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Question 1
Incorrect
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Screening for Group B Streptococcus (GBS) at around 36 weeks of gestation now is common practice as up to 20% of women carry the organism in the vagina.
If a pregnant woman is found to have GBS at this stage, which treatment would be most appropriate?Your Answer:
Correct Answer: Parenteral penicillin given six-hourly in labour.
Explanation:Up to 20% of women have been found to have Group B streptococcus (GBS). GBS is considered a normal flora of the gastrointestinal tract. GBS infection is generally asymptomatic although some women might end up having a UTI. Infants born to mothers who are colonised with GBS during labour are at a higher risk of developing early-onset GBS infection. If a pregnant woman develops a UTI due to GBS, it is suggestive of significant GBS colonisation. IV penicillin would be the drug of choice and is to be administered to the mother during labour which would provide sufficient protection for the foetus and would be effective enough. If penicillin is unavailable, ampicillin is a reasonable alternative. If a patient has penicillin allergy, vancomycin can be used. If not for penicillin, roughly 50% of babies delivered vaginally to women who are GBS positive would be colonised with the organism and out of this percentage, 1-2% can go on to develop a severe infection such as septicaemia and meningitis which could often be fatal.
IM penicillin can be administered to the newborn immediately post-delivery would be an effective prophylaxis in most cases but one should not wait until signs of infection are present to give the injection. Many newborns would still have an immature immune system which could cause some to die. Hence, it is more suitable to treat all women who tested positive during labour and the newborn as well if any signs of infection do appear. The majority of babies don’t need antibiotic treatment if their mother has been treated.
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This question is part of the following fields:
- Obstetrics
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Question 2
Incorrect
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Multiple Gestation is frequently associated with all of the following EXCEPT:
Your Answer:
Correct Answer: Post-maturity
Explanation:Multiple pregnancy is considered a high risk for obstetric complications such as spontaneous abortion, hypertensive disorders, placenta previa, and fetal malformations. Specifically, the incidence of hypertensive disorders, a common source of maternal morbidity, is 15% to 35% in twin pregnancies, which is two to five times higher than in singleton pregnancies. Additionally, the aetiology of preterm birth is not completely understood, but the association between multiple pregnancy and preterm birth is well known. A secondary analysis of the WHO Global Survey dataset indicated that 35.2% of multiple births were preterm (< 37 weeks gestation); of all multiple births, 6.1% of births were before 32 weeks gestation, 5.8% were during weeks 32 and 33, and 23.2% were during weeks 34 through 37
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This question is part of the following fields:
- Obstetrics
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Question 3
Incorrect
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Fetal distress commonly occurs when the head is in the occipito-posterior (OP) position during labour. Which of the following statements is the most probable explanation for this?
Your Answer:
Correct Answer: Incoordinate uterine action.
Explanation:Incoordinate uterine action almost always results in fetal distress due to increased resting intrauterine pressure. All other statements can also cause fetal distress, however, these are not as common as incoordinate uterine action. Syntocin infusion for labour augmentation and administration of epidural anaesthetic for pain relief can also increase the risk of fetal distress.
Cardiotocograph (CTG) monitoring during labour is highly recommended in patients where the fetal head is found in the OP position. Moreover, it is mandatory when there is Syntocin infusion or epidural anaesthesia. -
This question is part of the following fields:
- Obstetrics
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Question 4
Incorrect
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A 32-year-old woman visited your clinic at her 30th week of gestation, complaining of left lower limb pain.
The doppler ultrasound findings had confirmed proximal deep vein thrombosis and she was treated with low molecular weight heparin.
Now she is at her 34 weeks of gestation, and is expecting delivery in next four weeks. What would be your advice for her today?Your Answer:
Correct Answer: Low molecular weight heparin should be switched to unfractionated heparin
Explanation:This patient has developed deep vein thrombosis during pregnancy and required anti-coagulation as part of treatment for up to 3-6 months. Enoxaparin, which is a low molecular weight heparin, is preferred over heparin due to the once or twice a day therapeutic dosing. Also monitoring of aPTT is not required in this case.
There is an association between Enoxaparin and an increased risk for epidural hematoma in women receiving epidural anaesthesia during labour. Considering that the patient mentioned is expected to go for delivery in 4 weeks and the possibility of her needing an epidural anaesthesia or general anaesthesia in case of undergoing a cesarean section, enoxaparin should be switched to unfractionated heparin, four weeks prior to the anticipated delivery. This is because of the fact that heparin can be antidoted with protamine sulphate.
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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 34-year-old woman, gravida 1 para 1, presented to the emergency department complaining of left breast pain six weeks after a spontaneous, uncomplicated term vaginal delivery. She reported having noticed the pain and redness on her left breast a week ago. From her unaffected breast, she continued to breastfeed her infant.
Upon history taking, it was noted that she has no chronic medical conditions and for medication, she only takes a daily multivitamin. Her temperature was taken and the result was 38.3 deg C (101 deg F).
Further observation was done and the presence of an erythematous area surrounding a well-circumscribed, 4-cm area of fluctuance extending from the areola to the lateral edge of the left breast was noted. There was also the presence of axillary lymphadenopathy.
