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  • Question 1 - A 29-year-old female is 24 weeks pregnant and visits the midwife for a...

    Correct

    • A 29-year-old female is 24 weeks pregnant and visits the midwife for a check-up. The foetal heart rate is detected on the Doppler scan and growth rates are appropriate for the gestational age. The mother reports to the midwife that she has been experiencing increased breathing rate lately. The midwife explains that this is a common occurrence during pregnancy.

      What other physiological alterations are typical during pregnancy?

      Your Answer: Red blood cell volume increases

      Explanation:

      During pregnancy, women are checked for anaemia twice – once at the initial booking visit (usually at 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 woman requires oral iron therapy. For the first trimester, the cut-off is less than 110 g/L, for the second and third trimesters, it is less than 105 g/L, and for the postpartum period, it is less than 100 g/L. If a woman falls below these levels, she should receive oral ferrous sulfate or ferrous fumarate. Treatment should continue for three months after iron deficiency is corrected to allow for the replenishment of iron stores.

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      • Reproductive System
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  • Question 2 - You are about to start a young woman on the progesterone-only pill. How...

    Incorrect

    • You are about to start a young woman on the progesterone-only pill. How long will she need to use this form of birth control before it becomes reliable?

      Your Answer: It becomes effective after 7 days

      Correct Answer: It becomes effective after 48 hours

      Explanation:

      Effective contraception with the progestogen-only pill can be achieved immediately if it is started on the first to the fifth day of menstruation. However, if it is started at any other time or if the patient is uncertain, it is recommended to use additional contraceptive methods like condoms or abstinence for the first 48 hours.

      Counselling for Women Considering the Progestogen-Only Pill

      Women who are considering taking the progestogen-only pill (POP) should receive counselling on various aspects of the medication. One of the most common potential adverse effects is irregular vaginal bleeding. It is important to note that the POP should be taken at the same time every day, without a pill-free break, unlike the combined oral contraceptive (COC).

      When starting the POP, immediate protection is provided if commenced up to and including day 5 of the cycle. If started later, additional contraceptive methods such as condoms should be used for the first 2 days. If switching from a COC, immediate protection is provided if continued directly from the end of a pill packet.

      In case of missed pills, if the delay is less than 3 hours, the pill should be taken as usual. If the delay is more than 3 hours, the missed pill should be taken as soon as possible, and extra precautions such as condoms should be used until pill taking has been re-established for 48 hours.

      It is important to note that antibiotics have no effect on the POP, unless the antibiotic alters the P450 enzyme system. Liver enzyme inducers may reduce the effectiveness of the POP. In case of diarrhoea and vomiting, the POP should be continued, but it should be assumed that pills have been missed.

      Finally, it is important to discuss sexually transmitted infections (STIs) with healthcare providers when considering the POP. By providing comprehensive counselling, women can make informed decisions about whether the POP is the right contraceptive choice for them.

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  • Question 3 - A 26-year-old, gravida 1 para 1, is interested in learning about the pros...

    Correct

    • A 26-year-old, gravida 1 para 1, is interested in learning about the pros and cons of breastfeeding her upcoming newborn. She has been researching the benefits of breast milk online, but stumbled upon an article that presented a negative perspective on breastfeeding. As her healthcare provider, you inform her about the numerous advantages of breast milk, but also mention that there are some potential drawbacks.

      What is one recognized disadvantage of breast milk?

      Your Answer: Inadequate levels of vitamin K

      Explanation:

      Vitamin K levels in breast milk are insufficient, but lactoferrin levels are adequate and promote iron uptake and have antibacterial properties. Breastfeeding is also linked to lower rates of breast and ovarian cancer, ear infections, and type 1 diabetes mellitus.

      Advantages and Disadvantages of Breastfeeding

      Breastfeeding has numerous advantages for both the mother and the baby. For the mother, it promotes bonding with the baby and helps with the involution of the uterus. It also provides protection against breast and ovarian cancer and is a cheap alternative to formula feeding as there is no need to sterilize bottles. However, it should not be relied upon as a contraceptive method as it is unreliable.

      Breast milk contains immunological components such as IgA, lysozyme, and lactoferrin that protect mucosal surfaces, have bacteriolytic properties, and ensure rapid absorption of iron so it is not available to bacteria. This reduces the incidence of ear, chest, and gastrointestinal infections, as well as eczema, asthma, and type 1 diabetes mellitus. Breastfeeding also reduces the incidence of sudden infant death syndrome.

      One of the advantages of breastfeeding is that the baby is in control of how much milk it takes. However, there are also disadvantages such as the transmission of drugs and infections such as HIV. Prolonged breastfeeding may also lead to nutrient inadequacies such as vitamin D and vitamin K deficiencies, as well as breast milk jaundice.

      In conclusion, while breastfeeding has numerous advantages, it is important to be aware of the potential disadvantages and to consult with a healthcare professional to ensure that both the mother and the baby are receiving adequate nutrition and care.

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  • Question 4 - A 35-year-old female patient arrives with new vaginal bleeding right after her membranes...

    Correct

    • A 35-year-old female patient arrives with new vaginal bleeding right after her membranes rupture. There are fetal heart abnormalities, such as decelerations and bradycardias. Transvaginal ultrasonography confirms the presence of fetal-origin ruptured blood vessels overlying the cervix. What could be the probable cause of her bleeding?

      Your Answer: Vasa praevia

      Explanation:

      Placental abruption occurs when the placenta separates abnormally from the uterine wall, often resulting in bleeding during the second trimester. On the other hand, placenta praevia is caused by a placenta that is located in the lower uterine segment and typically causes painless vaginal bleeding after 28 weeks, which is usually not life-threatening. Placenta accreta is often not detected until the third stage of labor, when the placenta is found to be abnormally attached and requires surgical removal, or it may cause postpartum bleeding.

      Understanding Bleeding During Pregnancy

      Bleeding during pregnancy can be a cause for concern and should be promptly evaluated by a healthcare professional. The causes of bleeding can vary depending on the trimester of pregnancy. In the first trimester, bleeding may be due to a spontaneous abortion, ectopic pregnancy, or hydatidiform mole. In the second trimester, bleeding may be due to a spontaneous abortion, hydatidiform mole, placental abruption, or bloody show. In the third trimester, bleeding may be due to placental abruption, placenta praevia, or vasa praevia.

      It is important to rule out other conditions such as sexually transmitted infections and cervical polyps. Each condition has its own unique features. For example, a spontaneous abortion may present as painless vaginal bleeding around 6-9 weeks, while placental abruption may present as constant lower abdominal pain and a tender, tense uterus with normal lie and presentation.

      It is important to note that vaginal examination should not be performed in primary care for suspected antepartum haemorrhage, as women with placenta praevia may hemorrhage.

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  • Question 5 - A 68-year-old man is undergoing surgery for a hydrocele. During the procedure, the...

    Incorrect

    • A 68-year-old man is undergoing surgery for a hydrocele. During the procedure, the surgeons will be dividing the tunica vaginalis. What is the origin of this structure?

      Your Answer: External oblique aponeurosis

      Correct Answer: Peritoneum

      Explanation:

      The peritoneum gives rise to the tunica vaginalis, which produces the fluid that occupies the hydrocele space.

