future pregnancies. Paroxetine is recommended by SIGN because of the low milk/plasma ratio, while fluoxetine is best avoided due to a long half-life.
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This question is part of the following fields:
- Obstetrics
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Question 146
Incorrect
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A 32-year-old G3P2 woman at 16 weeks gestation visits her doctor with concerns about a new rash on her 6-year-old daughter's arm that appeared 2 days ago. The rash looks vesicular, and the mother reports that there is a chickenpox outbreak at school. The patient is unsure if she had chickenpox in her childhood.
What should be the next step in managing this situation?Your Answer:
Correct Answer: Check the patient's varicella-zoster antibodies
Explanation:The first step in managing chickenpox exposure during pregnancy is to confirm the patient’s immunity by checking her varicella-zoster antibodies. If the woman is unsure about her past exposure to chickenpox, this test will determine if she has antibodies to the virus. If the test confirms her immunity, no further action is necessary. Administering the varicella-zoster vaccine or IV immunoglobulin is not appropriate in this situation. Neglecting to check the patient’s immunity status can put her and her unborn child at risk.
Chickenpox exposure in pregnancy can pose risks to both the mother and fetus, including fetal varicella syndrome. Post-exposure prophylaxis (PEP) with varicella-zoster immunoglobulin (VZIG) or antivirals should be given to non-immune pregnant women, with timing dependent on gestational age. If a pregnant woman develops chickenpox, specialist advice should be sought and oral acyclovir may be given if she is ≥ 20 weeks and presents within 24 hours of onset of the rash.
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This question is part of the following fields:
- Obstetrics
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Question 147
Incorrect
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As a young doctor in obstetrics and gynaecology, you are assisting in the delivery of a patient when suddenly, shoulder dystocia occurs. You quickly call for senior assistance and decide to perform McRobert's manoeuvre by hyper flexing and abducting the mother's hips, moving her onto her back and bringing her thighs towards her abdomen.
What other action can be taken to enhance the effectiveness of the manoeuvre?Your Answer:
Correct Answer: Suprapubic pressure
Explanation:According to the shoulder dystocia guidelines of the Royal College of Obstetrics and Gynaecology, utilizing suprapubic pressure can enhance the efficacy of the McRoberts manoeuvre.
Shoulder dystocia is a complication that can occur during vaginal delivery when the body of the fetus cannot be delivered after the head has already been delivered. This is usually due to the anterior shoulder of the fetus becoming stuck on the mother’s pubic bone. Shoulder dystocia can cause harm to both the mother and the fetus. Risk factors for shoulder dystocia include fetal macrosomia, high maternal body mass index, diabetes mellitus, and prolonged labor.
If shoulder dystocia is identified, it is important to call for senior help immediately. The McRoberts’ maneuver is often performed, which involves flexing and abducting the mother’s hips to increase the angle of the pelvis and facilitate delivery. An episiotomy may be performed to provide better access for internal maneuvers, but it will not relieve the bony obstruction. Symphysiotomy and the Zavanelli maneuver are not recommended as they can cause significant maternal morbidity. Oxytocin administration is not indicated for shoulder dystocia.
Complications of shoulder dystocia can include postpartum hemorrhage and perineal tears for the mother, and brachial plexus injury and neonatal death for the fetus. It is important to manage shoulder dystocia promptly and appropriately to minimize the risk of these complications.
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This question is part of the following fields:
- Obstetrics
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Question 148
Incorrect
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A woman in her late twenties at 28 weeks gestation, complains of painless bright red vaginal bleeding. She mentions experiencing two previous instances of slight painless vaginal bleeding, but believes that this episode is much more severe. What is the probable diagnosis?
Your Answer:
Correct Answer: Placenta praevia
Explanation:Placenta praevia is characterized by painless and bright red bleeding, while placental abruption is accompanied by dark red bleeding and pain. The history of previous bleeding also suggests placenta praevia. Vasa praevia may also cause painless vaginal bleeding, but fetal bradycardia and membrane rupture are expected symptoms.
Understanding Placenta Praevia
Placenta praevia is a condition where the placenta is located wholly or partially in the lower uterine segment. It is a relatively rare condition, with only 5% of women having a low-lying placenta when scanned at 16-20 weeks gestation. However, the incidence at delivery is only 0.5%, as most placentas tend to rise away from the cervix.
There are several factors associated with placenta praevia, including multiparity, multiple pregnancy, and embryos implanting on a lower segment scar from a previous caesarean section. Clinical features of placenta praevia include shock in proportion to visible loss, no pain, a non-tender uterus, abnormal lie and presentation, and a usually normal fetal heart. Coagulation problems are rare, and small bleeds may occur before larger ones.
Diagnosis of placenta praevia should not involve digital vaginal examination before an ultrasound, as this may provoke severe haemorrhage. The condition is often picked up on routine 20-week abdominal ultrasounds, but the Royal College of Obstetricians and Gynaecologists recommends the use of transvaginal ultrasound for improved accuracy and safety. Placenta praevia is classified into four grades, with grade IV being the most severe, where the placenta completely covers the internal os.
In summary, placenta praevia is a rare condition that can have serious consequences if not diagnosed and managed appropriately. It is important for healthcare professionals to be aware of the associated factors and clinical features, and to use appropriate diagnostic methods for accurate grading and management.
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This question is part of the following fields:
- Obstetrics
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Question 149
Incorrect
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A 36-year-old woman presents with increasing bloating and mild lower abdominal pain that started 3 hours ago. On examination, there is abdominal tenderness and ascites, but no guarding. She denies any vaginal bleeding. Her vital signs include a heart rate of 98/minute, a blood pressure of 90/55 mmHg, and a respiratory rate of 22/minute. The patient is currently undergoing IVF treatment and had her final hCG injection 5 days ago. She has been having regular, unprotected sex during treatment. A pregnancy test confirms she is pregnant. What is the most likely diagnosis?
Your Answer:
Correct Answer: Ovarian hyperstimulation syndrome
Explanation:The patient’s symptoms suggest a gynecological issue, possibly ovarian hyperstimulation syndrome, which can occur as a side-effect of ovulation induction. The presence of ascites, low blood pressure, and tachycardia indicate fluid loss into the abdomen, but the absence of peritonitis suggests it is not a catastrophic hemorrhage. The recent hCG injection increases the likelihood of ovarian hyperstimulation syndrome, which is more common with IVF and injectable treatments than with oral fertility agents like clomiphene. Ovarian cyst rupture, ovarian torsion, red degeneration, and ruptured ectopic pregnancy are unlikely explanations for the patient’s symptoms.
Ovulation induction is often required for couples who have difficulty conceiving naturally due to ovulation disorders. Normal ovulation requires a balance of hormones and feedback loops between the hypothalamus, pituitary gland, and ovaries. There are three main categories of anovulation: hypogonadotropic hypogonadal anovulation, normogonadotropic normoestrogenic anovulation, and hypergonadotropic hypoestrogenic anovulation. The goal of ovulation induction is to induce mono-follicular development and subsequent ovulation to lead to a singleton pregnancy. Forms of ovulation induction include exercise and weight loss, letrozole, clomiphene citrate, and gonadotropin therapy. Ovarian hyperstimulation syndrome is a potential side effect of ovulation induction and can be life-threatening if not managed promptly.
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This question is part of the following fields:
- Obstetrics
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Question 150
Incorrect
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You are observing an antenatal clinic and your next patient is a 26-year-old woman who is 16 weeks pregnant with her first child. Take a brief history of this patient.
The patient has a past medical history of coeliac disease and hypothyroidism. She takes no regular medications and has no known drug allergies. Her family history is relevant for her father has type 1 diabetes. She has never smoked and since pregnancy, has stopped drinking alcohol.
What additional tests, if any, should be arranged for this patient based on her medical history?Your Answer:
Correct Answer: Oral glucose tolerance test at 24-28 weeks
Explanation:Pregnant women with a first-degree relative with diabetes should be screened for gestational diabetes with an OGTT at 24-28 weeks. No further tests are required, but thyroid function tests should be done in each trimester for those with an existing diagnosis of hypothyroidism. OGTT should not be done at 18-22 weeks.
Gestational diabetes is a common medical disorder affecting around 4% of pregnancies. Risk factors include a high BMI, previous gestational diabetes, and family history of diabetes. Screening is done through an oral glucose tolerance test, and diagnostic thresholds have recently been updated. Management includes self-monitoring of blood glucose, diet and exercise advice, and medication if necessary. For pre-existing diabetes, weight loss and insulin are recommended, and tight glycemic control is important. Targets for self-monitoring include fasting glucose of 5.3 mmol/l and 1-2 hour post-meal glucose levels.
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This question is part of the following fields:
- Obstetrics
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Question 151
Incorrect
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A 29-year-old nulliparous woman who is at 39 weeks gestation goes into spontaneous labour. You are summoned to aid in the vaginal delivery. During delivery, you observe the head retracting against the perineum. Downward traction is ineffective in delivering the anterior shoulder. What is a true statement about shoulder dystocia?
Your Answer:
Correct Answer: Immediately after shoulder dystocia is recognised, additional help should be called
Explanation:When managing shoulder dystocia, it is important to call for extra assistance immediately. Avoid using fundal pressure and note that an episiotomy may not always be required. Inducing labor at term can lower the occurrence of shoulder dystocia in women with gestational diabetes. The McRoberts manoeuvre is the preferred initial intervention due to its simplicity, speed, and effectiveness in most cases. These guidelines are based on the RCOG Green-top guideline no. 42 from March 2012 on Shoulder Dystocia.
Shoulder dystocia is a complication that can occur during vaginal delivery when the body of the fetus cannot be delivered after the head has already been delivered. This is usually due to the anterior shoulder of the fetus becoming stuck on the mother’s pubic bone. Shoulder dystocia can cause harm to both the mother and the fetus. Risk factors for shoulder dystocia include fetal macrosomia, high maternal body mass index, diabetes mellitus, and prolonged labor.
If shoulder dystocia is identified, it is important to call for senior help immediately. The McRoberts’ maneuver is often performed, which involves flexing and abducting the mother’s hips to increase the angle of the pelvis and facilitate delivery. An episiotomy may be performed to provide better access for internal maneuvers, but it will not relieve the bony obstruction. Symphysiotomy and the Zavanelli maneuver are not recommended as they can cause significant maternal morbidity. Oxytocin administration is not indicated for shoulder dystocia.
Complications of shoulder dystocia can include postpartum hemorrhage and perineal tears for the mother, and brachial plexus injury and neonatal death for the fetus. It is important to manage shoulder dystocia promptly and appropriately to minimize the risk of these complications.
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This question is part of the following fields:
- Obstetrics
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Question 152
Incorrect
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A 28-year-old female patient named Emily, who is a G2P1, visits you, a locum general practitioner, to inform you about her pregnancy. Upon reviewing her medical history, you discover that Emily has asthma, gastro-oesophageal reflux, constipation, and a recent deep vein thrombosis. She is currently taking senna, over the counter ranitidine, budesonide and salbutamol inhalers, and rivaroxaban. However, none of her medications have been altered due to her pregnancy status. Can you identify which medication needs to be changed?
Your Answer:
Correct Answer: Rivaroxaban
Explanation:Pregnant women should not use novel oral anticoagulants, so those who are currently taking them should switch to low molecular weight heparin.
Venous Thromboembolism in Pregnancy: Risk Assessment and Prophylactic Measures
Pregnancy increases the risk of developing venous thromboembolism (VTE), a condition that can be life-threatening for both the mother and the fetus. To prevent VTE, it is important to assess a woman’s individual risk during pregnancy and initiate appropriate prophylactic measures. This risk assessment should be done at the first antenatal booking and on any subsequent hospital admission.
Women with a previous history of VTE are automatically considered high risk and require low molecular weight heparin throughout the antenatal period, as well as input from experts. Women at intermediate risk due to hospitalization, surgery, co-morbidities, or thrombophilia should also be considered for antenatal prophylactic low molecular weight heparin.
The risk assessment at booking should include factors that increase the likelihood of developing VTE, such as age over 35, body mass index over 30, parity over 3, smoking, gross varicose veins, current pre-eclampsia, immobility, family history of unprovoked VTE, low-risk thrombophilia, multiple pregnancy, and IVF pregnancy.
If a woman has four or more risk factors, immediate treatment with low molecular weight heparin should be initiated and continued until six weeks postnatal. If a woman has three risk factors, low molecular weight heparin should be initiated from 28 weeks and continued until six weeks postnatal.
If a diagnosis of deep vein thrombosis (DVT) is made shortly before delivery, anticoagulation treatment should be continued for at least three months, as in other patients with provoked DVTs. Low molecular weight heparin is the treatment of choice for VTE prophylaxis in pregnancy, while direct oral anticoagulants (DOACs) and warfarin should be avoided.
In summary, a thorough risk assessment and appropriate prophylactic measures can help prevent VTE in pregnancy, which is crucial for the health and safety of both the mother and the fetus.