Which of the following is the next step to best manage the condition of the patient?Your Answer:
Correct Answer: Needle aspiration and antibiotics
Explanation:Breast infections can be associated with superficial skin or an underlying lesion. Breast abscesses are more common in lactating women but do occur in nonlactating women as well.
The breast contains breast lobules, each of which drains to a lactiferous duct, which in turn empties to the surface of the nipple. There are lactiferous sinuses which are reservoirs for milk during lactation. The lactiferous ducts undergo epidermalization where keratin production may cause the duct to become obstructed, and in turn, can result in abscess formation. Abscesses associated with lactation usually begin with abrasion or tissue at the nipple, providing an entry point for bacteria. The infection often presents in the second postpartum week and is often precipitated in the presence of milk stasis. The most common organism known to cause a breast abscess is S. aureus, but in some cases, Streptococci, and Staphylococcus epidermidis may also be involved.
The patient will usually provide a history of breast pain, erythema, warmth, and possibly oedema. Patients may provide lactation history. It is important to ask about any history of prior breast infections and the previous treatment. Patients may also complain of fever, nausea, vomiting, purulent drainage from the nipple, or the site of erythema. It is also important to ask about the patient’s medical history, including diabetes. The majority of postpartum mastitis are seen within 6 weeks of while breast-feeding
The patient will have erythema, induration, warmth, and tenderness to palpation at the site in question on the exam. It may feel like there is a palpable mass or area of fluctuance. There may be purulent discharge at the nipple or site of fluctuance. The patient may also have reactive axillary adenopathy. The patient may have a fever or tachycardia on the exam, although these are less common.
Incision and drainage are the standard of care for breast abscesses. If the patient is seen in a primary care setting by a provider that is not comfortable in performing these procedures, the patient may be started on antibiotics and referred to a general surgeon for definitive treatment. Needle aspiration may be attempted for abscesses smaller than 3 cm or in lactational abscesses. A course of antibiotics may be given before or following drainage of breast abscesses.
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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 29-year-old lady presents to your clinic at her 26 weeks of gestation. She is worried as she came in contact with a child having chicken pox 48 hours ago and she has no symptoms.
You checked her pre-pregnancy IgG level for chicken pox which was negative, as she missed getting vaccinated for chickenpox before pregnancy.
What is the best next step in managing this patient?Your Answer:
Correct Answer: Give varicella zoster immunoglobulins
Explanation:This woman who is 26 weeks pregnant, has come in contact with a child having chickenpox 48 hours ago. As her IgG antibodies were negative during prenatal testing, she has no immunity against Varicella which makes her susceptible to get chickenpox.
Prophylactic treatment is required if a susceptible pregnant woman is exposed to chickenpox, which includes administration of varicella zoster immune globulin (VZIG), within 72 hours of exposure to infection.
As the patient has already checked for and was found to be negative, checking IgG level again is not relevant. Also, it was already revealed that she is not vaccinated against varicella before pregnancy.
If the patient had any symptoms typical of chickenpox, measuring IgM would have been helpful, but patient is completely asymptomatic in this case so measuring IgM is not indicated.
Vaccine for chickenpox is contraindicated during pregnancy as it is a live vaccine.
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This question is part of the following fields:
- Obstetrics
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Question 7
Incorrect
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Which of the following is the most likely anaesthetic or analgesic causing reduced variability on cardiotocograph?
Your Answer:
Correct Answer: Intramuscular pethidine
Explanation:Opiates and spinal anaesthetics reduce the variability of a CTG. Including some antihypertensives like labetalol and alpha methyl dopa.
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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 27-year-old woman G1P0 at 14 weeks of gestation came to you with presentation of chicken pox rashes which started 2 days ago. Varicella IgM came back positive with negative IgG.
What is the most appropriate management in this patient?Your Answer:
Correct Answer: Do nothing and arranged a detailed fetal ultrasound 5 weeks later
Explanation:Varicella or chickenpox, is a highly contagious disease caused by primary infection with varicella-zoster virus (VZV) which can result in maternal mortality or serious morbidity. The virus which remains dormant in the sensory nerve root ganglia following a primary infection can get reactivated to cause a vesicular erythematous skin rash along the dermatomal distribution known as herpes zoster, ‘zoster’ or ‘shingles’. Though rare the risk of acquiring infection from an immunocompetent individual with herpes zoster in non-exposed sites like thoracolumbar regions can also occur. As the viral shedding will be greater, a disseminated zoster or exposed zoster (e.g. ophthalmic) in an individual or localised zoster in an immunosuppressed patient should be considered very infectious.
In industrialised countries, over 85 % of women in childbearing age are immune to varicella zoster virus (VZV), however, women from tropical and subtropical areas are more susceptible to chickenpox in pregnancy as they are more likely to be seronegative for VZV IgG. Up to 10% cases of VZV in pregnancy are complicated with Varicella pneumonia, whereas perinatal varicella/ chickenpox carries a 20 to 30 % risk of transmitting infection to the neonate. Studies on maternal varicella infection from 12-28 weeks gestation suggests a 1.4% risk of fetal varicella syndrome (FVS) whose subsequent abnormalities include:
– Skin scarring (78%)
– Eye abnormalities (60%)
– Limb abnormalities (68%)
– Prematurity and low birthweight (50%)
– Cortical atrophy, intellectual disability (46%)
– Poor sphincter control (32%)
– Early death (29%)In the case mentioned above, patient had developed chickenpox rashes in her 2nd trimester and presented to you at day 2 of illness. Her varicella IgM came back positive along with a negative IgG indicating that she is not being immunized and that she is currently having active varicella infection. The best management in this case will be to reassured and allowed patient to be monitored at home. As there is no underlying lung disease, she is not immunocompromised and she is a non-smoker, so antiviral therapy is not required.