      Anatomy of the Scrotum and Testes

      The scrotum is composed of skin and dartos fascia, with an arterial supply from the anterior and posterior scrotal arteries. It is also the site of lymphatic drainage to the inguinal lymph nodes. The testes are surrounded by the tunica vaginalis, a closed peritoneal sac, with the parietal layer adjacent to the internal spermatic fascia. The testicular arteries arise from the aorta, just below the renal arteries, and the pampiniform plexus drains into the testicular veins. The left testicular vein drains into the left renal vein, while the right testicular vein drains into the inferior vena cava. Lymphatic drainage occurs to the para-aortic nodes.

      The spermatic cord is formed by the vas deferens and is covered by the internal spermatic fascia, cremasteric fascia, and external spermatic fascia. The cord contains the vas deferens, testicular artery, artery of vas deferens, cremasteric artery, pampiniform plexus, sympathetic nerve fibers, genital branch of the genitofemoral nerve, and lymphatic vessels. The vas deferens transmits sperm and accessory gland secretions, while the testicular artery supplies the testis and epididymis. The cremasteric artery arises from the inferior epigastric artery, and the pampiniform plexus is a venous plexus that drains into the right or left testicular vein. The sympathetic nerve fibers lie on the arteries, while the parasympathetic fibers lie on the vas. The genital branch of the genitofemoral nerve supplies the cremaster. Lymphatic vessels drain to lumbar and para-aortic nodes.

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  • Question 6 - A 35-year-old primigravid woman visits the antenatal clinic for her 20-week scan. She...

    Incorrect

    • A 35-year-old primigravid woman visits the antenatal clinic for her 20-week scan. She is informed that the combined test results indicate a high probability of her fetus having Down's syndrome.

      What were the probable outcomes of her combined test?

      Your Answer: ↑ HCG, ↓ PAPP-A, normal amount of nuchal fluid

      Correct Answer: ↑ HCG, ↓ PAPP-A, increased amount of nuchal fluid

      Explanation:

      The presence of ↑ HCG, ↓ PAPP-A, and a thickened nuchal translucency is indicative of Down’s syndrome. The combined screening test, which includes an ultrasound scan and blood test, is used to assess the risk of the fetus having Down’s syndrome, Edwards’ syndrome, and Patau’s syndrome. However, a diagnostic test such as amniocentesis or chorionic villus sampling is required to confirm the diagnosis. Advanced maternal age is also a significant risk factor for Down’s syndrome. The answer choices ‘↑ HCG, ↑ PAPP-A, increased amount of nuchal fluid’, ‘↑ HCG, ↓ PAPP-A, normal amount of nuchal fluid’, and ‘↓ HCG, ↓ PAPP-A, decreased amount of nuchal fluid’ are incorrect as they do not match the typical indicators 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 quadruple test should be offered between 15-20 weeks for women who book later in pregnancy. Results of both tests return either a ‘lower chance’ or ‘higher chance’ result. If a woman receives a ‘higher chance’ result, she will be offered a second screening test (NIPT) or a diagnostic test. NIPT analyzes cell-free fetal DNA from placental cells in the mother’s blood and has high sensitivity and specificity for detecting chromosomal abnormalities, with private companies offering screening from 10 weeks gestation.

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  • Question 7 - A pair arrives concerned about their inability to conceive after 20 months of...

    Incorrect

    • A pair arrives concerned about their inability to conceive after 20 months of consistent unprotected intercourse. What could be a factor contributing to hypergonadotropic hypogonadism?

      Your Answer: Kallmann’s syndrome

      Correct Answer: Turner’s syndrome

      Explanation:

      Hypergonadotropic hypogonadism occurs when the gonads fail to respond to gonadotropins produced by the anterior pituitary gland. This is commonly seen in Turner’s syndrome, where gonadal dysgenesis leads to low sex steroid levels despite elevated levels of LH and FSH. On the other hand, hypogonadotropic hypogonadism can be caused by Kallmann syndrome, Sheehan’s syndrome, and anorexia nervosa. In Asherman’s syndrome, intrauterine adhesions develop, often due to surgery.

      Understanding Infertility: Initial Investigations and Key Counselling Points

      Infertility is a common issue that affects approximately 1 in 7 couples. However, it is important to note that around 84% of couples who have regular sex will conceive within 1 year, and 92% within 2 years. The causes of infertility can vary, with male factor accounting for 30%, unexplained causes accounting for 20%, ovulation failure accounting for 20%, tubal damage accounting for 15%, and other causes accounting for the remaining 15%.

      To determine the cause of infertility, basic investigations are typically conducted. These include a semen analysis and a serum progesterone test, which is done 7 days prior to the expected next period. The interpretation of the serum progesterone level is as follows: if the level is less than 16 nmol/l, it should be repeated and if it consistently remains low, referral to a specialist is necessary. If the level is between 16-30 nmol/l, it should be repeated, and if it is greater than 30 nmol/l, it indicates ovulation.

      In addition to these investigations, there are key counselling points that should be addressed. These include advising the patient to take folic acid, aiming for a BMI between 20-25, and having regular sexual intercourse every 2 to 3 days. Patients should also be advised to quit smoking and limit alcohol consumption.

      By understanding the initial investigations and key counselling points for infertility, healthcare professionals can provide their patients with the necessary information and support to help them conceive.

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  • Question 8 - A 36-year-old woman at 38 weeks gestation arrives at the Emergency Department complaining...

    Incorrect

    • A 36-year-old woman at 38 weeks gestation arrives at the Emergency Department complaining of right upper quadrant pain and nausea that has persisted for 12 hours. She has oedema in her hands and feet, and a urine dip reveals protein 2+. Her blood pressure is 160/110 mmHg, and her most recent blood tests are as follows:

      - Hb: 95 g/l
      - Platelets: 60 * 109/l
      - WBC: 5.5 * 109/l
      - Bilirubin: 88 µmol/l
      - ALP: 526 u/l
      - ALT: 110 u/l

      What is the definitive treatment for this condition?

      Your Answer:

      Correct Answer: Delivery of the fetus

      Explanation:

      The woman has HELLP syndrome, a severe form of pre-eclampsia. Management includes magnesium sulfate, dexamethasone, blood pressure control, and blood product replacement. Delivery of the fetus is the only cure.

      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, age over 40, high BMI, family history of pre-eclampsia, and multiple pregnancy. To reduce the risk of hypertensive disorders in pregnancy, women with high or moderate risk factors should take aspirin daily. Management involves emergency assessment, admission for severe cases, 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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  • Question 9 - As the medical resident on the delivery ward, you are conducting routine baby...

    Incorrect

    • As the medical resident on the delivery ward, you are conducting routine baby checks on a 10-day old boy who was delivered via emergency Caesarian section at term due to prolonged labour. During the examination, you notice that the baby appears slightly yellow, but is otherwise healthy with no signs of cardiorespiratory distress. The mother expresses concern that there may be something serious going on. What could be a potential cause of prolonged neonatal jaundice in this infant?