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This question is part of the following fields:
- Obstetrics
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Question 153
Incorrect
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A 32-year-old multiparous woman presents very anxious on day 10 postpartum. She is struggling with breastfeeding; her nipples are sore, and she feels her son is not feeding enough, as he is fussy and crying for most of the day. Breast examination reveals bilateral breast engorgement, but no evidence of infection. The patient tells you she felt embarrassed to ask the nurse for advice when she had her first postnatal visit, as she did not want her to think she was incompetent as a mother.
What is the most appropriate course of action for this patient?Your Answer:
Correct Answer: Arrange a one-to-one appointment with a health visitor
Explanation:Management options for breastfeeding problems in new mothers
Breastfeeding is a common challenge for new mothers, and it is important to provide them with effective management options. The first-line option recommended by NICE guidelines is a one-to-one visit from a health visitor or breastfeeding specialist nurse. This allows for observation and advice on optimal positioning, milk expressing techniques, and pain management during breastfeeding. Information leaflets and national breastfeeding support organisation websites can supplement this training, but they are not as effective as one-to-one observation. Prescribing formula milk may be an option if there is evidence of significant weight loss in the baby. It is important to reassure the mother that establishing a good breastfeeding technique can take time, but active support should be provided to maximise the chances of success.
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This question is part of the following fields:
- Obstetrics
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Question 154
Incorrect
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A 27-year-old woman comes in for her regular prenatal check-up at 30 weeks gestation. She reports feeling well and has had an uncomplicated pregnancy thus far. Her vital signs are as follows:
Respiratory rate: 18 breaths/min
Heart rate: 70 beats/min
Blood pressure: 130/88 mmHg
Temperature: 37.2ºC
Oxygen saturation: 97% on room air
Urinalysis results show:
Protein: +
Glucose: -
Nitrites: -
What is the most appropriate course of action for this patient?Your Answer:
Correct Answer: Routine management
Explanation:If a pregnant woman has new-onset BP ≥ 140/90 mmHg after 20 weeks AND ≥ 1 of proteinuria, organ dysfunction, she is diagnosed with pre-eclampsia. However, if a patient presents to a routine antenatal appointment at 28 weeks gestation and her blood pressure does not meet the threshold of ≥ 140/90 mmHg, she should continue with routine management even if her urine is positive for protein. Therefore, commencing nifedipine and fluid restriction is incorrect as they are only used in the management of severe pre-eclampsia. Similarly, commencing prophylactic aspirin, prophylactic aspirin and labetalol, or prophylactic aspirin and nifedipine is incorrect as they are only used if the patient is diagnosed with pre-eclampsia.
Pre-eclampsia is a condition that occurs during pregnancy and is characterized by high blood pressure, proteinuria, and edema. It can lead to complications such as eclampsia, neurological issues, fetal growth problems, liver involvement, and cardiac failure. Severe pre-eclampsia is marked by hypertension, proteinuria, headache, visual disturbances, and other symptoms. Risk factors for pre-eclampsia include hypertension in a previous pregnancy, chronic kidney disease, autoimmune disease, diabetes, chronic hypertension, first pregnancy, and age over 40. Aspirin may be recommended for women with high or moderate risk factors. Treatment involves emergency assessment, admission for observation, and medication such as labetalol, nifedipine, or hydralazine. Delivery of the baby is the most important step in management, with timing depending on the individual case.
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This question is part of the following fields:
- Obstetrics
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Question 155
Incorrect
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A 28-year-old woman presents at 29 weeks’ gestation very concerned as she has not felt her baby move at all since the night before. She has a history of coeliac disease. No fetal movements can be palpated. An ultrasound scan confirms fetal death. Blood investigations were performed: thyroid-stimulating hormone (TSH) 10.5 μu/l (0.17–3.2 μu/l) and free thyroxine (fT4) 4 pmol/l (11–22 pmol/l). These were not performed at booking.
According to the national antenatal screening programme, which of the following groups of patients should be screened for thyroid disorders in pregnancy?Your Answer:
Correct Answer: Type 1 diabetes mellitus
Explanation:Thyroid Screening in Pregnancy: Identifying High-Risk Patients
Pregnancy can increase the risk of developing thyroid disorders, which can have detrimental effects on both the mother and fetus. Therefore, it is important to identify high-risk patients and screen them for thyroid function early in pregnancy. According to updated guidelines, patients with a current or previous thyroid disease, family history of thyroid disease in a first-degree relative, autoimmune conditions such as coeliac disease, type 1 and type 2 diabetes mellitus, as well as gestational diabetes are considered at higher risk. These patients should be screened by performing TSH and serum fT4 levels in the preconception period, if possible, or as soon as pregnancy is confirmed.
Detecting hypothyroidism early is crucial, as symptoms can mimic those of a normal pregnancy, making detection harder. Hypothyroidism in the mother can lead to fetal demise, severe neurodevelopmental abnormalities, congenital malformations, and congenital hypothyroidism. Patients diagnosed with overt hypothyroidism in pregnancy should be started on levothyroxine immediately.
There is no recommendation to screen women with a history of chronic kidney disease or hypertension for thyroid disease in pregnancy. However, chronic kidney disease is a high-risk factor for pre-eclampsia, and commencing aspirin at 12 weeks through to delivery is essential to reduce the risk of developing pre-eclampsia or any of its complications. Women who are carriers of the thalassaemia trait are not screened for thyroid disease in pregnancy, but their partner should be tested for carrier status to assess the risk to the fetus.
In conclusion, identifying high-risk patients and screening for thyroid function early in pregnancy can help prevent adverse outcomes for both the mother and fetus.
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This question is part of the following fields:
- Obstetrics
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Question 156
Incorrect
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A 32-year-old woman presents with vaginal bleeding at 34 weeks gestation (gravida 3, parity 2). The patient reports no abdominal pain but is worried about the possibility of a miscarriage. She has a history of two uncomplicated caesarean sections. What is the recommended first step in diagnosing her condition?
Your Answer:
Correct Answer: Transvaginal ultrasound
Explanation:Understanding Placenta Praevia
Placenta praevia is a condition where the placenta is located wholly or partially in the lower uterine segment. It is a relatively rare condition, with only 5% of women having a low-lying placenta when scanned at 16-20 weeks gestation. However, the incidence at delivery is only 0.5%, as most placentas tend to rise away from the cervix.
There are several factors associated with placenta praevia, including multiparity, multiple pregnancy, and embryos implanting on a lower segment scar from a previous caesarean section. Clinical features of placenta praevia include shock in proportion to visible loss, no pain, a non-tender uterus, abnormal lie and presentation, and a usually normal fetal heart. Coagulation problems are rare, and small bleeds may occur before larger ones.
Diagnosis of placenta praevia should not involve digital vaginal examination before an ultrasound, as this may provoke severe haemorrhage. The condition is often picked up on routine 20-week abdominal ultrasounds, but the Royal College of Obstetricians and Gynaecologists recommends the use of transvaginal ultrasound for improved accuracy and safety. Placenta praevia is classified into four grades, with grade IV being the most severe, where the placenta completely covers the internal os.
In summary, placenta praevia is a rare condition that can have serious consequences if not diagnosed and managed appropriately. It is important for healthcare professionals to be aware of the associated factors and clinical features, and to use appropriate diagnostic methods for accurate grading and management.
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This question is part of the following fields:
- Obstetrics
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Question 157
Incorrect
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A 28-year-old woman gives birth vaginally at 38 weeks gestation to a healthy baby girl weighing 4.2 kg. This is her third delivery. However, she experiences ongoing bleeding even after the placenta is removed, resulting in a loss of approximately 900 ml of blood. Upon examination, her heart rate is 98 bpm, her blood pressure is 100/60 mmHg, and her oxygen saturation is 97% on room air. The medical team immediately takes an ABCDE approach and notifies senior members to become involved. What is the most likely underlying factor that has contributed to her presentation?
Your Answer:
Correct Answer: Failure of adequate uterine contractions
Explanation:The primary cause of postpartum haemorrhage (PPH) is the failure of adequate uterine contractions, also known as uterine atony. This is evident in a patient who has lost more than 500 ml of blood within 24 hours following a vaginal delivery. Other causes of PPH include trauma (e.g. perineal tear), tissue (e.g. retained placenta), and thrombin (e.g. coagulopathy), which are collectively referred to as the 4 Ts. While it was previously believed that multiparity was a risk factor for PPH, recent studies suggest that nulliparity is a stronger risk factor. Nonetheless, uterine atony remains the most common cause of PPH. Uterine hyperstimulation, which is characterized by excessively frequent uterine contractions, is rare and typically seen following induced labor, but it is not a common cause of PPH.
Understanding Postpartum Haemorrhage
Postpartum haemorrhage (PPH) is a condition where a woman experiences blood loss of more than 500 ml after giving birth vaginally. It can be classified as primary or secondary. Primary PPH occurs within 24 hours after delivery and is caused by the 4 Ts: tone, trauma, tissue, and thrombin. The most common cause is uterine atony. Risk factors for primary PPH include previous PPH, prolonged labour, pre-eclampsia, increased maternal age, emergency Caesarean section, and placenta praevia.
In managing PPH, it is important to involve senior staff immediately and follow the ABC approach. This includes two peripheral cannulae, lying the woman flat, blood tests, and commencing a warmed crystalloid infusion. Mechanical interventions such as rubbing up the fundus and catheterisation are also done. Medical interventions include IV oxytocin, ergometrine, carboprost, and misoprostol. Surgical options such as intrauterine balloon tamponade, B-Lynch suture, ligation of uterine arteries, and hysterectomy may be considered if medical options fail to control the bleeding.
Secondary PPH occurs between 24 hours to 6 weeks after delivery and is typically due to retained placental tissue or endometritis. It is important to understand the causes and risk factors of PPH to prevent and manage this life-threatening emergency effectively.
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This question is part of the following fields:
- Obstetrics
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Question 158
Incorrect
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A 32-year-old woman presents on day 28 postpartum with burning pain in the nipples bilaterally and itching. She reports symptoms are worse after feeds.
On examination, you notice that the nipples are erythematosus, swollen and fissured. The breasts are unremarkable. Her observations are stable, and she is apyrexial. She tells you she wants you to review her baby and that she noticed small white patches in his mouth.
Given the likely diagnosis, which of the following is the most appropriate management?Your Answer:
Correct Answer: Topical antifungal cream
Explanation:Management of Breast Conditions: Understanding the Different Treatment Options
Breast conditions can present with a variety of symptoms, and it is important to understand the appropriate management for each. Here are some common breast conditions and their corresponding treatments:
1. Fungal infection of the nipples: This is characterized by bilateral symptoms and signs of nipple thrush. Treatment involves applying a topical miconazole 2% cream to the affected nipples after every feed for two weeks. The infant should also be treated with miconazole cream in the mouth.
2. Paget’s disease of the nipple: This is a form of in situ carcinoma that warrants urgent referral to the Breast team under the 2-week wait pathway. Symptoms include unilateral erythema, inflammation, burning pain, ulceration, and bleeding.
3. Breast cellulitis or mastitis: This is associated with the breast itself and is characterized by unilateral engorgement, erythematosus skin, and tenderness. Treatment involves oral flucloxacillin.
4. Eczema of the nipple: This affects both nipples and presents with a red, scaly rash that spares the base of the nipple. Treatment involves avoiding triggers and using regular emollients, with a topical steroid cream applied after feeds.
5. Bacterial infection of the nipples: This is treated with a topical antibacterial cream, such as topical fusidic acid.
Understanding the appropriate management for each breast condition is crucial in providing effective treatment and improving patient outcomes.
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This question is part of the following fields:
- Obstetrics
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Question 159
Incorrect
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A 35-year-old Gravida 3 Para 3 has given birth to a healthy baby girl. The baby's APGAR score was 9 at 1 minute and 10 at 5 and 10 minutes.
Regrettably, the mother experienced a perineal tear during delivery. The tear involves the superficial and deep transverse perineal muscles, but the anal sphincter remains intact.
What is the recommended course of action for management?Your Answer:
Correct Answer: Suturing on the ward
Explanation:A second-degree perineal tear can be repaired on the ward by a midwife or clinician with sufficient experience. This type of tear involves the perineal muscle but not the anal sphincter, and is commonly seen in first-time mothers. Repairing the tear on the ward is a safe option that does not pose any long-term risks. For first-degree tears, a conservative approach is usually taken as they only involve superficial damage. Packing and healing by secondary intention is not appropriate for perineal tears, as it is a treatment for abscesses. Referring the patient to a urogynaecology clinic is also not necessary, as perineal tears require immediate repair. Repair in theatre is reserved for third and fourth-degree tears, which involve the anal sphincter complex and rectal mucosa.
Perineal tears are a common occurrence during childbirth, and the Royal College of Obstetricians and Gynaecologists (RCOG) has developed guidelines to classify them based on their severity. First-degree tears are superficial and do not require any repair, while second-degree tears involve the perineal muscle and require suturing by a midwife or clinician. Third-degree tears involve the anal sphincter complex and require repair in theatre by a trained clinician, with subcategories based on the extent of the tear. Fourth-degree tears involve the anal sphincter complex and rectal mucosa and also require repair in theatre by a trained clinician.