Generally, for pregnant women with chickenpox if they present within 24 hours of onset of rash and are in 20+0 weeks of gestation or beyond oral aciclovir should be prescribed. However, the use of acyclovir before 20+0 weeks should be considered carefully as Aciclovir is rated category B3 (Pregnancy and Breastfeeding, eTG, January 2003, ISSN 1447-1868) and should only be prescribed if its potential benefits outweigh the potential risks caused to the fetus, with informed consent in pregnant women who present within 24 hours of onset of varicella rash. If the patient is immunocompromised or if there are respiratory symptoms, a haemorrhagic rash or persistent fever for more than six days it is advisable to use intravenous acyclovir. On the other hand, to prevent secondary bacterial infection of the lesions, symptomatic treatment and hygiene should also be advised and unless there is significant superimposed bacterial infection antibiotics are not required.
If the pregnant woman has had a significant exposure to chickenpox or shingles, and is not immune to VZV , she should be offered VZIG as soon as possible or at the very latest within 10 days of the exposure. However, since Varicella zoster immunoglobulins (VZIG) has no therapeutic benefit in already developed cases of chickenpox, it should not be given to the context patient who have already developed active rashes of chickenpox with serology showing positive IgM positive and negative IgG indicating primary infection.
At least five weeks after primary infection a detailed fetal ultrasound must be done checking for any anomalies and ultrasounds should be repeated until delivery; and consider a fetal MRI if any abnormalities are found. In cases were if ultrasound is found to be normal, VZV fetal serology and amniocentesis are not useful and is not routinely advised.
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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 26-year-old gravida 2 para 1 presents at 30 weeks gestation with a complaint of severe itching. She has excoriations from scratching in various areas. She says that she had the same problem during her last pregnancy, and her medical records reveal a diagnosis of intrahepatic cholestasis of pregnancy. Elevation of which one of the following ismost specific and sensitive markerof this disorder?
Your Answer:
Correct Answer: Bile acids
Explanation:Intrahepatic cholestasis of pregnancy (ICP) classically presents as severe pruritus in the third trimester. Characteristic findings include the absence of primary skin lesions and elevation of serum levels of total bile acids.
The most specific and sensitive marker of ICP is total serum bile acid (BA) levels greater than 10 micromol/L. In addition to the elevation in serum BA levels, the cholic acid level is significantly increased and the chenodeoxycholic acid level is mildly increased, leading to elevation in the cholic
henodeoxycholic acid level ratio. The elevation of aminotransferases associated with ICP varies from a mild increase to a 10- to 25-fold increase.Total bilirubin levels are also increased but usually the values are less than 5 mg/dL. Alkaline phosphatase (AP) is elevated in ICP up to 4-fold, but this is not helpful for diagnosis of the disorder since AP is elevated in pregnancy due to production by the placenta- Mild elevation of gamma glutamyl transferase (GGT) is seen with ICP but occurs in fewer than 30% of cases. However, if GGT is elevated in cases of ICP, that patient is more likely to have a genetic component of the liver disease.
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This question is part of the following fields:
- Obstetrics
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Question 10
Incorrect
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Which of the following conditions are the most common cause in post-partum haemorrhage?
Your Answer:
Correct Answer: Uterine atony
Explanation:Uterine atony is the most common cause for postpartum haemorrhage and the conditions like multiple pregnancy, polyhydramnions, macrosomia, prolonged labour and multiparity are the most common risk factor for uterine atony.
Whereas less common causes for postpartum haemorrhage are laceration of genital tract, uterine rupture, uterine inversion and coagulopathy.
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This question is part of the following fields:
- Obstetrics
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Question 11
Incorrect
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A 21-year old female, gravida 1 para 0, term pregnancy, comes in due to labour for eight hours. Two hours prior to onset of contractions, her membranes have allegedly ruptured. Fetal heart rate is at 144/min. Contractions are of good quality, noted every 2-3 minutes, with a duration of 45 seconds. On examination, her cervix is fully dilated and the patient has been pushing all throughout. Vertex is palpated in the occipito-anterior (OA) position and has descended to station 2 cm below the ischial spines in the previous hour. Which of the following most likely depicts the current condition of the patient?
Your Answer:
Correct Answer: Normal progress.
Explanation:The patient’s condition can be described as a normal progress of labour. The scenario shows a normal descent of the head in the pelvic cavity, with a favourable position, and occurring within an hour of the second stage of labour. A normal second stage of labour in a nulliparous individual occurs at a maximum of two hours, which is consistent with this patient. Hence, there is no delay in the second stage.
There is evident progress of labour in this patient, hence, obstructed labour or cephalopelvic disproportion is ruled out.