      Your Answer:

      Correct Answer: Breastfeeding

      Explanation:

      Breastfeeding has been linked to prolonged neonatal jaundice, which is characterized by high levels of bilirubin in an otherwise healthy breastfed newborn after the first week of life. This type of jaundice lasts longer than normal and has no other identifiable cause. It is important to consider the age at which jaundice appears in order to determine potential underlying causes, such as haemolytic disease, infections, G6PD deficiency, sepsis, polycythaemia, extrahepatic biliary atresia, congenital hypothyroidism, or breastfeeding.

      Advantages and Disadvantages of Breastfeeding

      Breastfeeding has numerous advantages for both the mother and the baby. For the mother, it promotes bonding with the baby and helps with the involution of the uterus. It also provides protection against breast and ovarian cancer and is a cheap alternative to formula feeding as there is no need to sterilize bottles. However, it should not be relied upon as a contraceptive method as it is unreliable.

      Breast milk contains immunological components such as IgA, lysozyme, and lactoferrin that protect mucosal surfaces, have bacteriolytic properties, and ensure rapid absorption of iron so it is not available to bacteria. This reduces the incidence of ear, chest, and gastrointestinal infections, as well as eczema, asthma, and type 1 diabetes mellitus. Breastfeeding also reduces the incidence of sudden infant death syndrome.

      One of the advantages of breastfeeding is that the baby is in control of how much milk it takes. However, there are also disadvantages such as the transmission of drugs and infections such as HIV. Prolonged breastfeeding may also lead to nutrient inadequacies such as vitamin D and vitamin K deficiencies, as well as breast milk jaundice.

      In conclusion, while breastfeeding has numerous advantages, it is important to be aware of the potential disadvantages and to consult with a healthcare professional to ensure that both the mother and the baby are receiving adequate nutrition and care.

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  • Question 10 - Which of the following breast tumors is most commonly linked to the risk...

    Incorrect

    • Which of the following breast tumors is most commonly linked to the risk of spreading to the opposite breast?

      Your Answer:

      Correct Answer: Invasive lobular carcinoma

      Explanation:

      A classic characteristic of invasive lobular carcinoma is the possibility of metastasis to the opposite breast.

      Understanding Lobular Carcinoma of the Breast

      Lobular carcinoma of the breast is a less common type of breast cancer that presents differently from ductal carcinoma. The mass is usually more diffuse and less obvious on imaging tests like ultrasound and mammography, which can result in inadequate treatment if the disease is understaged. For women with invasive lobular carcinoma, an MRI scan of the breast is usually recommended before breast conserving surgery is performed to ensure the safest approach.

      Lobular carcinomas are also more likely to be multifocal and metastasize to the opposite breast. In some cases, lobular carcinoma in situ may be diagnosed incidentally on core biopsies. Unlike ductal carcinoma in situ, lobular carcinoma in situ is less strongly associated with foci of invasion and is usually managed through close monitoring. Understanding the differences between lobular and ductal carcinoma can help healthcare professionals provide the best possible care for patients with breast cancer.

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  • Question 11 - A 57-year-old woman came to the breast clinic with a breast lump. During...

    Incorrect

    • A 57-year-old woman came to the breast clinic with a breast lump. During the examination, a non-tender, irregular, 3 cm lump was palpated in the left upper quadrant. The diagnosis was ductal carcinoma in situ of the left breast. The oncology team was consulted, and the patient was started on anastrozole.

      What is the mechanism of action of this medication?

      Your Answer:

      Correct Answer: Reduces peripheral oestrogen synthesis

      Explanation:

      Anastrozole and letrozole are medications that inhibit the production of oestrogen in peripheral tissues through the enzyme aromatase. These drugs are commonly used to treat breast cancer in postmenopausal women.

      Trastuzumab is a monoclonal antibody that targets HER2 receptors on cancer cells, inhibiting their growth and proliferation. It is effective in treating HER2-positive breast cancer.

      Fulvestrant is a selective oestrogen receptor degrader that breaks down oestrogen receptors without activating them, unlike tamoxifen. This leads to downregulation of the receptor.

      Goserelin is an LHRH agonist that suppresses oestrogen production by the ovaries. It is often used as adjuvant therapy in premenopausal women.

      Tamoxifen is an antagonist (and partial agonist) of the oestrogen receptor. It is particularly useful in treating oestrogen-receptor positive breast cancer, especially in patients who have not yet gone through menopause.

      Anti-oestrogen drugs are used in the management of oestrogen receptor-positive breast cancer. Selective oEstrogen Receptor Modulators (SERM) such as Tamoxifen act as an oestrogen receptor antagonist and partial agonist. However, Tamoxifen may cause adverse effects such as menstrual disturbance, hot flushes, venous thromboembolism, and endometrial cancer. On the other hand, aromatase inhibitors like Anastrozole and Letrozole reduce peripheral oestrogen synthesis, which is important in postmenopausal women. Anastrozole is used for ER +ve breast cancer in this group. However, aromatase inhibitors may cause adverse effects such as osteoporosis, hot flushes, arthralgia, myalgia, and insomnia. NICE recommends a DEXA scan when initiating a patient on aromatase inhibitors for breast cancer.

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  • Question 12 - A 25-year-old woman who is 36 weeks pregnant presents to the hospital with...

    Incorrect

    • A 25-year-old woman who is 36 weeks pregnant presents to the hospital with a blood pressure reading of 160/110 mmHg, proteinuria, headache, blurred vision, and abdominal pain. What typical feature would be anticipated in this scenario?

      Your Answer:

      Correct Answer: Haemolysis, elevated liver enzymes and low platelets

      Explanation:

      The patient’s medical history suggests pre-eclampsia, which is characterized by high blood pressure and protein in the urine after 20 weeks of pregnancy. antihypertensive medication should be used to manage blood pressure. Women with this condition may also develop HELLP syndrome, which is characterized by low platelets, elevated liver enzymes, and haemolysis (indicated by raised LDH levels). If left untreated, pre-eclampsia can progress to eclampsia, which can be prevented by administering magnesium sulphate. Delivery is the only definitive treatment for pre-eclampsia.

      Symptoms of shock include tachycardia and hypotension, while Cushing’s triad (bradycardia, hypertension, and respiratory irregularity) is indicative of raised intracranial pressure. Anaphylaxis is characterized by facial swelling, rash, and stridor, while sepsis may present with warm extremities, rigors, and a strong pulse.

      Jaundice During Pregnancy

      During pregnancy, jaundice can occur due to various reasons. One of the most common liver diseases during pregnancy is intrahepatic cholestasis of pregnancy, which affects around 1% of pregnancies and is usually seen in the third trimester. Symptoms include itching, especially in the palms and soles, and raised bilirubin levels. Ursodeoxycholic acid is used for symptomatic relief, and women are typically induced at 37 weeks. However, this condition can increase the risk of stillbirth.

      Acute fatty liver of pregnancy is a rare complication that can occur in the third trimester or immediately after delivery. Symptoms include abdominal pain, nausea, vomiting, headache, jaundice, and hypoglycemia. ALT levels are typically elevated. Supportive care is the initial management, and delivery is the definitive management once the patient is stabilized.

      Gilbert’s and Dubin-Johnson syndrome may also be exacerbated during pregnancy. Additionally, HELLP syndrome, which stands for Haemolysis, Elevated Liver enzymes, Low Platelets, can also cause jaundice during pregnancy. It is important to monitor liver function tests and seek medical attention if any symptoms of jaundice occur during pregnancy.