There are several risk factors for perineal tears, including being a first-time mother, having a large baby, experiencing a precipitant labour, and having a shoulder dystocia or forceps delivery. It is important for healthcare providers to be aware of these risk factors and to provide appropriate care and management during childbirth to minimize the risk of perineal tears. By following the RCOG guidelines and providing timely and effective treatment, healthcare providers can help ensure the best possible outcomes for both mother and baby.
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This question is part of the following fields:
- Obstetrics
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Question 160
Incorrect
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A patient 16/40 gestation contacts your clinic via phone. This is her first pregnancy and she is worried about not experiencing any foetal movements yet. You provide reassurance that foetal movements can be felt between 16-20 weeks gestation in first pregnancies. When should further investigation be considered if no foetal movements are felt by this time?
Your Answer:
Correct Answer: 24 weeks
Explanation:According to RCOG guidelines, women typically feel fetal movements by 20 weeks of gestation. However, if no movements are felt by 24 weeks, it is recommended to refer the woman to a maternal fetal medicine unit to assess for potential neuromuscular conditions.
Understanding Reduced Fetal Movements
Introduction:
Reduced fetal movements can indicate fetal distress and are a response to chronic hypoxia in utero. This can lead to stillbirth and fetal growth restriction. It is believed that placental insufficiency may also be linked to reduced fetal movements.Physiology:
Quickening is the first onset of fetal movements, which usually occurs between 18-20 weeks gestation and increases until 32 weeks gestation. Multiparous women may experience fetal movements sooner. Fetal movements should not reduce towards the end of pregnancy. There is no established definition for what constitutes reduced fetal movements, but less than 10 movements within 2 hours (in pregnancies past 28 weeks gestation) is an indication for further assessment.Epidemiology:
Reduced fetal movements affect up to 15% of pregnancies, with 3-5% of pregnant women having recurrent presentations with RFM. Fetal movements should be established by 24 weeks gestation.Risk factors for reduced fetal movements:
Posture, distraction, placental position, medication, fetal position, body habitus, amniotic fluid volume, and fetal size can all affect fetal movement awareness.Investigations:
Fetal movements are usually based on maternal perception, but can also be objectively assessed using handheld Doppler or ultrasonography. Investigations are dependent on gestation at onset of RFM. If concern remains, despite normal CTG, urgent (within 24 hours) ultrasound can be used.Prognosis:
Reduced fetal movements can represent fetal distress, but in 70% of pregnancies with a single episode of reduced fetal movement, there is no onward complication. However, between 40-55% of women who suffer from stillbirth experience reduced fetal movements prior to diagnosis. Recurrent RFM requires further investigations to consider structural or genetic fetal abnormalities. -
This question is part of the following fields:
- Obstetrics
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Question 161
Incorrect
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A 30-year-old woman visits the booking clinic for her 8-week pregnancy check-up. It is revealed during the consultation that she has a history of two deep vein thrombosis. What will be necessary for her management considering her previous VTEs?
Your Answer:
Correct Answer: Low molecular weight heparin, starting immediately until 6 weeks postnatal
Explanation:Pregnant women who have a history of VTE should receive LMWH throughout their pregnancy and up to 6 weeks after giving birth to prevent clotting. Warfarin is not recommended during pregnancy due to its teratogenic effects, and LMWH is preferred due to its lower side effect profile and reduced need for monitoring.
Venous Thromboembolism in Pregnancy: Risk Assessment and Prophylactic Measures
Pregnancy increases the risk of developing venous thromboembolism (VTE), a condition that can be life-threatening for both the mother and the fetus. To prevent VTE, it is important to assess a woman’s individual risk during pregnancy and initiate appropriate prophylactic measures. This risk assessment should be done at the first antenatal booking and on any subsequent hospital admission.
Women with a previous history of VTE are automatically considered high risk and require low molecular weight heparin throughout the antenatal period, as well as input from experts. Women at intermediate risk due to hospitalization, surgery, co-morbidities, or thrombophilia should also be considered for antenatal prophylactic low molecular weight heparin.
The risk assessment at booking should include factors that increase the likelihood of developing VTE, such as age over 35, body mass index over 30, parity over 3, smoking, gross varicose veins, current pre-eclampsia, immobility, family history of unprovoked VTE, low-risk thrombophilia, multiple pregnancy, and IVF pregnancy.
If a woman has four or more risk factors, immediate treatment with low molecular weight heparin should be initiated and continued until six weeks postnatal. If a woman has three risk factors, low molecular weight heparin should be initiated from 28 weeks and continued until six weeks postnatal.
If a diagnosis of deep vein thrombosis (DVT) is made shortly before delivery, anticoagulation treatment should be continued for at least three months, as in other patients with provoked DVTs. Low molecular weight heparin is the treatment of choice for VTE prophylaxis in pregnancy, while direct oral anticoagulants (DOACs) and warfarin should be avoided.
In summary, a thorough risk assessment and appropriate prophylactic measures can help prevent VTE in pregnancy, which is crucial for the health and safety of both the mother and the fetus.
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This question is part of the following fields:
- Obstetrics
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Question 162
Incorrect
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A 32-year-old female who is 20 weeks pregnant has a raised serum alpha-fetoprotein (AFP) and is worried about the possible causes. What could be responsible for the elevated AFP levels in this patient?
Your Answer:
Correct Answer: Omphalocele
Explanation:A raised level of maternal serum AFP is linked to fetal abdominal wall defects such as omphalocele. Conversely, low levels of maternal AFP are associated with Down’s syndrome, maternal diabetes mellitus, Edwards syndrome, and maternal obesity.
Alpha-fetoprotein (AFP) is a protein that is created by the fetus during development. When there is an increase in AFP levels, it may indicate the presence of certain conditions such as neural tube defects (meningocele, myelomeningocele and anencephaly), abdominal wall defects (omphalocele and gastroschisis), multiple pregnancy, Down’s syndrome, trisomy 18, and maternal diabetes mellitus. On the other hand, a decrease in AFP levels may also be significant and should be further investigated.
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This question is part of the following fields:
- Obstetrics
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Question 163
Incorrect
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A 25-year-old woman attends her first antenatal appointment, believing she is 10 weeks pregnant. Which of the following is not typically done during this appointment?
Your Answer:
Correct Answer: Pelvic examination
Explanation:NICE guidelines recommend 10 antenatal visits for first pregnancies and 7 for subsequent pregnancies if uncomplicated. The purpose of each visit is outlined, including booking visits, scans, screening for Down’s syndrome, routine care for blood pressure and urine, and discussions about labour and birth plans. Rhesus negative women are offered anti-D prophylaxis at 28 and 34 weeks. The guidelines also recommend discussing options for prolonged pregnancy at 41 weeks.
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This question is part of the following fields:
- Obstetrics
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Question 164
Incorrect
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A 30-year-old nulliparous woman with Factor V Leiden presents for her initial antenatal visit. She has a history of unprovoked VTE, and the physician discusses thromboprophylaxis with her. What treatment pathway should be followed based on her risk?
Your Answer:
Correct Answer: Low molecular weight heparin (LMWH) antenatally + 6 weeks postpartum
Explanation:Factor V Leiden is a genetic condition that causes resistance to the breakdown of Factor V by activated Protein C, leading to an increased risk of blood clots. The RCOG has issued guidelines (Green-top Guideline No.37a) for preventing blood clots in pregnant women with this condition. As this patient has a history of VTE, she is at high risk during and after pregnancy and requires both antenatal and postnatal thromboprophylaxis. It is important to note that postnatal prophylaxis must be given for six weeks following antenatal prophylaxis.
Venous Thromboembolism in Pregnancy: Risk Assessment and Prophylactic Measures
Pregnancy increases the risk of developing venous thromboembolism (VTE), a condition that can be life-threatening for both the mother and the fetus. To prevent VTE, it is important to assess a woman’s individual risk during pregnancy and initiate appropriate prophylactic measures. This risk assessment should be done at the first antenatal booking and on any subsequent hospital admission.
Women with a previous history of VTE are automatically considered high risk and require low molecular weight heparin throughout the antenatal period, as well as input from experts. Women at intermediate risk due to hospitalization, surgery, co-morbidities, or thrombophilia should also be considered for antenatal prophylactic low molecular weight heparin.
The risk assessment at booking should include factors that increase the likelihood of developing VTE, such as age over 35, body mass index over 30, parity over 3, smoking, gross varicose veins, current pre-eclampsia, immobility, family history of unprovoked VTE, low-risk thrombophilia, multiple pregnancy, and IVF pregnancy.
If a woman has four or more risk factors, immediate treatment with low molecular weight heparin should be initiated and continued until six weeks postnatal. If a woman has three risk factors, low molecular weight heparin should be initiated from 28 weeks and continued until six weeks postnatal.
If a diagnosis of deep vein thrombosis (DVT) is made shortly before delivery, anticoagulation treatment should be continued for at least three months, as in other patients with provoked DVTs. Low molecular weight heparin is the treatment of choice for VTE prophylaxis in pregnancy, while direct oral anticoagulants (DOACs) and warfarin should be avoided.
In summary, a thorough risk assessment and appropriate prophylactic measures can help prevent VTE in pregnancy, which is crucial for the health and safety of both the mother and the fetus.
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This question is part of the following fields:
- Obstetrics
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Question 165
Incorrect
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A 32-year-old woman who is 30 weeks pregnant presents with itch.
On examination, her abdomen is non-tender with the uterus an appropriate size for her gestation. There is no visible rash, although she is mildly jaundiced. Her heart rate is 76/min, blood pressure 130/64 mmHg, respiratory rate 18/min, oxygen saturations are 99% in air, temperature 36.9°C.
A set of blood results reveal:
Hb 112g/l Na+ 140 mmol/l Bilirubin 56 µmol/l Platelets 240 109/l K+ 4.2 mmol/l ALP 360 u/l WBC 8.5 109/l Urea 4.8 mmol/l ALT 86 u/l Neuts 5.9 109/l Creatinine 76 µmol/l γGT 210 u/l Lymphs 1.6 * 109/l Albumin 35 g/l
What is the most likely cause of her symptoms?Your Answer:
Correct Answer: Intrahepatic cholestasis of pregnancy
Explanation:The likely diagnosis for this patient is intrahepatic cholestasis of pregnancy, which commonly causes itching in the third trimester. This condition is characterized by elevated liver function tests (LFTs), particularly alkaline phosphatase (ALP) and gamma-glutamyl transferase (GGT), with a lesser increase in alanine transaminase (ALT). Patients may also experience jaundice, right upper quadrant pain, and steatorrhea. Treatment often involves ursodeoxycholic acid. Biliary colic is unlikely due to the absence of abdominal pain. Acute fatty liver of pregnancy is rare and presents with a hepatic picture on LFTs, along with nausea, vomiting, jaundice, and potential encephalopathy. HELLP syndrome is characterized by haemolytic anaemia and low platelets, which are not present in this case. Pre-eclampsia is also unlikely as the patient does not have hypertension or other related symptoms, although late pre-eclampsia may cause hepatic derangement on LFTs.
Liver Complications During Pregnancy
During pregnancy, there are several liver complications that may arise. One of the most common is intrahepatic cholestasis of pregnancy, which occurs in about 1% of pregnancies and is typically seen in the third trimester. Symptoms include intense itching, especially in the palms and soles, as well as elevated bilirubin levels. Treatment involves the use of ursodeoxycholic acid for relief and weekly liver function tests. Women with this condition are usually induced at 37 weeks to prevent stillbirth, although maternal morbidity is not typically increased.
Another rare complication is acute fatty liver of pregnancy, which may occur in the third trimester or immediately after delivery. Symptoms include abdominal pain, nausea and vomiting, headache, jaundice, and hypoglycemia. Severe cases may result in pre-eclampsia. ALT levels are typically elevated, and support care is the primary management until delivery can be performed once the patient is stabilized.
Finally, conditions such as Gilbert’s and Dubin-Johnson syndrome may be exacerbated during pregnancy. Additionally, HELLP syndrome, which stands for haemolysis, elevated liver enzymes, and low platelets, is a serious complication that can occur in the third trimester and requires immediate medical attention. Overall, it is important for pregnant women to be aware of these potential liver complications and to seek medical attention if any symptoms arise.
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This question is part of the following fields:
- Obstetrics
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Question 166
Incorrect
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A 20-year-old woman presents with a positive pregnancy test and is diagnosed with an ectopic pregnancy after ruling out an intrauterine pregnancy. She is asymptomatic and her serum beta-human chorionic gonadotropin (B-hCG) level is 877 IU/L. A transvaginal ultrasound shows a 24mm adnexal mass without a heartbeat and no free fluid in the abdomen. Although expectant management is an option, she declines. What is the recommended initial treatment?