No signs of maternal distress such as tachycardia or pyrexia is described in this patient.
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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 27-year-old woman presented to the medical clinic for antenatal advice because she plans to get pregnant soon. However, she is worried about how she should change her diet once she becomes pregnant already.
Which of the following is considered the best to give to the patient in addition to giving folic acid?Your Answer:
Correct Answer: Iodine
Explanation:There is evidence that folic acid, iodine and vitamin D are important for reproductive outcomes. Folic acid and iodine supplementation is recommended for women planning to conceive and in pregnancy.
The recommended dose of folic acid for women without special considerations planning to conceive is 400-500 mcg. The recommended dose of folic acid for women with special considerations is 2-5 mg per day.
Women planning a pregnancy, including those with thyroid disease, should take iodine supplements in the dose of 150 mcg per day prior to and during pregnancy.
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This question is part of the following fields:
- Obstetrics
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Question 13
Incorrect
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A 36-year-old woman is brought to the emergency department after she twisted her ankle, once initial management of her current problem is done, you realize that she is 10 weeks pregnant.
On further questioning, she admits to heroin addiction and says that Doc, I sometimes need to get high on meth, but my favorite wings to fly are cocaine though, since I cannot afford it, I take a bit when I manage to crash a party. She also drinks a bottle of whisky every day. During the past few weeks, she started worrying about not being a good mother, and for this she is taking diazepam at night which she managed to get illegally.
Considering everything this patient revealed, which is most likely to cause fetal malformations?Your Answer:
Correct Answer: Alcohol
Explanation:Woman in the given case is taking a full bottle of Whisky every day. As per standards, a small glass of Whisky (1.5 Oz) is equivalent of a standard drink and a bottle definitely exceeds 12 standard drinks. This makes her fetus at significant risk for fetal alcohol syndrome (FAS) which is associated with many congenital malformations. Low-set ears, midfacial hypoplasia, elongated philtrum, upturned nose and microcephaly along with skeletal and cardiac malformations are the congenital malformations commonly associated with fetal alcohol syndrome.
Health risks of benzodiazepines during pregnancy has not been clearly established, but there are inconsistent reports of teratogenic effects associated with fetal exposure to benzodiazepines. Neonatal abstinence syndrome of delayed onset can be associated with regular use of benzodiazepine in pregnancy.
Use of Amphetamine in controlled doses during pregnancy is unlikely to pose a substantial teratogenic risk, but a range of obstetric complications such as reduced birth weight and many these outcomes which are not specific to amphetamines but influenced by use of other drug and lifestyle factors in addition to amphetamine are found commonly among women who use it during pregnancy. Exposure to amphetamines in utero may influence prenatal brain development, but the nature of this influence and its potential clinical significance are not well established.
3,4- methylenedioxymetham phetamine(MOMA), which is an amphetamine derivative and commonly known as ecstasy, have existing evidences suggesting that its use during first trimester poses a potential teratogenic risk. So it is strongly recommended to avoided the use of ecstasy during 2-8 weeks post conception or between weeks four to ten after last menstrual period as these are the considered periods of organogenesis.
Role of cocaine in congenital malformations is controversial as cases reported of malformations caused by cocaine are extremely rare. However, it may lead to fetal intracranial haemorrhage leading to a devastating outcome.
Opiate addictions carry a significant risk for several perinatal complications, but it has no proven association with congenital malformation.
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This question is part of the following fields:
- Obstetrics
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Question 14
Incorrect
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Among the below given options, which is NOT associated with an increased risk for preeclampsia?
Your Answer:
Correct Answer: Age between 18 and 40 years
Explanation:Any new onset of hypertension associated with proteinuria after 20 weeks of gestation in a previously normotensive woman is referred to as Preeclampsia.
Most commonly found risk factors for pre-eclampsia are:
– Preeclampsia in a previous pregnancy
– Family history of preeclampsia
– a prior pregnancy with poor outcome like placental abruption, IUGR, fetal death in utero, etc
– An interdelivery interval greater than 10 years
– Nulliparity, increases risk by 8 times
– Pre-existing chronic medical conditions or chronic hypertension
– pre-existing or gestational Diabetes
– chronic Renal disease
– Thrombophilias g. protein C and S deficiency, antithrombin Ill deficiency, or Factor V Leiden mutation
– Antiphospholipid syndrome
– Systemic lupus erythematous
– Maternal age greater than or equal to 40 years
– Body Mass Index (BMI) greater than 30 kg/m2
– Multiple pregnancy
– Raised blood pressure at booking
– Gestational trophoblastic disease
– Fetal triploidyMaternal age between 18 and 40 years is found to be associated with a decreased risk for developing preeclampsia, and not an increased risk.