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  • Question 13 - A 45-year-old woman with a history of endometriosis is having a hysterectomy. During...

    Incorrect

    • A 45-year-old woman with a history of endometriosis is having a hysterectomy. During the procedure, the gynaecology registrar observes the position of the ureter in relation to the uterus. Can you describe the location of the ureter in relation to the nearby blood vessels?

      Your Answer:

      Correct Answer: Ureter passes underneath uterine artery

      Explanation:

      Long Term Complications of Vaginal Hysterectomy

      Vaginal hysterectomy with antero-posterior repair can lead to enterocoele and vaginal vault prolapse as common long term complications. While urinary retention may occur immediately after the procedure, it is not typically a chronic complication. These complications can cause discomfort and affect the quality of life of the patient. It is important for healthcare providers to monitor patients for these complications and provide appropriate treatment if necessary. Additionally, patients should be educated on the potential risks and benefits of the procedure before undergoing a vaginal hysterectomy. Proper postoperative care and follow-up can help prevent or manage these complications.

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  • Question 14 - A pair of twin sisters are delivered in the delivery room. The midwife...

    Incorrect

    • A pair of twin sisters are delivered in the delivery room. The midwife observes that they are identical. These twins separated after implantation but before day 6. What category of twins do they belong to?

      Your Answer:

      Correct Answer: Monochorionic diamniotic

      Explanation:

      The most uncommon and recent occurrence of twins is when they are conjoined, resulting in a unique cleavage.

      When twins share the same placenta, known as monochorionic twins, there is a possibility of uneven blood flow between them. This can lead to one twin receiving more blood than the other, which often requires medical intervention.

      Dizygotic twins, which come from two separate eggs, have a higher chance of occurring in certain situations. These include being between the ages of 35-40, having a family history of twins, previously giving birth to multiples, having a high BMI, smoking, and conceiving in the summer or autumn.

      Around 1 in 10 dichorionic twins are monozygotic, meaning they come from a single fertilized egg that splits into two embryos.

      Triplets can occur when two eggs are fertilized, and one of them splits into a pair of monozygotic twins.

      Twin Pregnancies: Incidence, Types, and Complications

      Twin pregnancies occur in approximately 1 out of 105 pregnancies, with the majority being dizygotic or non-identical twins. Monozygotic or identical twins, on the other hand, develop from a single ovum that has divided to form two embryos. However, monoamniotic monozygotic twins are associated with increased risks of spontaneous miscarriage, perinatal mortality rate, malformations, intrauterine growth restriction, prematurity, and twin-to-twin transfusions. The incidence of dizygotic twins is increasing due to infertility treatment, and predisposing factors include previous twins, family history, increasing maternal age, multigravida, induced ovulation, in-vitro fertilisation, and race, particularly Afro-Caribbean.

      Antenatal complications of twin pregnancies include polyhydramnios, pregnancy-induced hypertension, anaemia, and antepartum haemorrhage. Fetal complications include perinatal mortality, prematurity, light-for-date babies, and malformations, especially in monozygotic twins. Labour complications may also arise, such as postpartum haemorrhage, malpresentation, cord prolapse, and entanglement.

      Management of twin pregnancies involves rest, ultrasound for diagnosis and monthly checks, additional iron and folate, more antenatal care, and precautions during labour, such as having two obstetricians present. Most twins deliver by 38 weeks, and if longer, most are induced at 38-40 weeks. Overall, twin pregnancies require close monitoring and management to ensure the best possible outcomes for both mother and babies.

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  • Question 15 - A 16-year-old girl arrives at the Emergency Department complaining of dizziness and pain...

    Incorrect

    • A 16-year-old girl arrives at the Emergency Department complaining of dizziness and pain in her right iliac fossa. She had taken a home pregnancy test the day before, which came back positive. After a diagnosis of ectopic pregnancy, the patient's condition worsens, and she undergoes an emergency salpingectomy. What is the most common site of fertilization in the excised structure?

      Your Answer:

      Correct Answer: Ampulla

      Explanation:

      Fertilisation typically takes place in the ampulla of the fallopian tube. Salpingectomy involves removing the fallopian tube and is often performed in cases of a ruptured ectopic pregnancy. It is rare for fertilisation to occur in the uterus, which is not removed during salpingectomy. The infundibulum, located closest to the ovary, is the third most common site of fertilisation, while the isthmus, the narrowest part of the fallopian tube, is the second most common site. The myometrium refers to the muscular wall of the uterus.

      Anatomy of the Uterus

      The uterus is a female reproductive organ that is located within the pelvis and is covered by the peritoneum. It is supplied with blood by the uterine artery, which runs alongside the uterus and anastomoses with the ovarian artery. The uterus is supported by various ligaments, including the central perineal tendon, lateral cervical, round, and uterosacral ligaments. The ureter is located close to the uterus, and injuries to the ureter can occur when there is pathology in the area.

      The uterus is typically anteverted and anteflexed in most women. Its topography can be visualized through imaging techniques such as ultrasound or MRI. Understanding the anatomy of the uterus is important for diagnosing and treating various gynecological conditions.

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  • Question 16 - A 48-year-old woman visits her general practice for her regular cervical screening. During...

    Incorrect

    • A 48-year-old woman visits her general practice for her regular cervical screening. During the screening, a sample of cells is collected from the endocervix and sent to the laboratory for analysis. The initial screening reveals the detection of high-risk human papillomavirus (hrHPV).

      What is the subsequent step in the screening process for this patient?

      Your Answer:

      Correct Answer: Cytological examination of the current smear

      Explanation:

      When a cervical smear sample tests positive for high-risk HPV (hrHPV), it undergoes cytological examination to check for abnormal cellular changes that may indicate early cervical cancer. In the UK, cervical screening is offered to women between the ages of 25 and 65, with those aged 25-50 offered a smear every 3 years and those aged 50-65 offered a smear every 5 years. The aim of the screening programme is to detect cervical changes early on. HPV, a sexually transmitted virus, is present in almost all sexually active individuals, and HPV 16 or 18 is present in almost all cases of cervical cancer. If hrHPV is not detected, no further testing is required, and the patient can return to routine screening. Repeating the smear is not necessary following the presence of hrHPV, but a repeat smear may be required if the laboratory report an inadequate sample. Prior to colposcopy investigation, the sample must be positive for hrHPV and dyskaryosis.

      Understanding Cervical Cancer Screening Results

      The cervical cancer screening program has evolved significantly in recent years, with the introduction of HPV testing allowing for further risk stratification. The NHS now uses an HPV first system, where a sample is tested for high-risk strains of human papillomavirus (hrHPV) first, and cytological examination is only performed if this is positive.

      If the hrHPV test is negative, individuals can return to normal recall, unless they fall under the test of cure pathway, untreated CIN1 pathway, or require follow-up for incompletely excised cervical glandular intraepithelial neoplasia (CGIN) / stratified mucin producing intraepithelial lesion (SMILE) or cervical cancer. If the hrHPV test is positive, samples are examined cytologically, and if the cytology is abnormal, individuals will require colposcopy.

