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Question 1
Incorrect
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A 28-year-old woman who is at the 18th week of gestation presented to the medical clinic due to a vaginal discharge. Upon history taking, it was revealed that she had a history of preterm labour at 24 weeks of gestation during her last pregnancy. Upon examination, the presence of a clear fluid coming out of the vagina was noted. Which of the following is considered to be the best in predicting pre-term labour?
Your Answer: Fibronectin test
Correct Answer: Cervical length of 15mm
Explanation:Preterm birth is the leading cause of neonatal morbidity and mortality not attributable to congenital anomalies or aneuploidy. It has been shown that a shortened cervix is a powerful indicator of preterm births in women with singleton and twin gestations – the shorter the cervical length, the higher the risk of spontaneous preterm birth. Ultrasound measurements of the cervix are a more accurate way of determining cervical length (CL) than using a digital method.
25 mm has been chosen as the ‘cut off’ at above which a cervix can be regarded as normal, and below which can be called short. A cervix that is less than 25 mm may be indicative of preterm birth.
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This question is part of the following fields:
- Obstetrics
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Question 2
Incorrect
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A 30-year-old primigravida woman presented to the clinic for her first antenatal check-up. Upon interview, it was noted that she was taking folic acid along with some other nutritional supplements as medication. All of the following are considered correct regarding neural tube defects and folate before and during pregnancy, except:
Your Answer: Folate intake should be increased at least one month before and three months after conception
Correct Answer: Prevalence of neural tube defects among non-indigenous population is almost double than that in Aboriginal and Torres Strait Islander babies
Explanation:Neural tube defects (NTDs) are common complex congenital malformations resulting from failure of the neural tube closure during embryogenesis. It is established that folic acid supplementation decreases the prevalence of NTDs, which has led to national public health policies regarding folic acid.
Neural tube defects (NTD) were 43% more common in Indigenous than in non-Indigenous infants in Western Australia in the 1980s, and there has been a fall in NTD overall in Western Australia since promotion of folate and voluntary fortification of food has occurred.
Women should take 5 mg/d of folic acid for the 2 months before conception and during the first trimester.
Women planning pregnancy might be exposed to medications with known antifolate activities affecting different parts of the folic acid metabolic cascade. A relatively large number of epidemiologic studies have shown an increased risk of NTDs among babies exposed in early gestation to antiepileptic drugs (carbamazepine, valproate, barbiturates), sulphonamides, or methotrexate. Hence, whenever women use these medications, or have used them near conception, they should take 5 mg/d of folic acid until the end of the first trimester of pregnancy.
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This question is part of the following fields:
- Obstetrics
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Question 3
Correct
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A 25-year-old woman at her 26 weeks of gestation visits your office after she has noticed intermittent leakage of watery liquor per vagina for the past eight hours, especially after straining, coughing or sneezing. Speculum vaginal exam reveals clear fluid in the posterior vaginal fornix, with flow of liquid through the cervical os. Further evaluation establishes preterm premature rupture of the membranes (PPROM) as the diagnosis. No uterine contraction is felt and there is a tertiary hospital 50 km away. Which of the following is the most appropriate next step in management of this patient?
Your Answer: Administration of corticosteroids
Explanation:The case above gives a classic presentation of preterm premature rupture of membranes(PPROM). In term or near term women rupture of membrane harbingers labor, so if ROM does not end up in established labor in 4 hours, is called as premature ROM (PROM). In other words, PROM is defined as ROM before the onset of labor and if it occurs before 37 weeks, the preferred term is PPROM. In both these scenarios treatment approach will be different.
A sudden gush of watery fluid per vagina, continuous or intermittent leakage of fluid, a sensation of wetness within the vagina or perineum are the classic presentation of rupture of the membranes(ROM), regardless of the gestational age. Pathognomonic symptoms symptoms of ROM are presence of liquor flowing from the cervical os or pooling in the posterior vaginal fornix.
PPROM is associated with many risk factors and some of them are as follows:
– Preterm labor
– Cord prolapse
– Placental abruption
– Chorioamnionitis
– Fetal pulmonary hypoplasia and other features of prematurity
– Limb positioning defects
– Perinatal mortality
Once the diagnosis is confirmed the following measures should be considered in the management plan:
a) Maternal corticosteroids
Adverse perinatal outcomes like respiratory distress syndrome, intraventricular hemorrhage, and necrotizing enterocolitis can be effectively reduced using corticosteroids. The duration of using neonatal respiratory support, in case of respiratory distress, can be significantly reduced by the administration of corticosteroids. If preterm labor is a concern in cases were gestational age is between 23•0d and 34•6d weeks or if preterm birth is planned or expected within the next 7 days corticosteroids are indicated.
Recommended regimens to the woman are IM betamethasone in two doses of 11.4 mg, given 24 hours apart and if betamethasone is unavailable, IM dexamethasone given 24 hours apart in two doses of 12 mg.