NOTE– Previously, age 16 years or younger was thought to be a risk factor for developing preeclampsia; however, recent studies conducted had failed to establish any meaningful relationship between the two. -
This question is part of the following fields:
- Obstetrics
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Question 15
Incorrect
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During early pregnancy, a pelvic examination may reveal that one adnexa is slightly enlarged. This is most likely due to:
Your Answer:
Correct Answer: Corpus luteal cyst
Explanation:Adnexa refer to the anatomical area adjacent to the uterus, and contains the fallopian tube, ovary, and associated vessels, ligaments, and connective tissue. The reported incidence of adnexal masses in pregnancy ranges from 1 in 81 to 1 in 8000 pregnancies. Most of these adnexal masses are diagnosed incidentally at the time of dating or first trimester screening ultrasound (USS). Functional cyst is the most common adnexal mass in pregnancy, similar to the nonpregnant state. A corpus luteum persisting into the second trimester accounts for 13-17% of all cystic adnexal masses. Pain due to rupture, haemorrhage into the cyst, infection, venous congestion, or torsion may be of sudden onset or of a more chronic nature.
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This question is part of the following fields:
- Obstetrics
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Question 16
Incorrect
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The most common aetiology for spontaneous abortion of a recognized first trimester gestation:
Your Answer:
Correct Answer: Chromosomal anomaly in 50-60% of gestations
Explanation:Chromosomal abnormalities are the most common cause of first trimester miscarriage and are detected in 50-85% of pregnancy tissue specimens after spontaneous miscarriage.
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This question is part of the following fields:
- Obstetrics
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Question 17
Incorrect
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A 30-year-old pregnant woman presents to the emergency department.
She is at 38 weeks gestation and has gone into labour.
On examination, her cervix is 7cm dilated.
Which of the following would be indicative of obstructed labour and the need for delivery by Caesarean section?Your Answer:
Correct Answer: A brow presentation in a nulliparous woman.
Explanation:A brow presentation in a nulliparous woman is associated with high risk of obstructed labour and the need for delivery by Caesarean section.
Brow presentation occurs when the presenting part of the fetal head is the part between the orbital ridge and anterior fontanelle.
In multiparous women, the indications differ as vaginal manipulation or spontaneous flexion to a vertex presentation or extension to a face presentation can occur after full cervical dilatation.
Early fetal heart decelerations are indicative of a mild abnormality on cardiotocograph (CTG). It does not indicate obstructive labour or need for delivery by Caesarean section.
The slow descent of the fetal head can be controlled subsequently by good uterine contractions and allow for vaginal birth.
Prolonged labour can cause maternal fever, but that in isolation is not an indication for Caesarean section.
Caput and head moulding are associated with a ‘tight fit’ of the fetal head in the pelvis, but does not contraindicate vaginal birth.
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This question is part of the following fields:
- Obstetrics
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Question 18
Incorrect
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An ultrasound in the 1st trimester of pregnancy is done for?
Your Answer:
Correct Answer: Dating of the pregnancy
Explanation:Early ultrasound improves the early detection of multiple pregnancies and improved gestational dating may result in fewer inductions for post maturity.
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This question is part of the following fields:
- Obstetrics
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Question 19
Incorrect
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A 32-year-old woman who is multigravida and with breech presentation presented to the emergency department for vaginal delivery. Upon spontaneous rupture of the membranes, bradycardia and variable deceleration was noted on the fetal heart rate monitoring.
Vaginal examination was performed and revealed cord prolapse that is still pulsating.
Which of the following is considered the most appropriate next step in managing the patient?Your Answer:
Correct Answer: Arrange for emergency caesarean delivery
Explanation:Umbilical cord prolapse (UCP) occurs when the umbilical cord exits the cervical opening before the fetal presenting part. It is a rare obstetric emergency that carries a high rate of potential fetal morbidity and mortality. Resultant compression of the cord by the descending foetus during delivery leads to fetal hypoxia and bradycardia, which can result in fetal death or permanent disability.
Certain features of pregnancy increase the risk for the development of umbilical cord prolapse by preventing appropriate engagement of the presenting part with the pelvis. These include fetal malpresentation, multiple gestations, polyhydramnios, preterm rupture of membranes, intrauterine growth restriction, preterm delivery, and fetal and cord abnormalities.
The occurrence of fetal bradycardia in the setting of ruptured membranes should prompt immediate evaluation for potential cord prolapse.
In overt prolapse, the cord is palpable as a pulsating structure in the vaginal vault. In occult prolapse, the cord is not visible or palpable ahead of the fetal presenting part. The definitive management of umbilical cord prolapse is expedient delivery; this is usually by caesarean section.
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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 woman in her 27 weeks of gestation presents to your clinic with gushing of clear yellow vaginal fluid.
Premature rupture of membrane (PPROM ) is confirmed on speculum examination, and the cervical os is closed.
Which of the following would be the most appropriate management, in addition to transfer to a tertiary center?Your Answer:
Correct Answer: Systemic corticosteroids
Explanation:Cases with spontaneous rupture of membrane before the onset of labour, prior to 37 weeks of gestation is defined as preterm premature rupture of membranes(PPROM). It complicates almost 2-4% of all singleton and 7- 20% of twin pregnancies and is commonly associated with more than 60% of all preterm births.
Management of PPROM In the absence of chorioamnionitis, depends on the gestational age. That is in cases of PPROM before 23 weeks, labor may be induced or the patient be sent home for bed rest and is asked to wait until any signs of spontaneous delivery to start. Between 23 and 34 + 0/7 weeks, the patient should be transferred to a tertiary hospital and be admitted there as it is very important to administer systemic corticosteroids, for the fetal lung to attain maturity. It is also mandatory the patient gets adequate bed rest, cervical and vaginal swabs for microscopy and culture, along with prophylactic antibiotics for prevention of chorioamnionitis.