      If the cytology is normal but the hrHPV test is positive, the test is repeated at 12 months. If the repeat test is still hrHPV positive and cytology is normal, a further repeat test is done 12 months later. If the hrHPV test is negative at 24 months, individuals can return to normal recall, but if it is still positive, they will require colposcopy. If the sample is inadequate, it will need to be repeated within 3 months, and if two consecutive samples are inadequate, colposcopy will be required.

      For individuals who have previously had CIN, they should be invited for a test of cure repeat cervical sample in the community 6 months after treatment. The most common treatment for cervical intraepithelial neoplasia is large loop excision of transformation zone (LLETZ), which may be done during the initial colposcopy visit or at a later date depending on the individual clinic. Cryotherapy is an alternative technique.

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  • Question 17 - A 75-year-old man comes to the smoking cessation clinic seeking help to quit...

    Incorrect

    • A 75-year-old man comes to the smoking cessation clinic seeking help to quit smoking. He is motivated to quit after witnessing his brother's death from lung cancer.

      What health condition is the patient more susceptible to if he successfully quits smoking?

      Your Answer:

      Correct Answer: Endometrial cancer

      Explanation:

      Smoking is a protective factor against only one type of cancer, which is endometrial cancer (3), as found by a meta-analysis. However, smoking is a risk factor for all the other types of cancer mentioned.

      For bladder cancer (1), it is suggested that the aromatic amines found in cigarettes are a known carcinogen of the bladder, thus contributing to the increased risk of bladder cancer with smoking.

      Although smoking is a well-established co-factor for the development of cervical cancer (2), the mechanism by which smoking increases the risk is not known, although there are two theories.

      Smoking has been found to cause numerous DNA changes in laryngeal cancer (4), including TP53 gene mutations.

      Smoking is also theorized to cause renal cell cancer (5) as cigarette smoke induces oxidative stress and injury in the kidney, and free radicals in cigarettes can cause DNA damage that may lead to the development of cancer.

      Endometrial cancer is a type of cancer that is commonly found in women who have gone through menopause, but it can also occur in around 25% of cases before menopause. The prognosis for this type of cancer is usually good due to early detection. There are several risk factors associated with endometrial cancer, including obesity, nulliparity, early menarche, late menopause, unopposed estrogen, diabetes mellitus, tamoxifen, polycystic ovarian syndrome, and hereditary non-polyposis colorectal carcinoma. Symptoms of endometrial cancer include postmenopausal bleeding, which is usually slight and intermittent at first before becoming heavier, and changes in intermenstrual bleeding for premenopausal women. Pain is not common and typically signifies extensive disease, while vaginal discharge is unusual.

      When investigating endometrial cancer, women who are 55 years or older and present with postmenopausal bleeding should be referred using the suspected cancer pathway. The first-line investigation is trans-vaginal ultrasound, which has a high negative predictive value for a normal endometrial thickness of less than 4 mm. Hysteroscopy with endometrial biopsy is also commonly used for diagnosis. Treatment for localized disease typically involves total abdominal hysterectomy with bilateral salpingo-oophorectomy, while patients with high-risk disease may require postoperative radiotherapy. Progestogen therapy may be used in frail elderly women who are not considered suitable for surgery. It is important to note that the combined oral contraceptive pill and smoking are protective against endometrial cancer.

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  • Question 18 - A preteen girl presents with vaginal discharge and itching. She is subsequently diagnosed...

    Incorrect

    • A preteen girl presents with vaginal discharge and itching. She is subsequently diagnosed with preadolescent atrophic vaginitis which her doctor explains is because she has not yet entered adolescence. What is the underlying pathophysiology of preadolescent atrophic vaginitis?

      Your Answer:

      Correct Answer: Lack of vaginal oestrogen causing infection-prone alkaline environment

      Explanation:

      The cause of prepubertal atrophic vaginitis is a deficiency of vaginal estrogen, making any response suggesting otherwise incorrect. This leads to an environment that is prone to infection due to its alkalinity, as estrogen boosts lactobacilli levels, which aid in the conversion of glucose to lactic acid. It is critical to consider this diagnosis when a prepubertal female patient complains of vaginal itching and discharge.

      Understanding Atrophic Vaginitis

      Atrophic vaginitis is a condition that commonly affects women who have gone through menopause. Its symptoms include vaginal dryness, painful intercourse, and occasional spotting. Upon examination, the vagina may appear dry and pale. The condition can be treated with vaginal lubricants and moisturizers. However, if these remedies do not provide relief, a topical estrogen cream may be prescribed.

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  • Question 19 - A woman in her mid-thirties, who is HIV positive, seeks advice on starting...

    Incorrect

    • A woman in her mid-thirties, who is HIV positive, seeks advice on starting a family. She expresses her desire to become pregnant but is concerned about the risk of transmitting the virus to her baby. What guidance should be provided to her?

      Your Answer:

      Correct Answer: With treatment and correct advice, the rate of vertical transmission of HIV is 2%

      Explanation:

      HIV and Pregnancy: Guidelines for Minimizing Vertical Transmission

      With the increasing prevalence of HIV infection among heterosexual individuals, there has been a rise in the number of HIV-positive women giving birth in the UK. In London, the incidence may be as high as 0.4% of pregnant women. The goal of treating HIV-positive women during pregnancy is to minimize harm to both the mother and fetus and to reduce the chance of vertical transmission.

      To achieve this goal, various factors must be considered. Guidelines on this subject are regularly updated, and the most recent guidelines can be found using the links provided. Factors that can reduce vertical transmission from 25-30% to 2% include maternal antiretroviral therapy, mode of delivery (caesarean section), neonatal antiretroviral therapy, and infant feeding (bottle feeding).

      To ensure that HIV-positive women receive appropriate care during pregnancy, NICE guidelines recommend offering HIV screening to all pregnant women. Additionally, all pregnant women should be offered antiretroviral therapy, regardless of whether they were taking it previously.

      The mode of delivery is also an important consideration. Vaginal delivery is recommended if the viral load is less than 50 copies/ml at 36 weeks. Otherwise, a caesarean section is recommended, and a zidovudine infusion should be started four hours before beginning the procedure.

      Neonatal antiretroviral therapy is also crucial in minimizing vertical transmission. Zidovudine is usually administered orally to the neonate if the maternal viral load is less than 50 copies/ml. Otherwise, triple ART should be used, and therapy should be continued for 4-6 weeks.

      Finally, infant feeding is another important factor to consider. In the UK, all women should be advised not to breastfeed to minimize the risk of vertical transmission. By following these guidelines, healthcare providers can help minimize the risk of vertical transmission and ensure that HIV-positive women receive appropriate care during pregnancy.

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  • Question 20 - A 7-month-old infant is presented to the surgical clinic due to undescended testicles....

    Incorrect

    • A 7-month-old infant is presented to the surgical clinic due to undescended testicles. What is the primary structure that determines the descent route of the testis?

      Your Answer:

      Correct Answer: Gubernaculum

      Explanation:

      The gubernaculum is a strip of mesenchymal tissue that links the testis to the lower part of the scrotum. In the initial stages of embryonic development, the gubernaculum is lengthy and the testis are situated on the back abdominal wall. As the fetus grows, the body expands in proportion to the gubernaculum, causing the testis to descend.