A single repeat dose of corticosteroid given seven days or more after the first dose is suggestive in cases were the gestational age is less than 32• 6d, if the woman is still considered to be at risk of preterm labor, up to 3 repeated doses can be considered.
Another option is Tocolysis using nifedipine and is indicated if the woman is in labor. This helps in cessation of labor for at least 48 hours, providing a window for corticosteroid to establish its effects. Tocolysis is not indicated in cases with absence of uterine contractions suggestive of labor.
It is appropriate to transfer this woman to a tertiary hospital after administering the first doses of corticosteroid and antibiotics. This ensures optimal neonatal care in case of premature delivery.
As the patient needs investigations and fetal monitoring along with close observation for development of any signs of infection and preterm labor, it is not appropriate to discharge this patient on oral antibiotics
Admitting to a primary care center without neonatal ICU (NICU) does no good to the outcome of this patient. -
This question is part of the following fields:
- Obstetrics
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Question 4
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: Gamma - Glutamyl transferase (GGT)
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 5
Incorrect
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A 31-year-old woman presented with abdominal pain and vaginal bleeding of around 600 ml at 40 weeks of gestation. On examination, her vital signs were found to be stable, with a tender abdomen and there were no fetal heart sounds heard on auscultation. Which among the following is considered the most appropriate next step?
Your Answer: Ultrasound of uterus
Correct Answer: Amniotomy
Explanation:Placental abruption is commonly defined as the premature separation of the placenta, which complicates approximately 1% of births. During the second half of pregnancy abruption is considered an important cause for vaginal bleeding and is mostly associated with significant perinatal mortality and morbidity.
Clinical presentation of abruption varies from asymptomatic cases to those complicated with fetal death and severe maternal morbidity. Classical symptoms of placental abruption are vaginal bleeding and abdominal pain, but at times severe cases might occur with neither or just of one of these signs. In some cases the amount of vaginal bleeding may not correlates with the degree of abruption, this is because the severity of symptoms is always depend on the location of abruption, whether it is revealed or concealed and the degree of abruption.
Diagnosis of abruption is clinical and the condition should be suspected in every women who presents with vaginal bleeding, abdominal pain or both, with a history of trauma, and in those women who present with an unexplained preterm labor. All causes of abdominal pain and bleeding, like placenta previa, appendicitis, urinary tract infections, preterm labor, fibroid degeneration, ovarian pathology and muscular pain are considered as differential diagnosis of abruption.In the given case patient has developed signs and symptoms of placental abruption, like severe vaginal bleeding with abdominal pain, whose management depends on its presentation, gestational age and the degree of maternal and fetal compromise. As the presentation is widely variable, it is important to individualize the management on a case-by-case basis. More aggressive management is desirable in cases of severe abruption, which is not appropriate in milder cases of abruption. In cases of severe abruption with fetal death, as seen in the given case, it is reasonable to allow the patient to have a vaginal delivery,regardless of gestational age, as long as the mother is stable and there are no other contraindications.
The uterus is contracting vigorously, and labor occurs rapidly and progresses, so amniotomy is mostly sufficient to speed up delivery. There is a significant risk for coagulopathy and hypovolemic shock so intravenous access should be established with aggressive replacement of blood and coagulation factors. Meticulous attention should be paid to the amount of blood loss; general investigations like complete blood count, coagulation studies and type and crossmatch should be done and the blood bank should be informed of the potential for coagulopathy. A Foley catheter should be placed and an hourly urine output should be monitored.
It is prudent to involve an anesthesiologist in the patient’s care, because if labor does not progress rapidly as in cases like feto-pelvic disproportion, fetal malpresentation, or a prior classical cesarean delivery, it will be necessary to conduct a cesarean delivery to avoid worsening of the coagulopathy.
Bleeding from surgical incisions in the presence of DIC may be difficult to control, and it is equally important to stabilize the patient and to correct any coagulation derangement occuring during surgery. The patient should be monitored closely after delivery, with particular attention paid to her vital signs, amount of blood loss, and urine output. In addition, the uterus should be observed closely to ensure that it remains contracted and is not increasing in size.
Immediate delivery is indicated in cases of abruption at term or near term with a live fetus. In such cases the main question is whether vaginal delivery can be achieved without fetal or maternal death or severe morbidity. In cases where there is evidence of fetal compromise, delivery is not imminent and cesarean delivery should be performed promptly, because total placental detachment could occur without warning. -
This question is part of the following fields:
- Obstetrics
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Question 6
Incorrect
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A 26-year-old female G2P1 is in labour at the 38th week of gestation. Her membranes ruptured about 8 hours ago. At the moment, she is having contractions lasting 60 seconds every 4 minutes and is 8 cm dilated. The fetal heart tone baseline is currently 80/min with absent variability. The pregnancy was uneventful and she had regular prenatal check-ups. Which of the following is the most appropriate next step in management?