NOTE – regardless of the gestational age, chorioamnionitis is said to be an absolute indication for the termination of pregnancy.In the given case, patient is currently in her 28th week of gestation, so she should be immediately transferred to a tertiary hospital and given systemic steroids to promote fetal lung maturation in case preterm delivery ensues.
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This question is part of the following fields:
- Obstetrics
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Question 21
Incorrect
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A 34-year-old woman, known to have had a history of mild pulmonary hypertension, was admitted to the labour ward. She is at 36 weeks of pregnancy and is keen to have her baby delivered via caesarean section.
Which of the following is the most appropriate advice to give to the patient given her situation?Your Answer:
Correct Answer: Caesarean section
Explanation:Pulmonary hypertension (PH) is an increase of blood pressure in the pulmonary artery, pulmonary vein, or pulmonary capillaries, leading to shortness of breath, dizziness, fainting, and other symptoms, all of which are exacerbated by exertion. PH in pregnancy carries a 25–56% maternal mortality rate with a mixture of intrapartum and postpartum deaths.
Current recommendations for management of PH in pregnancy include termination of pregnancy if diagnosed early, or utilizing a controlled interventional approach with early nebulized prostanoid therapy and early elective caesarean section under regional anaesthesia. Other recommended therapies for peripartum management of PH include sildenafil and nitric oxide.
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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 22-year-old female is at her second trimester of pregnancy and she presented to the medical clinic to receive human papillomavirus vaccination.
Which of the following is considered the best step to do?Your Answer:
Correct Answer: Postpone vaccination until after delivery
Explanation:Genital HPV is a common virus that is passed from one person to another through direct skin-to-skin contact during sexual activity. Most HPV types cause no symptoms and go away on their own, but some types can cause cervical cancer in women and other less common cancers — like cancers of the anus, penis, vagina, and vulva and oropharynx. Other types of HPV can cause warts in the genital areas of men and women, called genital warts.
HPV vaccination is recommended for 11 and 12 year-old girls. It is also recommended for girls and women age 13 through 26 years of age who have not yet been vaccinated or completed the vaccine series; HPV vaccine can also be given to girls beginning at age 9 years. CDC recommends 11 to 12 year olds get two doses of HPV vaccine to protect against cancers caused by HPV.
The vaccine is not recommended for pregnant women. Studies show that the HPV vaccine does not cause problems for babies born to women who were vaccinated while pregnant, but more research is still needed. A pregnant woman should not get any doses of the HPV vaccine until her pregnancy is completed.
Getting the HPV vaccine when pregnant is not a reason to consider ending a pregnancy. If a woman realizes that she got one or more shots of an HPV vaccine while pregnant, she should wait until after her pregnancy to finish any remaining HPV vaccine doses.
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This question is part of the following fields:
- Obstetrics
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Question 23
Incorrect
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A 27-year-old woman comes to you during her first trimester seeking antenatal advice as she have a history of pre-eclampsia and obesity.
On examination her blood pressure is 130/80 mmHg and BMI is 38.
Administration of which among the following can reduce her risk of pre-eclampsia during this pregnancy?Your Answer:
Correct Answer: Calcium 1000mg daily
Explanation:This patient with a previous history of pre-eclampsia and obesity is at high risk for developing pre-eclampsia.
A daily intake of 1000mg of calcium is observed to be helpful in reducing the incidence of any hypertensive disorders and preterm labour.
Vitamin A should always be avoided during pregnancy as it is fetotoxic.
All other options are incorrect.
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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 33-year-old woman was admitted to a hospital's maternity unit for labour. Her pregnancy has been unremarkable so far and she had regular antenatal visits. Meconium liquor passage was noted during the labour. Cardiotocography was done and revealed a fetal heart rate (FHR) of 149bpm. There were no noted decelerations or accelerations. The beat-to-beat variability is established at 15 bpm. Upon vaginal examination, there were no reported abnormalities.
Which of the following is considered to be the next most appropriate step in managing this patient?Your Answer:
Correct Answer: The CTG is normal and close monitoring until delivery is all required for now
Explanation:Meconium is the earliest stool of a newborn. Occasionally, newborns pass meconium during labour or delivery, resulting in a meconium-stained amniotic fluid (MSAF).
No particular cardio-tocograph pattern can be considered to have a poor prognostic value in the presence of thick MSAF and the decision to deliver and the mode of delivery should be based on the overall assessment and the stage and progress of labour. While management should be individualized, a higher Caesarean section rate in thick MSAF can be justified to ensure a better outcome for the neonate even in the presence of a normal CTG trace.
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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 24-year-old woman comes to your office at 38 weeks of gestation with a urinary dipstick result positive for leukocyte and nitrite. She is otherwise asymptomatic so you send her urine for culture and sensitivity test.