      The Development of Testicles in Foetal Life

      During foetal life, the testicles are situated within the abdominal cavity. They are initially found on the posterior abdominal wall, at the same level as the upper lumbar vertebrae. The gubernaculum testis, which is attached to the inferior aspect of the testis, extends downwards to the inguinal region and through the canal to the superficial skin. Both the testis and the gubernaculum are located outside the peritoneum.

      As the foetus grows, the gubernaculum becomes progressively shorter. It carries the peritoneum of the anterior abdominal wall, known as the processus vaginalis. The testis is guided by the gubernaculum down the posterior abdominal wall and the back of the processus vaginalis into the scrotum. By the third month of foetal life, the testes are located in the iliac fossae, and by the seventh month, they lie at the level of the deep inguinal ring.

      After birth, the processus vaginalis usually closes, but it may persist and become the site of indirect hernias. Partial closure may also lead to the development of cysts on the cord.

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  • Question 21 - A 29-year-old woman visits the antenatal clinic for her week 28 anti-D injection...

    Incorrect

    • A 29-year-old woman visits the antenatal clinic for her week 28 anti-D injection during her first pregnancy. Blood tests were conducted, and the following outcomes were obtained:

      pH 7.47 (7.35 - 7.45)
      PO2 10 kPa (11 - 15)
      PCO2 4.0 kPa (4.6 - 6.4)
      Bicarbonate 20 mmol/L (22 - 29)

      What pregnancy-related physiological alteration is accountable for these findings?

      Your Answer:

      Correct Answer: Increase in pulmonary ventilation and tidal volume

      Explanation:

      A haemoglobin level of 105 g/L is considered normal at 28 weeks of pregnancy, with the non-pregnant reference range being 115-165 g/L.

      During pregnancy, a woman’s body undergoes various physiological changes. The cardiovascular system experiences an increase in stroke volume, heart rate, and cardiac output, while systolic blood pressure remains unchanged and diastolic blood pressure decreases in the first and second trimesters before returning to normal levels by term. The enlarged uterus may cause issues with venous return, leading to ankle swelling, supine hypotension, and varicose veins.

      The respiratory system sees an increase in pulmonary ventilation and tidal volume, with oxygen requirements only increasing by 20%. This can lead to a sense of dyspnea due to over-breathing and a fall in pCO2. The basal metabolic rate also increases, potentially due to increased thyroxine and adrenocortical hormones.

      Maternal blood volume increases by 30%, with red blood cells increasing by 20% and plasma increasing by 50%, leading to a decrease in hemoglobin levels. Coagulant activity increases slightly, while fibrinolytic activity decreases. Platelet count falls, and white blood cell count and erythrocyte sedimentation rate rise.

      The urinary system experiences an increase in blood flow and glomerular filtration rate, with elevated sex steroid levels leading to increased salt and water reabsorption and urinary protein losses. Trace glycosuria may also occur.

      Calcium requirements increase during pregnancy, with gut absorption increasing substantially due to increased 1,25 dihydroxy vitamin D. Serum levels of calcium and phosphate may fall, but ionized calcium levels remain stable. The liver experiences an increase in alkaline phosphatase and a decrease in albumin levels.

      The uterus undergoes significant changes, increasing in weight from 100g to 1100g and transitioning from hyperplasia to hypertrophy. Cervical ectropion and discharge may increase, and Braxton-Hicks contractions may occur in late pregnancy. Retroversion may lead to retention in the first trimester but usually self-corrects.

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  • Question 22 - A 26-year-old woman visits her doctor, 9 weeks postpartum, with complaints of pain...

    Incorrect

    • A 26-year-old woman visits her doctor, 9 weeks postpartum, with complaints of pain in her left breast while breastfeeding. She is concerned about continuing to feed her baby. During the examination, the doctor observes a 2 cm x 2 cm reddish lesion on the left breast, which is tender and warm to the touch. The right breast appears normal. As the patient has a temperature of 38.2ºC, the doctor prescribes antibiotics and advises her to continue breastfeeding. What is the primary location for lymphatic drainage in the affected area?

      Your Answer:

      Correct Answer: Ipsilateral axillary nodes

      Explanation:

      The primary location for lymphatic drainage of the breast is the ipsilateral axillary nodes. While there have been cases of breast cancer spreading to contralateral axillary nodes, these nodes do not represent the main site of lymphatic drainage for the opposite breast. The parasternal nodes receive some lymphatic drainage, but they are not the primary site for breast drainage. The supraclavicular nodes may occasionally receive drainage from the breast, but this is not significant. The infraclavicular nodes, despite their proximity, do not drain the breast; they instead receive drainage from the forearm and hand.

      The breast is situated on a layer of pectoral fascia and is surrounded by the pectoralis major, serratus anterior, and external oblique muscles. The nerve supply to the breast comes from branches of intercostal nerves from T4-T6, while the arterial supply comes from the internal mammary (thoracic) artery, external mammary artery (laterally), anterior intercostal arteries, and thoraco-acromial artery. The breast’s venous drainage is through a superficial venous plexus to subclavian, axillary, and intercostal veins. Lymphatic drainage occurs through the axillary nodes, internal mammary chain, and other lymphatic sites such as deep cervical and supraclavicular fossa (later in disease).

      The preparation for lactation involves the hormones oestrogen, progesterone, and human placental lactogen. Oestrogen promotes duct development in high concentrations, while high levels of progesterone stimulate the formation of lobules. Human placental lactogen prepares the mammary glands for lactation. The two hormones involved in stimulating lactation are prolactin and oxytocin. Prolactin causes milk secretion, while oxytocin causes contraction of the myoepithelial cells surrounding the mammary alveoli to result in milk ejection from the breast. Suckling of the baby stimulates the mechanoreceptors in the nipple, resulting in the release of both prolactin and oxytocin from the pituitary gland (anterior and posterior parts respectively).

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  • Question 23 - A 33-year-old woman is 28 weeks pregnant and has been diagnosed with gestational...

    Incorrect

    • A 33-year-old woman is 28 weeks pregnant and has been diagnosed with gestational diabetes following an oral glucose tolerance test. What are the possible complications associated with this condition?

      Your Answer:

      Correct Answer: Macrosomia, shoulder dystocia, polyhydramnios

      Explanation:

      During pregnancy, the development of carbohydrate intolerance is referred to as gestational diabetes mellitus. To diagnose this condition, an OGTT is typically performed at 28 weeks, although it may be done earlier for those at higher risk (such as those of Asian or Afro-Caribbean ethnicity, with a BMI over 30, a history of stillbirth, or family members with diabetes). Diabetes during pregnancy can increase the likelihood of various complications, including macrosomia, polyhydramnios, shoulder dystocia, congenital heart defects, neural tube defects, and neonatal hypoglycemia. Ebstein’s anomaly of the heart can occur as a result of lithium use during pregnancy, while prolonged rupture of membranes during pregnancy can lead to neonatal infection.

      Gestational diabetes is a common medical disorder that affects around 4% of pregnancies. It can develop during pregnancy or be a pre-existing condition. According to NICE, 87.5% of cases are gestational diabetes, 7.5% are type 1 diabetes, and 5% are type 2 diabetes. Risk factors for gestational diabetes include a BMI of > 30 kg/m², previous gestational diabetes, a family history of diabetes, and family origin with a high prevalence of diabetes. Screening for gestational diabetes involves an oral glucose tolerance test (OGTT), which should be performed as soon as possible after booking and at 24-28 weeks if the first test is normal.