Your Answer:
Correct Answer: Methotrexate
Explanation:According to the National Institute for Health and Care Excellence (NICE), if a woman has an unruptured ectopic pregnancy measuring less than 35mm without visible heartbeat, a serum B-hCG level of less than 1500 IU/L, no intrauterine pregnancy, and no pain, the recommended first-line treatment is methotrexate, provided the patient is willing to attend follow-up appointments. However, if the woman declines expectant management, which is an option for a small number of women with low B-hCG, no symptoms, and a tubal ectopic pregnancy measuring less than 35mm without heartbeat, methotrexate is the preferred treatment option. Methotrexate is a chemotherapeutic drug that interferes with DNA synthesis and disrupts cell multiplication, preventing the pregnancy from developing. Laparoscopic salpingectomy (or salpingostomy if there is a risk of infertility) is the other treatment option, which should be offered if the ectopic pregnancy is larger than 35mm, causing severe pain, or if the B-hCG level is greater than 1500. However, there is a risk of infertility if a problem arises with the remaining Fallopian tube in the future. Misoprostol and mifepristone are not recommended for the management of ectopic pregnancy.
Understanding Ectopic Pregnancy
Ectopic pregnancy occurs when a fertilized egg implants outside the uterus. This condition is characterized by lower abdominal pain and vaginal bleeding, typically occurring 6-8 weeks after the start of the last period. The pain is usually constant and may be felt on one side of the abdomen due to tubal spasm. Vaginal bleeding is usually less than a normal period and may be dark brown in color. Other symptoms may include shoulder tip pain, pain on defecation/urination, dizziness, fainting, or syncope. Breast tenderness may also be reported.
During examination, abdominal tenderness and cervical excitation may be observed. However, it is not recommended to examine for an adnexal mass due to the risk of rupturing the pregnancy. Instead, a pelvic examination to check for cervical excitation is recommended. In cases of pregnancy of unknown location, serum bHCG levels >1,500 may indicate an ectopic pregnancy. It is important to seek medical attention immediately if ectopic pregnancy is suspected as it can be life-threatening.
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This question is part of the following fields:
- Obstetrics
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Question 167
Incorrect
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A 26-year-old primigravida at 32 weeks gestation presents with vaginal bleeding and severe abdominal pain. The abdominal pain started suddenly in the night, about 3 hours ago. It is a severe dull pain in the suprapubic region and doesn't radiate anywhere. The pain has not settled at all since onset and is not positional. She rates the pain as 10/10 in severity. She passed about 2 cupfuls of blood 1 hour previously. She reports that the bleeding has soaked through 2 sanitary pads. She also complains of back pain and is exquisitely tender on suprapubic palpation. She has not noticed any decreased foetal movements, although says that her baby is not particularly active usually. What is the most likely diagnosis?
Your Answer:
Correct Answer: Placenta abruption
Explanation:Placenta abruptio is characterized by painful vaginal bleeding, while placenta praevia typically does not cause pain. In cases of placenta abruptio, the uterus may feel hard and woody to the touch due to retroplacental blood tracking into the myometrium. The absence of fetal heart rate and shock in the mother are common symptoms. Immediate resuscitation is crucial, and once stable, the baby will require urgent delivery. Postpartum hemorrhage is more likely to occur in these cases.
Placental Abruption: Causes, Symptoms, and Risk Factors
Placental abruption is a condition that occurs when the placenta separates from the uterine wall, leading to maternal bleeding into the space between them. Although the exact cause of this condition is unknown, certain factors have been associated with it, including proteinuric hypertension, cocaine use, multiparity, maternal trauma, and increasing maternal age. Placental abruption is not a common occurrence, affecting approximately 1 in 200 pregnancies.
The clinical features of placental abruption include shock that is disproportionate to the visible blood loss, constant pain, a tender and tense uterus, and a normal lie and presentation of the fetus. The fetal heart may be absent or distressed, and there may be coagulation problems. It is important to be aware of other conditions that may present with similar symptoms, such as pre-eclampsia, disseminated intravascular coagulation (DIC), and anuria.
In summary, placental abruption is a serious condition that can have significant consequences for both the mother and the fetus. Understanding the risk factors and symptoms of this condition is important for early detection and appropriate management.
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This question is part of the following fields:
- Obstetrics
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Question 168
Incorrect
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A 28-year-old woman comes to the General Practitioner three weeks after giving birth. She breastfeeds her baby mostly but uses formula milk when she is out in public as she feels uncomfortable breastfeeding in front of others. She wants to talk about contraception. She is the sole caregiver for her newborn during the day and finds it challenging to manage her sleep schedule and daily routine. There are no other significant medical histories.
What are the most feasible contraceptive options for this patient?Your Answer:
Correct Answer: Progesterone implant
Explanation:When caring for a newborn, it can be difficult for a mother to remember to take the progesterone-only pill at the same time every day. Long-acting reversible contraception options, such as the progesterone implant, copper coil, and levonorgestrel-releasing intrauterine system, are recommended. The progesterone implant is safe for breastfeeding women and can last for up to three years. The levonorgestrel-releasing intrauterine system can be used after four weeks postpartum, but insertion should be avoided in the first few weeks due to the risk of perforation. The combined oral contraceptive pill is not recommended until six weeks postpartum due to the increased risk of thromboembolism. The copper coil can be considered after four weeks postpartum, and the progesterone-only pill can be used from the first day postpartum, but it must be taken at the same time every day. A long-acting progesterone contraceptive device may be more suitable for a mother who finds it difficult to take medication at the same time every day.
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This question is part of the following fields:
- Obstetrics
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Question 169
Incorrect
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A mother brings her 5-day old daughter to see you as she is worried about her daughter's weight loss. The baby was born at term without any complications. She is exclusively breastfed and has had a normal amount of wet nappies today. The baby is not showing any signs of distress and all observations are within normal limits. However, her birth weight was 3200g and today she weighs 2900g. What would be the best course of action to manage this infant's weight loss?
Your Answer:
Correct Answer: Referral to midwife-led breastfeeding clinic
Explanation:If the baby loses more than 10% of his birth weight in the first week, immediate measures must be taken to ensure proper feeding.
Breastfeeding Problems and Their Management
Breastfeeding is a natural process, but it can come with its own set of challenges. Some of the minor problems that breastfeeding mothers may encounter include frequent feeding, nipple pain, blocked ducts, and nipple candidiasis. These issues can be managed by seeking advice on proper positioning, trying breast massage, and using appropriate medication.
Mastitis is a more serious problem that affects around 1 in 10 breastfeeding women. It is characterized by symptoms such as fever, nipple fissure, and persistent pain. Treatment involves the use of antibiotics, such as flucloxacillin, for 10-14 days. Breastfeeding or expressing milk should continue during treatment to prevent complications such as breast abscess.
Breast engorgement is another common problem that causes breast pain in breastfeeding women. It occurs in the first few days after birth and affects both breasts. Hand expression of milk can help relieve the discomfort of engorgement. Raynaud’s disease of the nipple is a less common problem that causes nipple pain and blanching. Treatment involves minimizing exposure to cold, using heat packs, and avoiding caffeine and smoking.
If a breastfed baby loses more than 10% of their birth weight in the first week of life, it may be a sign of poor weight gain. This should prompt consideration of the above breastfeeding problems and an expert review of feeding. Monitoring of weight should continue until weight gain is satisfactory.
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This question is part of the following fields:
- Obstetrics
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Question 170
Incorrect
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A 29-year-old woman presents to the emergency department with her partner. She is currently 36 weeks pregnant and G2P1. Her pregnancy has been progressing normally without concerns raised at her antenatal appointments. However, she experienced a sudden gush of fluid earlier today, which soaked her trousers. On examination, fluid is seen pooling in the posterior vaginal fornix, and a swab of the fluid returns a positive partosure. The patient is afebrile and has no other abnormal vital signs. What is the most appropriate management for this likely diagnosis?
Your Answer:
Correct Answer: IM corticosteroids
Explanation:Antenatal corticosteroids should be given in cases of preterm prelabour rupture of membranes to reduce the risk of respiratory distress syndrome in the neonate. IM corticosteroids are the appropriate form of administration for this purpose. Cervical cerclage is not recommended in this scenario as it is contraindicated in cases of preterm prelabour rupture of membranes. Expectant management is also not the best option as it increases the risk of intraamniotic infection. Indomethacin tocolysis is not recommended as it can cause complications such as ductus arteriosus closure and oligohydramnios. Nifedipine is the preferred medication for delaying labour in this scenario.
Preterm prelabour rupture of the membranes (PPROM) is a condition that occurs in approximately 2% of pregnancies, but it is responsible for around 40% of preterm deliveries. This condition can lead to various complications, including prematurity, infection, and pulmonary hypoplasia in the fetus, as well as chorioamnionitis in the mother. To confirm PPROM, a sterile speculum examination should be performed to check for pooling of amniotic fluid in the posterior vaginal vault. However, digital examination should be avoided due to the risk of infection. If pooling of fluid is not observed, testing the fluid for placental alpha microglobulin-1 protein (PAMG-1) or insulin-like growth factor binding protein-1 is recommended. Ultrasound may also be useful to show oligohydramnios.
The management of PPROM involves admission and regular observations to ensure that chorioamnionitis is not developing. Oral erythromycin should be given for ten days, and antenatal corticosteroids should be administered to reduce the risk of respiratory distress syndrome. Delivery should be considered at 34 weeks of gestation, but there is a trade-off between an increased risk of maternal chorioamnionitis and a decreased risk of respiratory distress syndrome as the pregnancy progresses. PPROM is a serious condition that requires prompt diagnosis and management to minimize the risk of complications for both the mother and the fetus.
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This question is part of the following fields:
- Obstetrics
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Question 171
Incorrect
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A 32-year-old primigravida woman is 41 weeks pregnant and has been offered a vaginal examination and membrane sweeping at her antenatal visit. Despite these efforts, she has not gone into labor after 6 hours. Upon examination, her cervix is firm, 1 cm dilated, 1.5 cm in length, and in the middle position. The fetal head station is -3, but there have been no complications during the pregnancy. What should be the next appropriate step?
Your Answer:
Correct Answer: Vaginal prostaglandin gel
Explanation:If the Bishop score is less than or equal to 6, the recommended method for inducing labor is through vaginal PGE2 or oral misoprostol. In this case, since the Bishop score was less than 5, labor is unlikely without induction. One option could be to repeat a membrane sweep, but the most appropriate course of action would be to use a vaginal prostaglandin gel.
Induction of labour is a process where labour is artificially started and is required in about 20% of pregnancies. It is indicated in cases of prolonged pregnancy, prelabour premature rupture of the membranes, maternal medical problems, diabetic mother over 38 weeks, pre-eclampsia, obstetric cholestasis, and intrauterine fetal death. The Bishop score is used to assess whether induction of labour is necessary and includes cervical position, consistency, effacement, dilation, and fetal station. A score of less than 5 indicates that labour is unlikely to start without induction, while a score of 8 or more indicates a high chance of spontaneous labour or response to interventions made to induce labour.
Possible methods of induction include membrane sweep, vaginal prostaglandin E2, oral prostaglandin E1, maternal oxytocin infusion, amniotomy, and cervical ripening balloon. The NICE guidelines recommend vaginal prostaglandins or oral misoprostol if the Bishop score is less than or equal to 6, while amniotomy and an intravenous oxytocin infusion are recommended if the score is greater than 6.
The main complication of induction of labour is uterine hyperstimulation, which refers to prolonged and frequent uterine contractions that can interrupt blood flow to the intervillous space and result in fetal hypoxemia and acidemia. Uterine rupture is a rare but serious complication. Management includes removing vaginal prostaglandins and stopping the oxytocin infusion if one has been started, and considering tocolysis.
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This question is part of the following fields:
- Obstetrics
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Question 172
Incorrect
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A 32-year-old woman comes to the antenatal clinic at 14 weeks pregnant. She was surprised to discover her pregnancy just last week, as it was unexpected. This is her fourth pregnancy, but she has had three miscarriages in the past. The midwife suggests a quadruple test due to the late discovery of her pregnancy, which reveals the following results:
- Alpha-fetoprotein (AFP) is low
- Unconjugated oestriol (uE3) is low
- Total human chorionic gonadotrophin (hCG) is low
- Inhibin-A is normal
What is the most likely diagnosis?Your Answer:
Correct Answer: Edward's syndrome
Explanation:The quadruple test result shows a decrease in AFP, oestriol, and hCG, without change in inhibin A, indicating Edward’s syndrome. This condition is caused by trisomy 18 and can present with physical features such as micrognathia, low-set ears, rocker bottom feet, and overlapping fingers. The quadruple test is a screening test used to identify pregnancies with a higher risk of Down’s syndrome, Edwards’ syndrome, Patau’s syndrome, or neural tube defects. It is typically offered to patients who discover their pregnancy late and are no longer eligible for the combined test. ARPKD cannot be diagnosed with a quadruple test, but it can be detected prenatally with an ultrasound. Down’s syndrome would present with low AFP, low unconjugated oestriol, high hCG, and inhibin A, while neural tube defects would present with high AFP and normal oestriol, hCG, and inhibin A.
