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  • Question 1 - A 32-year-old woman gave birth to a baby of normal weight through vaginal...

    Incorrect

    • A 32-year-old woman gave birth to a baby of normal weight through vaginal delivery, which was complicated by a small perianal tear that was taken care of without stitching. On the fifth day of postpartum patient presents with heavy bright red vaginal bleeding and mentions that lochia was in scant amounts compared to her previous pregnancy.
      On examination, her temperature was 38.8°C and uterus is mildly tender to palpation.
      Which one of the following would most likely be her diagnosis?

      Your Answer: Infection of the perianal tear

      Correct Answer: Retained products of conception

      Explanation:

      Secondary postpartum hemorrhage of bright red character accompanied with fever, between 24 hours to 12 weeks of postpartum is suggestive of retained products of conception (RPOC).
      The basal portion of the decidua may remain after separation of placenta in many cases. This decidua will then divides into two layers, the superficial layer which will be shed spontaneously and the deep layer which will regenerates and covers the entire endometrial cavity with in 16 days of postpartum.
      Normal shedding of blood and decidua is referred to as lochia rubra, which is red / reddish brown in colour and it lasts for few days following delivery. This vaginal discharge gradually becomes watery and pinkish brown in colour, lasting for 2 to 3 weeks and is called as lochia serosa. Ultimately, this discharge becomes yellowish-white called as lochia alba.

      Scanty lochia in the first few days after delivery is suggestive of the placental site not undergoing involution, which occurs mostly due to RPOC. Later these retained products will undergo necrosis resulting in fibrin deposition which will eventually form a placental polyp. Detachment of this scar of polyp will result in brisk hemorrhage and the remaining necrotic products will get infected resulting in uterine infection which will present with fever, lower abdominal pain and uterine tenderness.

      Endometritis can lead to fever, offensive lochia and abdominal pain with tenderness. It is the most common cause of postpartum fever, but occurs within the first 5 days of postpartum with the peak incidence between days 2 and 3. Though vaginal bleeding is a presenting feature, bright red bleeding is unlikely of endometritis.

      Another cause of postpartum fever is genital lacerations which have a peak incidence of wound infection between 4th and 5th days. Although fever as a temporal symptom favours wound infection, this diagnosis is less likely in the given case as wound infection will not affect the normal course of lochia, also it does not present as heavy bright red bleeding. Moreover, there are no symptoms like erythema, tenderness or discharge in history suggestive of wound infection.

      Another cause of bleeding and fever can be cervical tear but this tends to present as primary postpartum hemorrhage rather than secondary, which occurs after 24 hours of postpartum. An overlooked and infected minor cervical laceration can cause fever but ii will not result in bright red bleeding, also genital tract lacerations do not affect lochia.

      It is very unlikely for uterine rupture to occur 24 hours after delivery.

    • This question is part of the following fields:

      • Obstetrics
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  • Question 2 - Excessive increased level of β-HCG is expected in: ...

    Incorrect

    • Excessive increased level of β-HCG is expected in:

      Your Answer:

      Correct Answer: Twin pregnancy

      Explanation:

      Human chorionic gonadotropin levels dynamically increase during early gestation and the levels are significantly greater in viable pregnancies than in ectopic gestation, biochemical pregnancy, or spontaneous abortions. Similarly, the hCG concentrations are significantly higher in multiple pregnancy as compared with singleton.

    • This question is part of the following fields:

      • Physiology
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  • Question 3 - The round ligament develops from which structure? ...

    Incorrect

    • The round ligament develops from which structure?

      Your Answer:

      Correct Answer: Gubernaculum

      Explanation:

      The round ligament develops from the lower end of the gubernaculum in females. In the males it persists as the scrotal ligament.

    • This question is part of the following fields:

      • Anatomy
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  • Question 4 - You are called to see a 24 year old patient in A&E. She...

    Incorrect

    • You are called to see a 24 year old patient in A&E. She is 34 weeks gestation and her blood pressure is 149/98. Urine dip shows protein 3+. You send a for a protein:creatinine ratio. What level would be diagnostic of significant proteinuria?

      Your Answer:

      Correct Answer: >30 mg/mmol

      Explanation:

      Significant proteinuria = urinary protein:creatinine ratio >30 mg/mmol or 24-hour urine collection result shows greater than 300 mg protein

    • This question is part of the following fields:

      • Clinical Management
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  • Question 5 - An otherwise healthy 21 year old primigravida comes to your office for a...

    Incorrect

    • An otherwise healthy 21 year old primigravida comes to your office for a routine visit at 16 weeks gestation. She has had a normal pregnancy to date, and her only medication is a multivitamin with 0.4 mg folic acid. You order a maternal serum alpha-fetoprotein level. Adjusted for gestational age, maternal weight, and race, the results are significantly elevated. Which one of the following would you now recommend?

      Your Answer:

      Correct Answer: Fetal ultrasonography

      Explanation:

      A 16-week visit is advised for all pregnant women to offer an alpha-fetoprotein (AFP) screening for neural tube defects and Down syndrome- An AFP level 2-5 times the median value for normal controls at the same gestational age is considered elevate- Approximately 5%-10% of patients who undergo AFP screening will have an elevated level, and most of these women will have normal foetuses. Fetal ultrasonography should be performed to detect multiple gestation, fetal demise, or fetal anomalies (neural tube defects, ventral abdominal wall defects, and urinary tract anomalies) as well as to confirm gestational age, as all of these factors are associated with elevated AFP levels. Amniocentesis is offered if the ultrasonography does not indicate the reason for the elevated AFP. Chorionic villus sampling is offered in the evaluation of suspected chromosomal anomalies as an adjunct to amniocentesis. Serum hCG would be indicated in the workup of suspected Down syndrome, where the AFP would be low, not elevate- The hCG level would be expected to be over 2-5 multiples of the mean (MoM) with Down syndrome.