      To diagnose gestational diabetes, NICE recommends using the following thresholds: fasting glucose is >= 5.6 mmol/L or 2-hour glucose is >= 7.8 mmol/L. Newly diagnosed women should be seen in a joint diabetes and antenatal clinic within a week and taught about self-monitoring of blood glucose. Advice about diet and exercise should be given, and if glucose targets are not met within 1-2 weeks of altering diet/exercise, metformin should be started. If glucose targets are still not met, insulin should be added to the treatment plan.

      For women with pre-existing diabetes, weight loss is recommended for those with a BMI of > 27 kg/m^2. Oral hypoglycaemic agents, apart from metformin, should be stopped, and insulin should be commenced. Folic acid 5 mg/day should be taken from pre-conception to 12 weeks gestation, and a detailed anomaly scan at 20 weeks, including four-chamber view of the heart and outflow tracts, should be performed. Tight glycaemic control reduces complication rates, and retinopathy should be treated as it can worsen during pregnancy.

      Targets for self-monitoring of pregnant women with diabetes include a fasting glucose level of 5.3 mmol/l and a 1-hour or 2-hour glucose level after meals of 7.8 mmol/l or 6.4 mmol/l, respectively. It is important to manage gestational diabetes and pre-existing diabetes during pregnancy to reduce the risk of complications for both the mother and baby.

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  • Question 24 - As a junior doctor at a reproductive medicine clinic, a patient inquires about...

    Incorrect

    • As a junior doctor at a reproductive medicine clinic, a patient inquires about the presence of eggs in a woman's ovaries at birth. Can you provide a brief explanation of oogenesis? Additionally, at what point during oogenesis do cells develop in the uterus?

      Your Answer:

      Correct Answer: Prophase I

      Explanation:

      Metaphase II is not the correct answer as it is the stage where secondary oocytes are arrested until fertilization occurs.

      Metaphase I is not the correct answer as the cell cycle does not halt at this stage.

      Prophase I is the correct answer as it is the stage during which primary oocytes develop in the uterus.

      Prophase II is not the correct answer as the cell cycle does not pause at this stage, and it occurs during meiosis II, which takes place after puberty and not in the uterus.

      Oogenesis: The Process of Egg Cell Formation

      During the process of oogenesis, cells undergo two rounds of meiosis. The first round, known as meiosis I, occurs while the cells are still primary oocytes. Meiosis II occurs after the primary oocytes have developed into secondary oocytes.

      Meiosis I begins before birth and is halted at prophase I, which lasts for many years. During each menstrual cycle, a few primary oocytes re-enter the cell cycle and continue to develop through meiosis I to become secondary oocytes. These secondary oocytes then begin meiosis II but are held in metaphase II until fertilization occurs.

      Overall, oogenesis is a complex process that involves the development and maturation of egg cells. The two rounds of meiosis ensure that the resulting egg cells have the correct number of chromosomes and are ready for fertilization.

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  • Question 25 - A 29-year-old man has suffered an irreparable injury to his left testicle. The...

    Incorrect

    • A 29-year-old man has suffered an irreparable injury to his left testicle. The surgeon opts for an orchidectomy and severs the artery supplying the left testicle. What is the origin of this vessel?

      Your Answer:

      Correct Answer: Abdominal aorta

      Explanation:

      The abdominal aorta gives rise to the testicular artery.

      Anatomy of the Scrotum and Testes

      The scrotum is composed of skin and dartos fascia, with an arterial supply from the anterior and posterior scrotal arteries. It is also the site of lymphatic drainage to the inguinal lymph nodes. The testes are surrounded by the tunica vaginalis, a closed peritoneal sac, with the parietal layer adjacent to the internal spermatic fascia. The testicular arteries arise from the aorta, just below the renal arteries, and the pampiniform plexus drains into the testicular veins. The left testicular vein drains into the left renal vein, while the right testicular vein drains into the inferior vena cava. Lymphatic drainage occurs to the para-aortic nodes.

      The spermatic cord is formed by the vas deferens and is covered by the internal spermatic fascia, cremasteric fascia, and external spermatic fascia. The cord contains the vas deferens, testicular artery, artery of vas deferens, cremasteric artery, pampiniform plexus, sympathetic nerve fibers, genital branch of the genitofemoral nerve, and lymphatic vessels. The vas deferens transmits sperm and accessory gland secretions, while the testicular artery supplies the testis and epididymis. The cremasteric artery arises from the inferior epigastric artery, and the pampiniform plexus is a venous plexus that drains into the right or left testicular vein. The sympathetic nerve fibers lie on the arteries, while the parasympathetic fibers lie on the vas. The genital branch of the genitofemoral nerve supplies the cremaster. Lymphatic vessels drain to lumbar and para-aortic nodes.

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  • Question 26 - A 30-year-old male presents with a recurrent history of chest infections. During the...

    Incorrect

    • A 30-year-old male presents with a recurrent history of chest infections. During the examination, it is observed that there is an absence of palpable vas deferens, but both testes are present in the scrotum. What is the probable underlying disease association?

      Your Answer:

      Correct Answer: Cystic fibrosis

      Explanation:

      Understanding Absence of the Vas Deferens

      Absence of the vas deferens is a condition that can occur either unilaterally or bilaterally. In 40% of cases, the cause is due to mutations in the CFTR gene, which is associated with cystic fibrosis. However, in some non-CF cases, the absence of the vas deferens is due to unilateral renal agenesis. Despite this condition, assisted conception may still be possible through sperm harvesting.

      It is important to understand the underlying causes of absence of the vas deferens, as it can impact fertility and the ability to conceive. While the condition may be associated with cystic fibrosis, it can also occur independently. However, with advancements in assisted reproductive technologies, individuals with this condition may still have options for starting a family. By seeking medical advice and exploring available options, individuals can make informed decisions about their reproductive health.

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  • Question 27 - A G2P1 woman visits her obstetrician for a routine antenatal check-up. She is...

    Incorrect

    • A G2P1 woman visits her obstetrician for a routine antenatal check-up. She is currently 32 weeks pregnant and has had an uneventful pregnancy so far. She denies any symptoms of fatigue, easy bleeding, or bruising.

      During the check-up, her physician orders routine blood tests, and her complete blood count results are as follows:

      - Hemoglobin (Hb): 98 g/L (Male: 135-180, Female: 115-160)
      - Platelets: 110 * 109/L (150-400)
      - White blood cells (WBC): 13 * 109/L (4.0-11.0)

      What is the probable diagnosis?

      Your Answer:

      Correct Answer: Physiological changes of pregnancy

      Explanation:

      During pregnancy, a woman’s body undergoes various physiological changes. The cardiovascular system experiences an increase in stroke volume, heart rate, and cardiac output, while systolic blood pressure remains unchanged and diastolic blood pressure decreases in the first and second trimesters before returning to normal levels by term. The enlarged uterus may cause issues with venous return, leading to ankle swelling, supine hypotension, and varicose veins.

      The respiratory system sees an increase in pulmonary ventilation and tidal volume, with oxygen requirements only increasing by 20%. This can lead to a sense of dyspnea due to over-breathing and a fall in pCO2. The basal metabolic rate also increases, potentially due to increased thyroxine and adrenocortical hormones.