NICE updated guidelines on antenatal care in 2021, recommending the combined test for screening for Down’s syndrome between 11-13+6 weeks. The test includes nuchal translucency measurement, serum B-HCG, and pregnancy-associated plasma protein A (PAPP-A). The quadruple test is offered between 15-20 weeks for women who book later in pregnancy. Results are interpreted as either a ‘lower chance’ or ‘higher chance’ of chromosomal abnormalities. If a woman receives a ‘higher chance’ result, she may be offered a non-invasive prenatal screening test (NIPT) or a diagnostic test. NIPT analyzes cell-free fetal DNA in the mother’s blood and has high sensitivity and specificity for detecting chromosomal abnormalities. Private companies offer NIPT screening from 10 weeks gestation.
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This question is part of the following fields:
- Obstetrics
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Question 173
Incorrect
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A 35-year-old woman who has never given birth is in labour at 37 weeks gestation. During examination, the cervix is found to be dilated at 7 cm, the head is in direct Occipito-Anterior position, the foetal station is at -1, and the head is palpable at 2/5 ths per abdomen. The cardiotocogram reveals late decelerations and a foetal heart rate of 100 beats/min, which persist for 15 minutes. What is the appropriate course of action in this scenario?
Your Answer:
Correct Answer: Caesarian section
Explanation:The cardiotocogram shows late decelerations and foetal bradycardia, indicating the need for immediate delivery. Instrumental delivery is not possible and oxytocin and vaginal prostaglandin are contraindicated. The safest approach is an emergency caesarian section.
Cardiotocography (CTG) is a medical procedure that measures pressure changes in the uterus using either internal or external pressure transducers. It is used to monitor the fetal heart rate, which normally ranges between 100-160 beats per minute. There are several features that can be observed during a CTG, including baseline bradycardia (heart rate below 100 beats per minute), which can be caused by increased fetal vagal tone or maternal beta-blocker use. Baseline tachycardia (heart rate above 160 beats per minute) can be caused by maternal pyrexia, chorioamnionitis, hypoxia, or prematurity. Loss of baseline variability (less than 5 beats per minute) can be caused by prematurity or hypoxia. Early deceleration, which is a decrease in heart rate that starts with the onset of a contraction and returns to normal after the contraction, is usually harmless and indicates head compression. Late deceleration, on the other hand, is a decrease in heart rate that lags behind the onset of a contraction and does not return to normal until after 30 seconds following the end of the contraction. This can indicate fetal distress, such as asphyxia or placental insufficiency. Variable decelerations, which are independent of contractions, may indicate cord compression.
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This question is part of the following fields:
- Obstetrics
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Question 174
Incorrect
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A 32-year-old woman is 38 weeks pregnant and has arrived at the hospital due to experiencing contractions. She has expressed her desire for a vaginal birth. Despite being in good health, alert, and stable, her cardiotocography indicates that the baby's heart rate has increased from 164/min to 170/min after 10 minutes. As the woman is at full term, the obstetrician has decided to perform a caesarean section. What classification of caesarean section is this considered to be?
Your Answer:
Correct Answer: Category 2
Explanation:Category 2 caesarean sections are performed when there is a non-immediate life-threatening emergency concerning the mother or the baby. This may include an abnormality detected by cardiotocography that requires an emergency caesarean section within 75 minutes of the decision being made. It is not immediately life-threatening to either the mother or the baby.
Category 1 caesarean sections are performed in immediately life-threatening situations, such as haemodynamic instability of the mother.
Category 3 caesarean sections are not immediately life-threatening to the mother but are necessary for the non-immediate life-threatening condition of the baby, such as distress.
Category 4 caesarean sections are elective and may be chosen by the mother or recommended based on past medical history.
Caesarean Section: Types, Indications, and Risks
Caesarean section, also known as C-section, is a surgical procedure that involves delivering a baby through an incision in the mother’s abdomen and uterus. In recent years, the rate of C-section has increased significantly due to an increased fear of litigation. There are two main types of C-section: lower segment C-section, which comprises 99% of cases, and classic C-section, which involves a longitudinal incision in the upper segment of the uterus.
C-section may be indicated for various reasons, including absolute cephalopelvic disproportion, placenta praevia grades 3/4, pre-eclampsia, post-maturity, IUGR, fetal distress in labor/prolapsed cord, failure of labor to progress, malpresentations, placental abruption, vaginal infection, and cervical cancer. The urgency of C-section may be categorized into four categories, with Category 1 being the most urgent and Category 4 being elective.
It is important for clinicians to inform women of the serious and frequent risks associated with C-section, including emergency hysterectomy, need for further surgery, admission to intensive care unit, thromboembolic disease, bladder injury, ureteric injury, and death. C-section may also increase the risk of uterine rupture, antepartum stillbirth, placenta praevia, and placenta accreta in subsequent pregnancies. Other complications may include persistent wound and abdominal discomfort, increased risk of repeat C-section, readmission to hospital, haemorrhage, infection, and fetal lacerations.
Vaginal birth after C-section (VBAC) may be an appropriate method of delivery for pregnant women with a single previous C-section delivery, except for those with previous uterine rupture or classical C-section scar. The success rate of VBAC is around 70-75%.
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This question is part of the following fields:
- Obstetrics
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Question 175
Incorrect
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A 29-year-old primiparous woman presented to Labour Ward triage at 34+1/40 with upper back/chest pain and a headache. The pregnancy had been uncomplicated up to this point, with only some lower back pain over the past 2 weeks.
Obs: blood pressure 151/102, respiratory rate 18, sats 100% room air, heart rate 60 bpm, afebrile. On examination, she appeared well – PERL. Heart sounds were normal, chest was clear, and there was no shortness of breath (SOB). Her abdomen and uterus were soft and non-tender (SNT), and her calves were also SNT. Reflexes were normal. A urine dip showed nitrate +, leukocytes +, protein 1+. Electrocardiography (ECG) and cardiotocography (CTG) were both normal. Blood tests were taken, and results were pending.
Considering the likely diagnosis, what would be your first step in management?Your Answer:
Correct Answer: Start po labetalol and admit for monitoring
Explanation:Management of Pre-eclampsia with Hypertension in Pregnancy
Pre-eclampsia is a common condition affecting pregnant women, with hypertension and proteinuria being the main clinical features. The first line of management for hypertension is oral labetalol, with close monitoring of blood pressure. In cases of mild hypertension, induction of labor is not necessary. However, admission for monitoring and commencement of labetalol is recommended. IV magnesium sulfate may be needed later on, but not initially. Discharge home is not appropriate for women with pre-eclampsia. Early recognition and management of pre-eclampsia is crucial for the well-being of both the mother and the baby.
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This question is part of the following fields:
- Obstetrics
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Question 176
Incorrect
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A 26-year-old woman with type 1 diabetes mellitus visits her General Practitioner (GP) with her partner to seek advice on nutritional supplementation as they plan to start trying for a baby. She is not using any contraception and her diabetes is well managed, with her latest HbA1c level at 32 mmol/mol (recommended by the Royal College of Obstetricians and Gynaecologists < 48 mmol/mol). What is the most suitable recommendation for folic acid supplementation?
Your Answer:
Correct Answer: Commence folic acid 5 mg daily now and continue until week 12 of gestation
Explanation:Folic Acid Supplementation in Pregnancy
Explanation: Folic acid supplementation is recommended for all women who are trying to conceive and during pregnancy to reduce the risk of neural tube defects and other congenital abnormalities. The recommended dose is 400 micrograms daily from the preconception period until the 12th week of gestation. However, women with certain high-risk factors, such as diabetes, a family history of neural tube defects, or obesity, are advised to take a higher dose of 5 mg daily from the preconception period until the 12th week of gestation. It is important to continue folic acid supplementation until the end of the first trimester to ensure proper formation of the brain and other major organs in the body. Side-effects of folic acid treatment may include abdominal distension, reduced appetite, nausea, and exacerbation of pernicious anaemia.
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This question is part of the following fields:
- Obstetrics
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Question 177
Incorrect
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As a result of her advanced maternal age, a 43-year-old pregnant woman undergoes screening for chromosomal abnormalities. If her fetus is diagnosed with trisomy 21 (Down's syndrome), what outcomes would be anticipated?
Your Answer:
Correct Answer: Low pregnancy-associated plasma protein A (PAPP-A)
Explanation:The ‘triple test’ can be utilized at 16 weeks, but its accuracy is lower than the ‘combined test’. Therefore, it should only be employed when screening for trisomy is conducted after 14 weeks. The test involves conducting blood tests for AFP, -HCG, and oestriol. One should note that the false positive rate may be higher with this test.
NICE updated guidelines on antenatal care in 2021, recommending the combined test for screening for Down’s syndrome between 11-13+6 weeks. The test includes nuchal translucency measurement, serum B-HCG, and pregnancy-associated plasma protein A (PAPP-A). The quadruple test is offered between 15-20 weeks for women who book later in pregnancy. Results are interpreted as either a ‘lower chance’ or ‘higher chance’ of chromosomal abnormalities. If a woman receives a ‘higher chance’ result, she may be offered a non-invasive prenatal screening test (NIPT) or a diagnostic test. NIPT analyzes cell-free fetal DNA in the mother’s blood and has high sensitivity and specificity for detecting chromosomal abnormalities. Private companies offer NIPT screening from 10 weeks gestation.
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This question is part of the following fields:
- Obstetrics
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Question 178
Incorrect
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A 28-year-old woman has recently given birth to a healthy baby without any complications. She is curious about iron supplementation and has undergone blood tests which reveal a Hb level of 107 g/L. What is the appropriate Hb cut-off for initiating treatment in this patient?
Your Answer:
Correct Answer: 100
Explanation:During pregnancy, women are checked for anaemia twice – once at the initial booking visit (usually around 8-10 weeks) and again at 28 weeks. The National Institute for Health and Care Excellence (NICE) has set specific cut-off levels to determine if a pregnant woman requires oral iron therapy. These levels are less than 110 g/L in the first trimester, less than 105 g/L in the second and third trimesters, and less than 100 g/L postpartum.
If a woman’s iron levels fall below these cut-offs, she will be prescribed oral ferrous sulfate or ferrous fumarate. It is important to continue this treatment for at least three months after the iron deficiency has been corrected to allow the body to replenish its iron stores. By following these guidelines, healthcare professionals can help ensure that pregnant women receive the appropriate care to prevent and manage anaemia during pregnancy.
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This question is part of the following fields:
- Obstetrics
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Question 179
Incorrect
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A 36 year-old female patient visits her GP complaining of a grape-sized lump in her breast that she discovered during a bath a week ago. The lump is firm, painless, and has no skin changes around it. The patient is generally healthy, without fever, and no prior history of breast disease. She recently stopped breastfeeding a month ago. An ultrasound scan reveals a well-defined lesion, and aspiration of the lump produces white fluid. What is the probable diagnosis?
Your Answer:
Correct Answer: Galactocele
Explanation:Fibrocystic change, breast cancer, and fat necrosis are unlikely based on the ultrasound results and aspiration findings.
Understanding Galactocele
Galactocele is a condition that commonly affects women who have recently stopped breastfeeding. It occurs when a lactiferous duct becomes blocked, leading to the accumulation of milk and the formation of a cystic lesion in the breast. Unlike an abscess, galactocele is usually painless and does not cause any local or systemic signs of infection.
In simpler terms, galactocele is a type of breast cyst that develops when milk gets trapped in a duct. It is not a serious condition and can be easily diagnosed by a doctor. Women who experience galactocele may notice a lump in their breast, but it is usually painless and does not require any treatment. However, if the lump becomes painful or infected, medical attention may be necessary. Overall, galactocele is a common and harmless condition that can be managed with proper care and monitoring.
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This question is part of the following fields:
- Obstetrics
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Question 180
Incorrect
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A 38-year-old woman visits her GP complaining of itching symptoms. She is currently 29 weeks pregnant and has had no complications thus far. She reports that her palms and soles of her feet have been extremely itchy for the past few days, and the sensation has now spread to her abdomen. However, she feels otherwise healthy and denies experiencing nausea, vomiting, or abdominal pain.
During the examination, the patient appears to be in good health, without signs of jaundice or rash. Her vital signs are normal, and her blood tests are generally unremarkable, except for a slightly elevated bilirubin level.
Based on the likely diagnosis, what is the most appropriate topic to discuss with her regarding definitive management?Your Answer:
Correct Answer: Induction of labour at 37 weeks
Explanation:The patient is experiencing intense pruritus and has elevated bilirubin levels, which are common symptoms of intrahepatic cholestasis of pregnancy. Due to the heightened risk of stillbirth, induction of labor at 37 weeks is typically recommended. While a caesarian section at 37 weeks may be considered, there is insufficient evidence to support this approach over induction. Induction at 34 weeks is not advisable, and reassurance with a normal delivery at term is not appropriate. Therefore, a discussion regarding induction at 37 weeks is necessary.
Intrahepatic Cholestasis of Pregnancy: Symptoms and Management
Intrahepatic cholestasis of pregnancy, also known as obstetric cholestasis, is a condition that affects approximately 1% of pregnancies in the UK. It is characterized by intense itching, particularly on the palms, soles, and abdomen, and may also result in clinically detectable jaundice in around 20% of patients. Raised bilirubin levels are seen in over 90% of cases.