    • This question is part of the following fields:

      • Obstetrics
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  • Question 6 - Presence of anisocytosis, poikilocytosis and hyperchromatism on cervical smear indicates? ...

    Incorrect

    • Presence of anisocytosis, poikilocytosis and hyperchromatism on cervical smear indicates?

      Your Answer:

      Correct Answer: Dysplasia

      Explanation:

      Dysplasia has 4 microscopic characteristics:
      Anisocytosis (unequal cell size)
      Poikilocytosis (abnormal cell shape)
      Hyperchromatism (pigmentation)
      Mitotic figures (increased cells currently dividing)

      Hyperplasia and hypertrophy is characterised by increase in cell number and increase in cell size respectively, whereas atrophy means decrease in cell size.
      Metaplasia is characterised by change of one form of cell to another type e.g. changes of columnar epithelium to squamous epithelium.

    • This question is part of the following fields:

      • Pathology
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  • Question 7 - A 31-year-old woman's blood results after having secondary amenorrhoea that lasted for 6...

    Incorrect

    • A 31-year-old woman's blood results after having secondary amenorrhoea that lasted for 6 months are: Testosterone = 3.4 nmol/L (<1.6), Oestradiol = 144 pmol/L (100-500), LH = 12 U/L and FSH = 4 U/L. What sign or symptom is she likely to have?

      Your Answer:

      Correct Answer:

      Explanation:

      Biochemical features suggest that this patient has polycystic ovary syndrome (PCOS). It is associated with signs and symptoms of hyperandrogenism (oligomenorrhea, irregular menstruation, hirsutism, hair loss, and acne) and elevated testosterone. PCOS patients are often overweight or obese, have insulin resistance (treated with Metformin) and an adverse risk profile for cardiovascular disease.

    • This question is part of the following fields:

      • Gynaecology
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  • Question 8 - A young couple, both 26 years of age, presents to you with 11...

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    • A young couple, both 26 years of age, presents to you with 11 months’ duration of infertility. On investigation, she is found to be ovulating, and her hysterosalpingogram is normal. On semen analysis, the following results were found:
      Semen volume 5mL (2-6 mL)
      Sperm count 1 million/mL * (>20 million)
      Motility 15% (>40%)
      Abnormal forms 95% (<60%)
      A second specimen three months later confirms the above results.
      Which would be the most suitable next step in management?

      Your Answer:

      Correct Answer: Carry out in vitro fertilisation (IVF) using intracytoplasmic sperm injection (ICSI).

      Explanation:

      Achieving spontaneous pregnancy is rare in cases where a couple have been infertile with abnormal semen analysis (count <5million/mL and reduced motility), hence there is generally an indication for treatment. FSH injection usually would not be expected to improve the semen specimen. Rate of pregnancy would be much lower if at the time of intrauterine insemination, the total motile count is less 5 million. In this case, his count is 1 million. Pregnancy is likely to be achieved with donor sperm but as it would not contain the husband’s genetic material, it would be only considered later on once all other methods involving his own sperm have failed. Out of all the options, IVF would most likely result in a pregnancy, in which it allows the husband’s sperm to spontaneously fertilise the oocyte. Rate of pregnancy would roughly be 2% per treatment cycle. This rate would increase to roughly 20% if ISCI is also used.

    • This question is part of the following fields:

      • Gynaecology
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  • Question 9 - Luteal phase deficiency is characterised by: ...

    Incorrect

    • Luteal phase deficiency is characterised by:

      Your Answer:

      Correct Answer: Has inadequate luteal progesterone production

      Explanation:

      Luteal phase occurs after the ovulation. Luteal defect means that the luteal phase is shorter than 10 days and women will find it difficult to sustain the pregnancy. There is decreased progesterone, LH and FSH production in this case.

    • This question is part of the following fields:

      • Physiology
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  • Question 10 - A 24 year old lady is rushed to the emergency department complaining of...

    Incorrect

    • A 24 year old lady is rushed to the emergency department complaining of vaginal spotting and abdominal cramping. Her 6 week pregnancy was confirmed by ultrasound scan last week. On speculum examination, the cervical os is open with blood noted around it.
      Which of the following is the most likely diagnosis?

      Your Answer:

      Correct Answer: Inevitable Miscarriage

      Explanation:

      A miscarriage is defined as the spontaneous loss of a pregnancy before the age of viability at 24 weeks in the UK. An inevitable miscarriage occurs with the usual symptoms of a miscarriage such as menstrual-like cramping, vaginal bleeding and a dilated cervix. The gestational sac has ruptured but products of conception have not been passed. The products of conception will eventually pass.

      A missed miscarriage is described as a loss of pregnancy without vaginal bleeding, loss of tissue, cervical changes or abdominal pain. During a scan, a fetal heartbeat is not observed, and the gestational sac may be small.

      A threatened miscarriage is when the cervix dilates and uterine bleeding is seen; the pregnancy could still be viable.

      A complete miscarriage occurs when all the products of conception are expelled from the uterus, bleeding has stopped, and the cervix has closed up after dilation. Recurrent miscarriages are described as spontaneous pregnancy loss of more than 2 to 3 consecutive times.

    • This question is part of the following fields:

      • Clinical Management
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