      Maternal blood volume increases by 30%, with red blood cells increasing by 20% and plasma increasing by 50%, leading to a decrease in hemoglobin levels. Coagulant activity increases slightly, while fibrinolytic activity decreases. Platelet count falls, and white blood cell count and erythrocyte sedimentation rate rise.

      The urinary system experiences an increase in blood flow and glomerular filtration rate, with elevated sex steroid levels leading to increased salt and water reabsorption and urinary protein losses. Trace glycosuria may also occur.

      Calcium requirements increase during pregnancy, with gut absorption increasing substantially due to increased 1,25 dihydroxy vitamin D. Serum levels of calcium and phosphate may fall, but ionized calcium levels remain stable. The liver experiences an increase in alkaline phosphatase and a decrease in albumin levels.

      The uterus undergoes significant changes, increasing in weight from 100g to 1100g and transitioning from hyperplasia to hypertrophy. Cervical ectropion and discharge may increase, and Braxton-Hicks contractions may occur in late pregnancy. Retroversion may lead to retention in the first trimester but usually self-corrects.

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  • Question 28 - A gravida 3, para 0 (G3P0) woman at 8 weeks gestation presents to...

    Incorrect

    • A gravida 3, para 0 (G3P0) woman at 8 weeks gestation presents to the clinic with a 2-week history of vomiting. She reports that she has been unable to keep anything down for the last 4 days and now feels extremely tired. She also reports 8 kg of weight loss since the start of her pregnancy, stating that she now weighs 57kg.

      During the examination, the patient's eyes are sunken, and her mucous membranes appear dry.

      A urine dip shows marked ketosis, but is otherwise unremarkable.

      What is a risk factor for the most likely diagnosis?

      Your Answer:

      Correct Answer: Trophoblastic disease

      Explanation:

      Hyperemesis gravidarum is a severe form of nausea and vomiting that affects around 1% of pregnancies. It is usually experienced between 8 and 12 weeks of pregnancy but can persist up to 20 weeks. The condition is thought to be related to raised beta hCG levels and is more common in women who are obese, nulliparous, or have multiple pregnancies, trophoblastic disease, or hyperthyroidism. Smoking is associated with a decreased incidence of hyperemesis.

      The Royal College of Obstetricians and Gynaecologists recommend that a woman must have a 5% pre-pregnancy weight loss, dehydration, and electrolyte imbalance before a diagnosis of hyperemesis gravidarum can be made. Validated scoring systems such as the Pregnancy-Unique Quantification of Emesis (PUQE) score can be used to classify the severity of NVP.

      Management of hyperemesis gravidarum involves using antihistamines as a first-line treatment, with oral cyclizine or oral promethazine being recommended by Clinical Knowledge Summaries. Oral prochlorperazine is an alternative, while ondansetron and metoclopramide may be used as second-line treatments. Ginger and P6 (wrist) acupressure can be tried, but there is little evidence of benefit. Admission may be needed for IV hydration.

      Complications of hyperemesis gravidarum can include Wernicke’s encephalopathy, Mallory-Weiss tear, central pontine myelinolysis, acute tubular necrosis, and fetal growth restriction, pre-term birth, and cleft lip/palate (if ondansetron is used during the first trimester). The NICE Clinical Knowledge Summaries recommend considering admission if a woman is unable to keep down liquids or oral antiemetics, has ketonuria and/or weight loss (greater than 5% of body weight), or has a confirmed or suspected comorbidity that may be adversely affected by nausea and vomiting.

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  • Question 29 - A 35-year-old woman visits her doctor suspecting that she might be pregnant as...

    Incorrect

    • A 35-year-old woman visits her doctor suspecting that she might be pregnant as she has missed her last two menstrual cycles. What hormone is expected to be present in the highest amount if her suspicion is true?

      Your Answer:

      Correct Answer: Human Chorionic Gonadotropin

      Explanation:

      It is important to be aware of the role that hormones play during pregnancy.

      Endocrine Changes During Pregnancy

      During pregnancy, there are several physiological changes that occur in the body, including endocrine changes. Progesterone, which is produced by the fallopian tubes during the first two weeks of pregnancy, stimulates the secretion of nutrients required by the zygote/blastocyst. At six weeks, the placenta takes over the production of progesterone, which inhibits uterine contractions by decreasing sensitivity to oxytocin and inhibiting the production of prostaglandins. Progesterone also stimulates the development of lobules and alveoli.

      Oestrogen, specifically oestriol, is another major hormone produced during pregnancy. It stimulates the growth of the myometrium and the ductal system of the breasts. Prolactin, which increases during pregnancy, initiates and maintains milk secretion of the mammary gland. It is essential for the expression of the mammotropic effects of oestrogen and progesterone. However, oestrogen and progesterone directly antagonize the stimulating effects of prolactin on milk synthesis.

      Human chorionic gonadotropin (hCG) is secreted by the syncitiotrophoblast and can be detected within nine days of pregnancy. It mimics LH, rescuing the corpus luteum from degenerating and ensuring early oestrogen and progesterone secretion. It also stimulates the production of relaxin and may inhibit contractions induced by oxytocin. Other hormones produced during pregnancy include relaxin, which suppresses myometrial contractions and relaxes the pelvic ligaments and pubic symphysis, and human placental lactogen (hPL), which has lactogenic actions and enhances protein metabolism while antagonizing insulin.

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  • Question 30 - The emergency buzzer is activated for a 32-year-old woman in labour. Despite gentle...

    Incorrect

    • The emergency buzzer is activated for a 32-year-old woman in labour. Despite gentle traction, the midwife is unable to deliver the foetal shoulders after the head is delivered during a vaginal cephalic delivery. What is the most probable risk factor for this labour complication?

      Your Answer:

      Correct Answer: Foetal macrosomia

      Explanation:

      Shoulder dystocia is the labour complication discussed in this case, and it is more likely to occur in cases of foetal macrosomia. This is because larger babies have a greater shoulder diameter, making it more difficult for the shoulders to pass through the pelvic outlet.

      Maternal pre-eclampsia is a risk factor for small for gestational age (SGA) pregnancies, but it is not directly linked to shoulder dystocia.

      Obstetric cholestasis is a liver disorder that can occur during pregnancy, but it does not increase the risk of shoulder dystocia.

      While a previous caesarean section may increase the likelihood of placenta praevia, placenta accreta, or uterine rupture, it is not a direct risk factor for shoulder dystocia.

      A previous post-term delivery may increase the likelihood of future post-term deliveries, but it does not directly increase the risk of 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 baby.

      There are several risk factors that increase the likelihood of shoulder dystocia, including fetal macrosomia (large baby), high maternal body mass index, diabetes mellitus, and prolonged labor.

      If shoulder dystocia is identified, it is important to call for senior medical assistance immediately. The McRoberts’ maneuver is often used to help deliver the baby. This 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 harm to the mother. Oxytocin administration is not effective in treating shoulder dystocia.

      Complications of shoulder dystocia can include postpartum hemorrhage and perineal tears for the mother, and brachial plexus injury or neonatal death for the baby. It is important to manage shoulder dystocia promptly and effectively to minimize these risks.

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