The management of intrahepatic cholestasis of pregnancy typically involves induction of labor at 37-38 weeks, although this practice may not be evidence-based. Ursodeoxycholic acid is also widely used, although the evidence base for its effectiveness is not clear. Additionally, vitamin K supplementation may be recommended.
It is important to note that the recurrence rate of intrahepatic cholestasis of pregnancy in subsequent pregnancies is high, ranging from 45-90%. Therefore, close monitoring and management are necessary for women who have experienced this condition in the past.
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This question is part of the following fields:
- Obstetrics
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Question 181
Incorrect
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A 32-year-old woman is 24 weeks pregnant and she receives a letter about her routine cervical smear. She asks her obstetrician if she should make an appointment for her smear. All her smears in the past have been negative. What should the obstetrician advise?
Your Answer:
Correct Answer: Reschedule the smear to occur at least 12 weeks post-delivery
Explanation:According to NICE guidelines, women who are due for routine cervical screening should wait until 12 weeks after giving birth. If a woman has had an abnormal smear in the past and becomes pregnant, she should seek specialist advice. If there are no contraindications, such as a low-lying placenta, a cervical smear can be performed during the middle trimester of pregnancy. It is crucial to encourage women to participate in regular cervical screening.
Cervical Cancer Screening in the UK
Cervical cancer screening is a well-established program in the UK that aims to detect pre-malignant changes in the cervix. This program is estimated to prevent 1,000-4,000 deaths per year. However, it should be noted that around 15% of cervical adenocarcinomas are frequently undetected by screening.
The screening program has evolved significantly in recent years. Initially, smears were examined for signs of dyskaryosis, which may indicate cervical intraepithelial neoplasia. However, the introduction of HPV testing allowed for further risk stratification, and the NHS has now moved to an HPV first system. This means that a sample is tested for high-risk strains of human papillomavirus (hrHPV) first, and cytological examination is only performed if this is positive.
All women between the ages of 25-64 years are offered a smear test. Women aged 25-49 years are screened every three years, while those aged 50-64 years are screened every five years. However, cervical screening cannot be offered to women over 64. In Scotland, screening is offered from 25-64 every five years.
In special situations, cervical screening in pregnancy is usually delayed until three months post-partum, unless there are missed screenings or previous abnormal smears. Women who have never been sexually active have a very low risk of developing cervical cancer and may wish to opt-out of screening.
It is recommended to take a cervical smear around mid-cycle, although there is limited evidence to support this advice. Overall, the UK’s cervical cancer screening program is an essential tool in preventing cervical cancer and promoting women’s health.
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This question is part of the following fields:
- Obstetrics
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Question 182
Incorrect
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A 28-year-old woman is on day one postpartum, following a normal vaginal delivery. She has called the midwife, as she is struggling to establish breastfeeding and correct positioning of the baby to the breast. She reports pain when the baby is breastfeeding.
Which of the following is a feature of a poor latch?Your Answer:
Correct Answer: Clicking noises are heard
Explanation:Understanding the Signs of a Good Latch for Successful Breastfeeding
Latching on the breast is crucial for successful breastfeeding, but many women struggle with it. A poor latch can lead to pain and frustration, causing some women to give up on breastfeeding altogether. However, there are clear signs of a good latch that can help mothers and babies achieve successful breastfeeding.
One indicator of a poor latch is clicking noises, which can be painful for the mother and indicate that the baby is chewing on the nipple. In contrast, a good latch is associated with visible and audible swallowing, a rhythmic suck, and relaxed arms and hands of the infant. The baby’s chin should touch the breast, with the nose free, and the lips should be rolled out, not turned in. The mouth should be open wide, and the tongue positioned below the nipple, with the latter touching the palate of the baby’s mouth.
Another sign of a good latch is that less areola should be visible below the chin than above the nipple. This indicates that the baby is taking in not only the nipple but also the areola, which is essential for effective milk expression and feeding. By understanding these signs of a good latch, mothers can ensure successful breastfeeding and a positive experience for both themselves and their babies.
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This question is part of the following fields:
- Obstetrics
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Question 183
Incorrect
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A 31-year-old woman arrives at the obstetric department in the initial stages of labour. She is 36+4 weeks pregnant and has been experiencing polyhydramnios during this pregnancy. During examination, the foetal head is palpable on the right side of the maternal pelvis, while the buttocks are palpable on the left side. The amniotic sac remains intact. What is the best course of action for managing this patient?
Your Answer:
Correct Answer: Offer external cephalic version
Explanation:The recommended course of action for a patient in early labour with a transverse foetal lie and intact amniotic sac is to offer external cephalic version (ECV) before considering other management options. Conservative management is not appropriate as it poses a high risk of maternal and foetal death. Offering an elective caesarean section is also not the first choice, as ECV should be attempted first. An immediate caesarean section is not necessary if there are no contraindications to ECV.
Understanding Transverse Lie in Foetal Presentation
Foetal lie refers to the position of the foetus in relation to the longitudinal axis of the uterus. There are three types of foetal lie: longitudinal, oblique, and transverse. Transverse lie is a rare abnormal foetal presentation where the foetal longitudinal axis is perpendicular to the long axis of the uterus. This means that the foetal head is on the lateral side of the pelvis, and the buttocks are opposite. Transverse lie is more common in women who have had previous pregnancies, have fibroids or other pelvic tumours, are pregnant with twins or triplets, have prematurity, polyhydramnios, or foetal abnormalities.
Transverse lie can be detected during routine antenatal appointments through abdominal examination or ultrasound scan. Complications of transverse lie include preterm rupture membranes, cord-prolapse, and compound presentation. Management options for transverse lie depend on the gestational age of the foetus. Before 36 weeks gestation, no management is required as most foetuses will spontaneously move into longitudinal lie during pregnancy. After 36 weeks gestation, active management through external cephalic version (ECV) or elective caesarian section is necessary. ECV should be offered to all women who would like a vaginal delivery, while caesarian section is the management for women who opt for it or if ECV is unsuccessful or contraindicated. The decision to perform caesarian section over ECV will depend on various factors, including the risks to the mother and foetus, the patient’s preference, and co-morbidities.
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This question is part of the following fields:
- Obstetrics
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Question 184
Incorrect
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You encounter a 36-year-old woman during her antenatal check-up. She has recently undergone an anomaly scan and is undergoing a routine review. During the consultation, she expresses her concern about not feeling any fetal movement yet, despite experiencing it by 18 weeks gestation in her previous pregnancies.
At what point in her gestation would it be appropriate to refer her to the maternal fetal medicine unit for further evaluation?Your Answer:
Correct Answer: 24 weeks
Explanation:Referral to a maternal fetal medicine unit is recommended if fetal movements have not been felt by 24 weeks, as reduced movements can be a sign of fetal distress and hypoxia. While most women feel their babies move around 18-20 weeks, it can happen earlier in some cases. Although singular episodes of reduced movements may not be harmful, they can also indicate stillbirths and restricted growth. The absence of movements is particularly concerning and requires further investigation. The RCOG has set the 24 week cut off as a guideline.
Understanding Reduced Fetal Movements
Introduction:
Reduced fetal movements can indicate fetal distress and are a response to chronic hypoxia in utero. This can lead to stillbirth and fetal growth restriction. It is believed that placental insufficiency may also be linked to reduced fetal movements.Physiology:
Quickening is the first onset of fetal movements, which usually occurs between 18-20 weeks gestation and increases until 32 weeks gestation. Multiparous women may experience fetal movements sooner. Fetal movements should not reduce towards the end of pregnancy. There is no established definition for what constitutes reduced fetal movements, but less than 10 movements within 2 hours (in pregnancies past 28 weeks gestation) is an indication for further assessment.Epidemiology:
Reduced fetal movements affect up to 15% of pregnancies, with 3-5% of pregnant women having recurrent presentations with RFM. Fetal movements should be established by 24 weeks gestation.Risk factors for reduced fetal movements:
Posture, distraction, placental position, medication, fetal position, body habitus, amniotic fluid volume, and fetal size can all affect fetal movement awareness.Investigations:
Fetal movements are usually based on maternal perception, but can also be objectively assessed using handheld Doppler or ultrasonography. Investigations are dependent on gestation at onset of RFM. If concern remains, despite normal CTG, urgent (within 24 hours) ultrasound can be used.Prognosis:
Reduced fetal movements can represent fetal distress, but in 70% of pregnancies with a single episode of reduced fetal movement, there is no onward complication. However, between 40-55% of women who suffer from stillbirth experience reduced fetal movements prior to diagnosis. Recurrent RFM requires further investigations to consider structural or genetic fetal abnormalities. -
This question is part of the following fields:
- Obstetrics
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Question 185
Incorrect
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A 28-year-old woman who is 20 weeks pregnant visits the obstetric clinic for a routine ultrasound scan. During the examination, it is observed that the mother's uterus is smaller than expected for her stage of pregnancy, and the ultrasound scan confirms the presence of intrauterine growth restriction (IUGR). The medical team inquires about any potential risk factors for IUGR that the mother may have.
What is a known maternal risk factor for intrauterine growth restriction?Your Answer:
Correct Answer: Smoking
Explanation:Understanding Risk Factors for Intrauterine Growth Restriction (IUGR)
Intrauterine growth restriction (IUGR) is a condition where a baby does not grow properly in the womb. There are various risk factors associated with IUGR, including smoking during pregnancy, which can increase the likelihood of developing the condition.
There are two types of IUGR: symmetrical and asymmetrical. Symmetrical growth retardation occurs at the start or during early pregnancy and is characterized by a small head and short length. Asymmetrical growth retardation occurs in advanced pregnancy and is characterized by reduced abdominal growth compared to head circumference, due to selective shunting of blood to the brain.
It’s important to note that a baby with a birthweight below the tenth centile is considered small for gestational age (SGA), which may be normal or due to IUGR.
Contrary to popular belief, hypotension (low blood pressure), obesity, and stress are not recognized risk factors for IUGR. However, poorly controlled diabetes is a risk factor for IUGR, while well-controlled diabetes is not.
Understanding these risk factors can help healthcare providers identify and manage IUGR early on, leading to better outcomes for both mother and baby.
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This question is part of the following fields:
- Obstetrics
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Question 186
Incorrect
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A 20-year-old primigravida at 8 weeks comes in with suprapubic pain and vaginal bleeding. She has passed tissue through her vagina and blood is pooled in the vaginal area. The cervix is closed and an ultrasound reveals an empty uterine cavity. What is the diagnosis?
Your Answer:
Correct Answer: Complete miscarriage
Explanation:A complete miscarriage occurs when the entire fetus is spontaneously aborted and expelled through the cervix. Once the fetus has been expelled, the pain and uterine contractions typically cease. An ultrasound can confirm that the uterus is now empty.
Miscarriage is a common complication that can occur in up to 25% of all pregnancies. There are different types of miscarriage, each with its own set of symptoms and characteristics. Threatened miscarriage is painless vaginal bleeding that occurs before 24 weeks, typically at 6-9 weeks. The bleeding is usually less than menstruation, and the cervical os is closed. Missed or delayed miscarriage is when a gestational sac containing a dead fetus is present before 20 weeks, without the symptoms of expulsion. The mother may experience light vaginal bleeding or discharge, and the symptoms of pregnancy may disappear. Pain is not usually a feature, and the cervical os is closed. Inevitable miscarriage is characterized by heavy bleeding with clots and pain, and the cervical os is open. Incomplete miscarriage occurs when not all products of conception have been expelled, and there is pain and vaginal bleeding. The cervical os is open in this type of miscarriage.
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This question is part of the following fields:
- Obstetrics
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Question 187
Incorrect
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A 27-year-old G4P3 woman presents with a lump in the breast, having ceased breastfeeding her youngest child two weeks prior. Her past medical history is significant for previous episodes of mastitis when breastfeeding her older children. On examination the lump is in the right breast at the six o'clock position, 3 cm from the nipple. The lump is non-tender and the overlying skin seems unaffected. Her observations are as follows:
Heart rate: 90,
Respiratory rate: 14,
Blood pressure: 112/72 mmHg,
Oxygen saturation: 99%,
Temperature: 37.5 Cº.
What is the probable diagnosis, and what is the most appropriate next step in investigation?Your Answer:
Correct Answer: Galactocele, no further investigation necessary
Explanation:Galactocele and breast abscess can be distinguished based on clinical history and examination findings, without the need for further investigation.
Recent discontinuation of breastfeeding is a risk factor for both mastitis/abscess formation and galactocele formation. Galactoceles are distinguishable from breast abscesses because they are painless and non-tender upon examination, and there are no signs of infection locally or systemically.
Although the patient’s history of mastitis increases the likelihood of a breast abscess, the clinical presentation strongly suggests a galactocele (i.e. painless lump, no localized redness, and absence of fever).Understanding Galactocele
Galactocele is a condition that commonly affects women who have recently stopped breastfeeding. It occurs when a lactiferous duct becomes blocked, leading to the accumulation of milk and the formation of a cystic lesion in the breast. Unlike an abscess, galactocele is usually painless and does not cause any local or systemic signs of infection.