From the options below mentioned, which is the next best management for her?Your Answer:
Correct Answer: Prescribe her with Oral Cephalexin
Explanation:There is an association between 20 to 30% increase in the risk for developing pyelonephritis during later pregnancy and untreated cases of bacteriuria in pregnancy. This is due to the physiological changes occurring to urinary tract during pregnancy, it is also found that untreated bacteriuria can be associated with even preterm birth and low birth weight. Risk of symptomatic urinary tract infection (UTI) during pregnancy can be reduced by antibiotic treatment of asymptomatic bacteriuria
The most common pathogen associated with asymptomatic bacteriuria is Escherichia coli, which accounts to more than 80% of isolates and the second most frequently cultured uropathogen is Staphylococcus saprophyticus. Other Gram-positive cocci, like group B streptococci, are less common. Gram-negative bacteria such as Klebsiella, Proteus or other Enterobacteriaceae are the other organisms involved in asymptomatic bacteriuria.
Although the context patient is asymptomatic, her urine dipstick shows positive nitrite and leukocyte, suggestive of urinary tract infection, so oral antibiotics like cephalexin or nitrofurantoin are advisable. Normally a five day course of oral antibiotic will be sufficient for the treatment of uncomplicated UTI or asymptomatic bacteraemia in pregnant women. As the patient is currently at her 38 weeks of gestation nitrofurantoin is contraindicated so it is best to prescribe her with Oral Cephalexin. This is because nitrofurantoin is associated with an increased risk of neonatal jaundice and haemolytic anaemia, so should not be used close to delivery, that is after 37 weeks of gestation or sooner if early delivery is planned.
Acute pyelonephritis should be treated with Intravenous antibiotic treatment, guided by urine culture and sensitivity reports as soon a available. A course of minimum of 10-14 days with IV + oral antibiotics is recommended as treatment for pyelonephritis, along with an increased fluid intake as intravenous fluids in clinically dehydrated patients. Even though urinary alkalisers are safe in pregnancy, prescription of urinary alkalisers alone is not recommended due to its low effectiveness compared to antibiotics, also as it can result in a loss of treatment efficacy urinary alkalisers should never be used in combination with nitrofurantoin.
At any stage of pregnancy, if Streptococcus agalactiae, a group B streptococcus [GBS], is detected in urine the intrapartum prophylaxis for GBS is usually indicated.
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This question is part of the following fields:
- Obstetrics
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Question 26
Incorrect
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All of the following are considered complications related to cigarette smoking affecting mothers during pregnancy, except:
Your Answer:
Correct Answer: Less likely to die of sudden infant death syndrome
Explanation:The effects of smoking on the outcomes of pregnancy are well documented and include an increased risk of preterm premature rupture of the membranes (PPROM), preterm birth, low birth weight, placenta previa, and placental abruption. Many studies have shown that the risk of Sudden Infant Death Syndrome (SIDS) is increased by maternal smoking during pregnancy.
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This question is part of the following fields:
- Obstetrics
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Question 27
Incorrect
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A 24-year-old primigravid woman comes to the office to establish prenatal care at 14 weeks gestation. Patient has had no vaginal bleeding or cramping, no chronic medical conditions, and her only medication is a daily dose of prenatal vitamin. Patient follows a vegan diet and drinks 2 cups of coffee in the morning, also she is an avid runner who runs 5 miles most days. Patient does not use tobacco, alcohol or any other illicit drugs.
On physical examination her vital signs are normal, with a pre-pregnancy BMI of 22 kg/m2.
Transvaginal ultrasound shows a single intrauterine gestation with a heart rate of 155/min.
Among the following possible lifestyle modifications needed during pregnancy, which is the most appropriate recommendation for this patient?Your Answer:
Correct Answer: Increase caloric intake by about 350 kcal/day
Explanation:Nutrition in pregnancy
Weight gain must be:
– In patients <18.5 kg/m2, there should be an increase of 12.7 - 18 kg (28-40 lb)
– In patients 18.5 – 24.9 kg/m2 there should be an increase of 11.4 – 15.9 kg (25-35 lb)
– In patients 25 – 29.9 kg/m2 there should be an increase of 6.8 – 11.4 kg (15-25 lb)
– In patients ≥30 kg/m2 there should be an increase of 5 – 9 kg (11-20 lb)Supplementation required:
– Intake of daily prenatal vitamin
– Additional specific supplements as indicated
– Avoidance of harmful substances like drugs, alcohol, etc
– Substance abuse counseling
– Avoidance of fish with high mercury levels
– Moderating caffeine intakeFood safety:
– Avoid undercooked meat, fish & eggs
– Clean raw fruits & vegetables before consuming
– Avoid unpasteurized dairy productsNutrition in pregnancy is addressed at the initial prenatal visit based on pre-pregnancy BMI. Appropriate weight gain for a women with a normal pre-pregnancy BMI of 18.5 – 24.9 kg/m2 should be 11.4 – 15.9 kg (25-35 lb) during pregnancy. This weight gain is equivalent to the increasing caloric intake of 350 kcal/day during the second and 450 kcal/day during the third trimesters. Patients following any specific diets like veganism can continue their usual diet throughout pregnancy as long as it contains a well-balanced quantity of protein, carbohydrates and fats.