In simpler terms, galactocele is a type of breast cyst that develops when milk gets trapped in a duct. It is not a serious condition and can be easily diagnosed by a doctor. Women who experience galactocele may notice a lump in their breast, but it is usually painless and does not require any treatment. However, if the lump becomes painful or infected, medical attention may be necessary. Overall, galactocele is a common and harmless condition that can be managed with proper care and monitoring.
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This question is part of the following fields:
- Obstetrics
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Question 188
Incorrect
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A 28-year-old woman attends the antenatal clinic at 41 weeks of gestation, worried that she has not yet gone into labour. She reports normal foetal movements and has not been recently ill. She has no significant medical history and this is her first pregnancy. On examination, her abdomen is soft and a palpable uterus is consistent with a term pregnancy. Her Bishop's score is calculated as 5. What is the first step in managing this patient?
Your Answer:
Correct Answer: Membrane sweep
Explanation:Before inducing a pregnancy, it is important to calculate the Bishop’s score to determine if spontaneous labor is likely or if induction may be needed. For this patient who is past her due date, a score below 8 suggests that induction may be necessary. The most initial step in this case is a membrane sweep, which can be performed in the antenatal clinic by a midwife or obstetrician. This method involves separating the chorionic membrane from the decidua to trigger natural labor and is considered an adjunct to labor rather than an actual method of induction.
While an artificial rupture of membranes (amniotomy) is another method of induction, it carries certain risks such as increased risk of cord prolapse and infection, making it a less favorable option. If a membrane sweep alone is not enough to induce labor, vaginal prostaglandins are recommended according to NICE guidelines. Oxytocin can also be used to stimulate uterine contraction, but it is not recommended as the initial step in induction due to the risks of uterine contraction against an unprimed cervix.
It is important to note that this patient’s Bishop’s score is 5 and she is already at 41-weeks gestation, which increases the risk of complications such as macrosomia and stillbirth. Therefore, it is inappropriate to discharge her without discussing methods of inducing labor.
Induction of labour is a process where labour is artificially started and is required in about 20% of pregnancies. It is indicated in cases of prolonged pregnancy, prelabour premature rupture of the membranes, maternal medical problems, diabetic mother over 38 weeks, pre-eclampsia, obstetric cholestasis, and intrauterine fetal death. The Bishop score is used to assess whether induction of labour is necessary and includes cervical position, consistency, effacement, dilation, and fetal station. A score of less than 5 indicates that labour is unlikely to start without induction, while a score of 8 or more indicates a high chance of spontaneous labour or response to interventions made to induce labour.
Possible methods of induction include membrane sweep, vaginal prostaglandin E2, oral prostaglandin E1, maternal oxytocin infusion, amniotomy, and cervical ripening balloon. The NICE guidelines recommend vaginal prostaglandins or oral misoprostol if the Bishop score is less than or equal to 6, while amniotomy and an intravenous oxytocin infusion are recommended if the score is greater than 6.
The main complication of induction of labour is uterine hyperstimulation, which refers to prolonged and frequent uterine contractions that can interrupt blood flow to the intervillous space and result in fetal hypoxemia and acidemia. Uterine rupture is a rare but serious complication. Management includes removing vaginal prostaglandins and stopping the oxytocin infusion if one has been started, and considering tocolysis.
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This question is part of the following fields:
- Obstetrics
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Question 189
Incorrect
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A 30-year-old healthy pregnant woman is about to give birth to her first child at 9-months gestation. The obstetrician decides to perform a caesarean section.
Which of the following abdominal surgical incisions will the obstetrician most likely use to perform the procedure?Your Answer:
Correct Answer: Suprapubic incision
Explanation:Different Types of Incisions for Surgical Procedures
There are various types of incisions used for different surgical procedures. Here are some common types of incisions and their uses:
1. Suprapubic Incision: Also known as the Pfannenstiel incision, this is the most common incision used for Gynaecological and obstetric operations like Caesarean sections. It is made at the pubic hairline.
2. Transverse Incision just below the Umbilicus: This incision is usually too superior for a Caesarean section because the scar would be visible and does not provide direct access to the uterus as the Pfannenstiel incision.
3. Right Subcostal Incision: This incision is used to access the gallbladder and biliary tree.
4. Median Longitudinal Incision: This incision is not commonly used because of cosmetic scarring, as well as the fact that the linea alba is relatively avascular and can undergo necrosis if the edges are not aligned and stitched properly.
5. McBurney’s Point Incision: This incision is used to access the vermiform appendix and is made at the McBurney’s point, which is approximately one-third of the distance of a line, the spino-umbilical line, starting at the right anterior superior iliac spine and ending at the umbilicus.
In conclusion, the type of incision used for a surgical procedure depends on the specific needs of the operation and the surgeon’s preference.
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This question is part of the following fields:
- Obstetrics
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Question 190
Incorrect
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A 35-year-old woman with G4P3 at 39 weeks gestation presents to the labour ward following a spontaneous rupture of membranes. She delivers a healthy baby vaginally but experiences excessive bleeding and hypotension. Despite attempts to control the bleeding, the senior doctor decides to perform a hysterectomy. Upon examination, the pathologist observes that the chorionic villi have deeply invaded the myometrium but not the perimetrium.
What is the diagnosis?Your Answer:
Correct Answer: Placenta increta
Explanation:The correct answer is placenta increta, where the chorionic villi invade the myometrium but not the perimetrium. The patient’s age and history of multiple pregnancies increase the risk of this abnormal placentation, which can be diagnosed through pathological studies. Placenta accreta, percreta, and previa are incorrect answers, as they involve different levels of placental attachment and can cause different symptoms.
Understanding Placenta Accreta
Placenta accreta is a condition where the placenta attaches to the myometrium instead of the decidua basalis, which can lead to postpartum hemorrhage. This condition is caused by a defective decidua basalis. There are three types of placenta accreta, which are categorized based on the degree of invasion. The first type is accreta, where the chorionic villi attach to the myometrium. The second type is increta, where the chorionic villi invade into the myometrium. The third type is percreta, where the chorionic villi invade through the perimetrium.
There are certain risk factors that increase the likelihood of developing placenta accreta, such as having a previous caesarean section or placenta previa. It is important for healthcare providers to be aware of these risk factors and monitor patients closely during pregnancy and delivery. Early detection and management of placenta accreta can help prevent complications and ensure the best possible outcome for both the mother and baby.
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This question is part of the following fields:
- Obstetrics
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Question 191
Incorrect
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A 36-year-old G5P2 woman comes to antenatal clinic at 35+2 gestation with a history of uneventful pregnancy except for moderate morning sickness in the first trimester. She reports several minor symptoms. What symptoms would require further investigation and raise concern?
Your Answer:
Correct Answer: Dysuria
Explanation:While many symptoms experienced during pregnancy are normal and not a cause for concern, it is important to be aware of symptoms that may indicate a medical issue, such as dysuria.
Dysuria, or painful urination, can be a sign of a urinary tract infection (UTI), which should be treated promptly during any stage of pregnancy. UTIs have been linked to premature birth, as the inflammation caused by the infection can irritate the cervix and trigger preterm labor.
Fatigue during pregnancy is a common experience and can have multiple causes. In the third trimester, it is considered normal. Lower back pain is also a common symptom, caused by the hormone relaxin increasing laxity in the sacroiliac joints and the added mechanical strain of pregnancy.
Nausea and vomiting are most commonly experienced in the first trimester, but can still occur throughout pregnancy and are generally considered normal.
Minor Symptoms of Pregnancy
During pregnancy, women may experience minor symptoms that are common and not usually a cause for concern. These symptoms may include nausea and vomiting, tiredness, and musculoskeletal pains. Nausea and vomiting, commonly known as morning sickness, can occur at any time of the day and may last throughout the first trimester. Tiredness is also a common symptom, especially during the first and third trimesters. Musculoskeletal pains, such as back pain and pelvic pain, may also occur due to the changes in the body’s structure and weight distribution. While these symptoms may be uncomfortable, they are typically manageable and can be relieved with rest, exercise, and proper nutrition. It is important to consult with a healthcare provider if these symptoms become severe or persistent.
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This question is part of the following fields:
- Obstetrics
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Question 192
Incorrect
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A 24-year-old primigravida is brought to the Emergency Department by her husband at 33 weeks of gestation after experiencing a generalised tonic–clonic seizure. Examination reveals blood pressure of 160/90 mmHg, temperature of 37 °C and 2+ pitting oedema in the lower extremities. She appears lethargic but responds to simple commands. What is the definitive treatment for this patient's condition?
Your Answer:
Correct Answer: Immediate delivery
Explanation:Eclampsia: Symptoms and Treatment
Eclampsia is a serious medical condition that can occur during pregnancy, characterized by pre-eclampsia and seizure activity. Symptoms may include hypertension, proteinuria, mental status changes, and blurred vision. Immediate delivery is the only definitive treatment for eclampsia, but magnesium can be given to reduce the risk of seizures in women with severe pre-eclampsia who are delivering within 24 hours. Eclampsia is more common in younger women with their first pregnancy and those with underlying vascular disorders. Hydralazine can be used to manage hypertension in pregnant women, but it is not the definitive treatment for eclampsia. Conservative management, such as salt and water restriction, bed rest, and close monitoring of blood pressure, is not appropriate for patients with eclampsia and associated seizure and mental state changes. ACE inhibitors are contraindicated during pregnancy, and labetalol is the first-line antihypertensive in pregnancy. Diazepam and magnesium sulfate can reduce seizures in eclampsia, but they are not the definitive treatment.
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This question is part of the following fields:
- Obstetrics
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Question 193
Incorrect
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Your next patient in an antenatal clinic is a woman who is 32 weeks pregnant. What examination findings would cause you to be concerned?
Your Answer:
Correct Answer: Fundal height growth of 2 cm per week
Explanation:The expected fundal height growth per week after 24 weeks is 1 cm, not 2 cm. If the fundal height is increasing by 2 cm per week, there may be a multiple pregnancy or the baby may be larger than expected, requiring further investigation. The fundus should be palpable at the umbilicus by 20 weeks and at the xiphoid sternum by 36 weeks. The head is typically free on palpation until around 37 weeks for nulliparous women, but may engage earlier in multiparous women. Breech presentation is common before 34 weeks and only becomes a concern if preterm labor occurs.
NICE guidelines recommend 10 antenatal visits for first pregnancies and 7 for subsequent pregnancies if uncomplicated. The purpose of each visit is outlined, including booking visits, scans, screening for Down’s syndrome, routine care for blood pressure and urine, and discussions about labour and birth plans. Rhesus negative women are offered anti-D prophylaxis at 28 and 34 weeks. The guidelines also recommend discussing options for prolonged pregnancy at 41 weeks.
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This question is part of the following fields:
- Obstetrics
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Question 194
Incorrect
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A 25-year-old female patient visits her GP seeking guidance on conceiving. She has a medical history of epilepsy and is currently taking lamotrigine. Her last seizure occurred 1 year ago. She is worried about the safety of epilepsy medications during pregnancy and wonders if there are any supplements she should take. What are the key counseling points to address her concerns?
Your Answer:
Correct Answer: Folic acid 5mg, continue lamotrigine
Explanation:When women who are taking antiepileptic medication plan to conceive, they should be given a higher dose of folic acid (5mg) instead of the usual 400 mcg once daily. Folic acid is recommended during pregnancy to prevent neural tube defects, and a higher dose is necessary for women with epilepsy due to their increased risk of low serum folate levels. It is important to note that certain antiepileptic medications can interfere with folate metabolism, and switching to sodium valproate is not recommended as it is a known teratogen. It is also important for women to continue taking their medication during pregnancy to avoid an increased risk of seizures.
Folic Acid: Importance, Deficiency, and Prevention
Folic acid is a vital nutrient that is converted to tetrahydrofolate (THF) in the body. It is found in green, leafy vegetables and plays a crucial role in the transfer of 1-carbon units to essential substrates involved in the synthesis of DNA and RNA. However, certain factors such as phenytoin, methotrexate, pregnancy, and alcohol excess can cause a deficiency in folic acid. This deficiency can lead to macrocytic, megaloblastic anemia and neural tube defects.
To prevent neural tube defects during pregnancy, it is recommended that all women take 400mcg of folic acid until the 12th week of pregnancy. Women at higher risk of conceiving a child with a neural tube defect should take 5mg of folic acid from before conception until the 12th week of pregnancy. Women are considered higher risk if they or their partner has a neural tube defect, they have had a previous pregnancy affected by a neural tube defect, or they have a family history of a neural tube defect. Additionally, women with certain medical conditions such as coeliac disease, diabetes, or thalassaemia trait, or those taking antiepileptic drugs, or who are obese (BMI of 30 kg/m2 or more) are also considered higher risk.
In summary, folic acid is an essential nutrient that plays a crucial role in DNA and RNA synthesis. Deficiency in folic acid can lead to serious health consequences, including neural tube defects. However, taking folic acid supplements during pregnancy can prevent these defects and ensure a healthy pregnancy.
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This question is part of the following fields:
- Obstetrics
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Question 195
Incorrect
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A 35-year-old primigravida presents for her 9-week antenatal appointment. She recently had a private ultrasound which revealed dichorionic, diamniotic twins. The patient has a medical history of hypothyroidism and a BMI of 38 kg/m². Although she has been smoking during her pregnancy, she has reduced her intake from 20 to 5 cigarettes per day and is interested in trying nicotine replacement therapy. Her main concern is that both her mother and sister suffered from hyperemesis gravidarum. What factor in her history is linked to a lower likelihood of developing this condition?
Your Answer:
Correct Answer: Smoking
Explanation:Smoking has been found to decrease the risk of hyperemesis gravidarum, which is believed to occur due to rapidly rising levels of human chorionic gonadotropin (HCG) and oestrogen. This is because smoking is considered to be anti-oestrogenic. Therefore, despite having other risk factors, the fact that the patient is a smoker may decrease her incidence of hyperemesis gravidarum. On the other hand, hypothyroidism is not a risk factor, but hyperthyroidism increases the risk of hyperemesis gravidarum. Obesity and underweight are associated with an increased risk of hyperemesis, but women with these conditions who smoked before pregnancy have been found to have no increased risk. Primigravida status is also associated with an increased risk of hyperemesis, but the reason for this is not clear. Finally, twin pregnancies carry an increased risk of hyperemesis gravidarum due to higher levels of beta-hCG released from the placenta.
Hyperemesis gravidarum is an extreme form of nausea and vomiting of pregnancy that occurs in around 1% of pregnancies and is most common between 8 and 12 weeks. It is associated with raised beta hCG levels and can be caused by multiple pregnancies, trophoblastic disease, hyperthyroidism, nulliparity, and obesity. Referral criteria for nausea and vomiting in pregnancy include continued symptoms with ketonuria and/or weight loss, a confirmed or suspected comorbidity, and inability to keep down liquids or oral antiemetics. The diagnosis of hyperemesis gravidarum requires the presence of 5% pre-pregnancy weight loss, dehydration, and electrolyte imbalance. Management includes first-line use of antihistamines and oral cyclizine or promethazine, with second-line options of ondansetron and metoclopramide. Admission may be needed for IV hydration. Complications can include Wernicke’s encephalopathy, Mallory-Weiss tear, central pontine myelinolysis, acute tubular necrosis, and fetal growth issues.
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This question is part of the following fields:
- Obstetrics
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Question 196
Incorrect
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A woman is in labour with her first child. The midwife becomes concerned that the cardiotocograph is showing late decelerations. She is reviewed by the obstetrician on-call who states that there is fetal compromise, but no immediate risk to life. A category two caesarean section is planned.
What is the timeframe for the delivery to be performed?Your Answer:
Correct Answer: Within 75 minutes
Explanation:Category 2 caesarean sections must be carried out within 75 minutes of the decision being made. This category is used when there is fetal or maternal compromise that is not immediately life-threatening. The delivery should be planned as soon as possible, but the target time is within 60-75 minutes. Category 1 caesarean section, on the other hand, is used when there is an immediate threat to the life of the woman or fetus, and the procedure should be performed within 30 minutes.
Caesarean Section: Types, Indications, and Risks
Caesarean section, also known as C-section, is a surgical procedure that involves delivering a baby through an incision in the mother’s abdomen and uterus. In recent years, the rate of C-section has increased significantly due to an increased fear of litigation. There are two main types of C-section: lower segment C-section, which comprises 99% of cases, and classic C-section, which involves a longitudinal incision in the upper segment of the uterus.
C-section may be indicated for various reasons, including absolute cephalopelvic disproportion, placenta praevia grades 3/4, pre-eclampsia, post-maturity, IUGR, fetal distress in labor/prolapsed cord, failure of labor to progress, malpresentations, placental abruption, vaginal infection, and cervical cancer. The urgency of C-section may be categorized into four categories, with Category 1 being the most urgent and Category 4 being elective.
It is important for clinicians to inform women of the serious and frequent risks associated with C-section, including emergency hysterectomy, need for further surgery, admission to intensive care unit, thromboembolic disease, bladder injury, ureteric injury, and death. C-section may also increase the risk of uterine rupture, antepartum stillbirth, placenta praevia, and placenta accreta in subsequent pregnancies. Other complications may include persistent wound and abdominal discomfort, increased risk of repeat C-section, readmission to hospital, haemorrhage, infection, and fetal lacerations.
Vaginal birth after C-section (VBAC) may be an appropriate method of delivery for pregnant women with a single previous C-section delivery, except for those with previous uterine rupture or classical C-section scar. The success rate of VBAC is around 70-75%.
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This question is part of the following fields:
- Obstetrics
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Question 197
Incorrect
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A 26-year-old primip presents at 28 weeks’ gestation, extremely worried as she attended her 5-year old nephew’s birthday party three days ago and stayed over at her sister’s house.
Today, her sister called to say that her nephew has developed a vesicular rash all over his body, and the general practitioner (GP) diagnosed him with chickenpox.
The patient denies any viral symptoms at present, but is unsure whether she has had chickenpox herself.
Which of the following should be performed?Your Answer:
Correct Answer: Blood test for varicella-zoster immunoglobulin G (IgG) antibodies
Explanation:Managing Chickenpox Exposure in Pregnant Women: Blood Test for Varicella-Zoster Immunoglobulin G (IgG) Antibodies
Chickenpox is a common childhood disease caused by the varicella-zoster virus. In pregnant women, exposure to chickenpox can have detrimental effects on the fetus. Therefore, strict guidelines exist for managing exposure to affected children.
If a pregnant woman has had significant exposure to chickenpox, a thorough history should be established. If there is uncertainty or no previous history or exposure, the first-line investigation is a blood test to test for the presence of varicella-zoster IgG antibodies. The presence of IgG antibodies in blood indicates that the person has immunity either by mounting a response to a previous infection or by vaccination.
Varicella-zoster immunoglobulin should not be administered to all pregnant women who report significant exposure to chickenpox, as it is of no benefit to women who are seropositive and it is a waste of resources. Seronegativity should be established first.
Admission is reserved for women who have a combination of symptoms suspicious of a primary varicella-zoster virus infection, ie chickenpox, and any of the following: immunosuppression, severe symptoms, haemorrhagic rash, and neurological or respiratory symptoms.
Testing for varicella-zoster antigen is not of clinical value and is not routinely performed when assessing a pregnant patient with significant exposure to chickenpox.
According to the Royal College of Obstetricians and Gynaecologists (RCOG) guidelines, a significant exposure is defined as contact within the same room for 15 minutes, face-to-face contact, or being in a large room such as a hospital ward or a kindergarten with a child or an adult with chickenpox during the infective period.
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This question is part of the following fields:
- Obstetrics
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Question 198
Incorrect
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A 28-year-old mother comes to see her GP. She had given birth to her child 8 weeks ago. She is feeling upset and tearful, explaining that motherhood is not what she expected. She is experiencing poor quality of sleep, loss of appetite, and feelings of guilt. She has not mentioned any thoughts of suicide. What screening tool should be used for this patient?
Your Answer:
Correct Answer: Edinburgh Scale
Explanation:To screen for postnatal depression, healthcare professionals can use the Edinburgh Scale questionnaire. Patients displaying symptoms of depression after giving birth should be assessed using either the Edinburgh Scale or the PHQ-9 form, according to NICE guidelines. The severity of anxiety can be measured using the GAD 7 questionnaire. The Bishop score is a scoring system used to determine if induction of labor is necessary.
Understanding Postpartum Mental Health Problems
Postpartum mental health problems can range from mild ‘baby-blues’ to severe puerperal psychosis. To screen for depression, healthcare professionals may use the Edinburgh Postnatal Depression Scale, which is a 10-item questionnaire that indicates how the mother has felt over the previous week. A score of more than 13 indicates a ‘depressive illness of varying severity’, with sensitivity and specificity of more than 90%. The questionnaire also includes a question about self-harm.
‘Baby-blues’ is seen in around 60-70% of women and typically occurs 3-7 days following birth. It is more common in primips, and mothers are characteristically anxious, tearful, and irritable. Reassurance and support from healthcare professionals, particularly health visitors, play a key role in managing this condition. Most women with the baby blues will not require specific treatment other than reassurance.
Postnatal depression affects around 10% of women, with most cases starting within a month and typically peaking at 3 months. The features are similar to depression seen in other circumstances, and cognitive behavioural therapy may be beneficial. Certain SSRIs such as sertraline and paroxetine may be used if symptoms are severe. Although these medications are secreted in breast milk, they are not thought to be harmful to the infant.
Puerperal psychosis affects approximately 0.2% of women and requires admission to hospital, ideally in a Mother & Baby Unit. Onset usually occurs within the first 2-3 weeks following birth, and features include severe swings in mood (similar to bipolar disorder) and disordered perception (e.g. auditory hallucinations). There is around a 25-50% risk of recurrence following future pregnancies. Paroxetine is recommended by SIGN because of the low milk/plasma ratio, while fluoxetine is best avoided due to a long half-life.
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This question is part of the following fields:
- Obstetrics
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Question 199
Incorrect
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A 38-year-old G7P3 mother presents with a show and waters breaking at 34+1 weeks, following three days of fever and left flank pain. Despite hoping for a home birth, she eventually agrees to go to the hospital after three hours of convincing from the midwife. Upon arrival, continuous cardiotocography is initiated and a foetal doppler reveals foetal bradycardia. On abdominal exam, the baby is found to be in a footling breech position, but the uterus is non-tender and contracting. A speculum examination reveals an exposed cord, with a soft 8 cm cervix and an exposed left foot.
What is the most appropriate initial management plan for this patient and her baby?Your Answer:
Correct Answer: Put the patient on all fours and push the foot back into the uterus
Explanation:In the case of umbilical cord prolapse, the priority is to limit compression on the cord and reduce the chance of cord vasospasm. This can be achieved by pushing any presenting part of the baby back into the uterus, putting the mother on all fours, and retrofilling the bladder with saline. In addition, warm damp towels can be placed over the cord to limit handling. It is important to note that this is a complex emergency that requires immediate attention, as it can lead to foetal bradycardia and limit the oxygen supply to the baby. In this scenario, a category 1 Caesarean section would be necessary, as the pathological CTG demands it. Delivering the baby as breech immediately is not recommended, as it is a high-risk strategy that can lead to morbidity and mortality. IM corticosteroids are indicated for premature rupture of membranes, but the immediate priority is to deal with the emergency. McRobert’s manoeuvre is not appropriate in this case, as it is used to correct shoulder dystocia, which is not the issue at hand.
Understanding Umbilical Cord Prolapse
Umbilical cord prolapse is a rare but serious complication that can occur during delivery. It happens when the umbilical cord descends ahead of the presenting part of the fetus, which can lead to compression or spasm of the cord. This can cause fetal hypoxia and potentially irreversible damage or death. Certain factors increase the risk of cord prolapse, such as prematurity, multiparity, polyhydramnios, twin pregnancy, cephalopelvic disproportion, and abnormal presentations like breech or transverse lie.
Around half of all cord prolapses occur when the membranes are artificially ruptured. Diagnosis is usually made when the fetal heart rate becomes abnormal and the cord is palpable vaginally or visible beyond the introitus. Cord prolapse is an obstetric emergency that requires immediate management. The presenting part of the fetus may be pushed back into the uterus to avoid compression, and the cord should be kept warm and moist to prevent vasospasm. The patient may be asked to go on all fours or assume the left lateral position until preparations for an immediate caesarian section have been carried out. Tocolytics may be used to reduce uterine contractions, and retrofilling the bladder with saline can help elevate the presenting part. Although caesarian section is the usual first-line method of delivery, an instrumental vaginal delivery may be possible if the cervix is fully dilated and the head is low.
In conclusion, umbilical cord prolapse is a rare but serious complication that requires prompt recognition and management. Understanding the risk factors and appropriate interventions can help reduce the incidence of fetal mortality associated with this condition.
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This question is part of the following fields:
- Obstetrics
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Question 200
Incorrect
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A 29-year-old woman, who is 12 weeks pregnant, visits her midwife for a check-up. She has a BMI of 33 kg/m² and no other medical conditions. The patient is anxious about gestational diabetes, which she believes is common in larger women. She has one child previously, a boy, who was born after a complicated and prolonged delivery. He weighed 4.6kg at birth and required no additional post-natal care. There is no family history of any pregnancy-related issues. What is the most appropriate test to address her concerns and medical history?
Your Answer:
Correct Answer: Oral glucose tolerance test at 24-28 weeks
Explanation:The preferred method for diagnosing gestational diabetes is still the oral glucose tolerance test.
Gestational diabetes is a common medical disorder affecting around 4% of pregnancies. Risk factors include a high BMI, previous gestational diabetes, and family history of diabetes. Screening is done through an oral glucose tolerance test, and diagnostic thresholds have recently been updated. Management includes self-monitoring of blood glucose, diet and exercise advice, and medication if necessary. For pre-existing diabetes, weight loss and insulin are recommended, and tight glycemic control is important. Targets for self-monitoring include fasting glucose of 5.3 mmol/l and 1-2 hour post-meal glucose levels.
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This question is part of the following fields:
- Obstetrics
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