Vitamin and mineral supplementation during pregnancy is a single, daily prenatal vitamin recommended for majority of pregnant women as it helps to fulfill most of the daily vitamin and mineral supplementation requirements. In case of patients with vitamin or mineral deficiencies like iron, calcium, etc, a specific supplementation of the deficit vitamin/mineral only is required rather than multiple prenatal vitamins to avoid consuming harmful amounts of other vitamins like vitamin A. Vegans, who are at risk for some vitamin and mineral deficiencies like vitamin B12, calcium, iron, etc, secondary to lack of meat consumption, may require supplementation.
Pregnant women are counselled on avoidance of harmful substances like alcohol, drugs, etc and substances like fish with high mercury levels. Although high caffeine intake during pregnancy can be harmful, a moderate intake ie, 1 or 2 cups of coffee a day is thought to be safe.
Safe handling of food is important because some food products are found to result in congenital infection and intrauterine fetal demise. Patients are also counselled to avoid undercooked meat, fish, and eggs; to thoroughly clean raw fruits and vegetables and to avoid consumption of unpasteurized dairy products.
By maintaining a proper maternal nutrition during pregnancy, patients are provide appropriate nutrition to the fetal and thereby reducing the risk of pregnancy related complications like low birth weight, preterm delivery, etc.
Pregnant patients are counseled to avoid exercises like contact sports, downhill skiing, etc which increases the risk of abdominal trauma resulting in increased risk of placental abruption. But those patients with an uncomplicated pregnancy, who are already accustomed with long-duration, high-intensity exercise like running 5 miles/day, as in the given case, can continue with their regimen if tolerated.
Proper nutrition in pregnancy includes appropriate weight gain, supplementation of vitamins and minerals, avoidance of any harmful substances, and safe handling of food. Patients with a normal pre-pregnancy BMI should gain around 11.4-15.9 kg (25-35 lb) during pregnancy by increasing their caloric intake by 350 kcal/day in the second and 450 kcal/day in the third trimesters.
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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 32-year-old lady is two weeks postpartum and in good health. She has painful defecation that is accompanied by some new blood on the toilet paper. Which of the following diagnoses is the most likely?
Your Answer:
Correct Answer: Acute anal fissure.
Explanation:The history of acutely painful defecation associated with spotting of bright blood is very suggestive of an acute anal fissure. Typically, the patient reports severe pain during a bowel movement, with the pain lasting several minutes to hours afterward. The pain recurs with every bowel movement, and the patient commonly becomes afraid or unwilling to have a bowel movement, leading to a cycle of worsening constipation, harder stools, and more anal pain. Approximately 70% of patients note bright-red blood on the toilet paper or stool. Occasionally, a few drops may fall in the toilet bowl, but significant bleeding does not usually occur with an anal fissure.. After gently spreading the buttocks, a close check of the anal verge can typically confirm the diagnosis.
Rectal inspection is excruciatingly painful and opposed by sphincter spasm; however, if the fissure can be seen, it is not necessary to make the diagnosis at first.A perianal abscess, which presents as a sore indurated area lateral to the anus, or local trauma linked with anal intercourse or a foreign body, are two more painful anorectal disorders to rule out.
Anal fistulae do not appear in this way, but rather with perianal discharge, and the diagnosis is based on determining the external orifice of the fistula.
Although first-degree haemorrhoids bleed, they do not cause defecation to be unpleasant.
Although carcinoma of the anus or rectum can cause painful defecation, it would be exceptional in this situation.
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This question is part of the following fields:
- Obstetrics
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Question 29
Incorrect
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An 8 week pregnant female presents to the ob-gyn with bleeding from the vagina for the last two days. Bimanual examination reveals the uterus to be 8 weeks in size. On speculum examination, the cervical os is closed. How would the fetal viability be confirmed?
Your Answer:
Correct Answer: Transvaginal ultrasound
Explanation:Indication for a transvaginal ultrasound during pregnancy include:
– to monitor the heartbeat of the foetus
– look at the cervix for any changes that could lead to complications such as miscarriage or premature delivery
– examine the placenta for abnormalities
– identify the source of any abnormal bleeding
– diagnose a possible miscarriage
– confirm an early pregnancyThis is an ultrasound examination that is usually carried out vaginally at 6-10 weeks of pregnancy.
The aims of this scan are to determine the number of embryos present and whether the pregnancy is progressing normally inside the uterus.
This scan is useful for women who are experiencing pain or bleeding in the pregnancy and those who have had previous miscarriages or ectopic pregnancies.
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This question is part of the following fields:
- Obstetrics
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Question 30
Incorrect
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Which ONE among the following factors does not increase the risk for developing postpartum endometritis?
Your Answer:
Correct Answer: Advanced maternal age
Explanation:The most common clinical findings in a postpartum women with endometritis are postpartum fever, with tachycardia relative to the rise in temperature, midline lower abdominal pain and uterine tenderness from the 2nd to 10th day of postpartum.
Most common risk factors for the development of postpartum endometritis are:
– Cesarean deliveries are considered as the most important risk factor for postpartum endometritis, especially those performed after the onset of labour.
– Young maternal age.
– Multiple digital cervical examinations.
– Prolonged rupture of membranes.
– Retention of placental products.
– Prolonged labour.
– Chorioamnionitis.
Advanced maternal age is not considered as a risk factor for development of postpartum endometritis. -
This question is part of the following fields:
- Obstetrics
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