Your Answer: Fetal scalp pH monitoring
Correct Answer: Maternal position change and oxygen
Explanation:This patient is towards the end of the first stage of labour and is having complications. Labour is divided into 3 stages. The first stage begins at regular uterine contractions and ends with complete cervical dilatation at 10 cm. It has a latent phase and an active phase- The active phase is usually considered to have begun when cervical dilatation reaches 4 cm. So this patient is in the active phase of the first stag- The second stage begins with complete cervical dilatation and ends with the delivery of the foetus. The third stage of labour is the period between the delivery of the foetus and the delivery of the placenta and fetal membranes.
This patient’s contractions seem adequate and yet the fetal heart tone with baseline 80/min and absent variability suggests fetal distress. This is category III of the fetal heart rate pattern because the baseline rate is < 110/min with absent variability. It is usually predictive of abnormal acid-base status. The recommended actions are maternal position change and oxygen administration, discontinuation of labour stimulus such as oxytocin, treatment of possible underlying conditions, and expedited delivery.
→ Magnesium sulphate infusion is mainly used to prevent eclamptic seizures and despite no evidence of its effectiveness as a tocolytic agent, it is used sometimes to reduce risks of preterm birth.
→ Fetal scalp pH monitoring would help determine if there is indeed an acidosis and should be done before deciding whether a Caesarean section is necessary, but maternal position change and oxygen administration should be done first.
→ Ultrasonography may be used for preinduction cervical length measurement or if the active stage has already started- It is considered more accurate than digital pelvic exam in the assessment of fetal descent; however, at this point maternal position change and oxygen administration should be done first.
→ Immediate Caesarean section would be done if fetal scalp pH monitoring revealed a pH < 7.20. At this point, the best next step is maternal position change and oxygen administration. -
This question is part of the following fields:
- Obstetrics
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Question 7
Correct
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A 29-year-old woman had just delivered a stillborn vaginally, following a major placental abruption. Choose the single most likely predisposing factor for developing PPH in this woman?
Your Answer: DIC
Explanation:Disseminated intravascular coagulation (DIC) in pregnancy is the most common cause of an abnormal haemorrhage tendency during pregnancy and the puerperium. Although pregnancy itself can cause DIC, its presence is invariably evidence of an underlying obstetric disorder such as abruptio placentae, eclampsia, retention of a dead foetus, amniotic fluid embolism, placental retention or bacterial sepsis.
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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 pregnant female who is a known diabetic presents to the clinic for a consultation and enquires about the harmful effects of vitamin deficiencies. A deficiency of which vitamin can lead to teratogenic effects in the child?
Your Answer: Riboflavin
Correct Answer: Folic acid
Explanation:Pregnant women need to get enough folic acid. The vitamin is important to the growth of the foetus’s spinal cord and brain. Folic acid deficiency can cause severe birth defects known as neural tube defects. The Recommended Dietary Allowance (RDA) for folate during pregnancy is 600 micrograms (µg)/day.
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This question is part of the following fields:
- Obstetrics
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Question 9
Correct
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An otherwise healthy 21 year old primigravida comes to your office for a routine visit at 16 weeks gestation. She has had a normal pregnancy to date, and her only medication is a multivitamin with 0.4 mg folic acid. You order a maternal serum alpha-fetoprotein level. Adjusted for gestational age, maternal weight, and race, the results are significantly elevated. Which one of the following would you now recommend?
Your Answer: Fetal ultrasonography
Explanation:A 16-week visit is advised for all pregnant women to offer an alpha-fetoprotein (AFP) screening for neural tube defects and Down syndrome- An AFP level 2-5 times the median value for normal controls at the same gestational age is considered elevate- Approximately 5%-10% of patients who undergo AFP screening will have an elevated level, and most of these women will have normal foetuses. Fetal ultrasonography should be performed to detect multiple gestation, fetal demise, or fetal anomalies (neural tube defects, ventral abdominal wall defects, and urinary tract anomalies) as well as to confirm gestational age, as all of these factors are associated with elevated AFP levels. Amniocentesis is offered if the ultrasonography does not indicate the reason for the elevated AFP. Chorionic villus sampling is offered in the evaluation of suspected chromosomal anomalies as an adjunct to amniocentesis. Serum hCG would be indicated in the workup of suspected Down syndrome, where the AFP would be low, not elevate- The hCG level would be expected to be over 2-5 multiples of the mean (MoM) with Down syndrome.
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This question is part of the following fields:
- Obstetrics
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Question 10
Incorrect
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A 21-year-old woman has been stable on medicating with lamotrigine after developing epilepsy 2 years ago. She is planning to conceive but is concerned about what her medications may do to her baby. Which of the following is considered to reduce the incidence of neural tube defects?
Your Answer: Increase lamotrigine dose
Correct Answer: High dose folic acid for one month before conception and during first trimester
Explanation:CDC urges all women of reproductive age to take 400 micrograms (mcg) of folic acid each day, in addition to consuming food with folate from a varied diet, to help prevent some major birth defects of the baby’s brain (anencephaly) and spine (spina bifida).
The use of lamotrigine during pregnancy has not been associated with an increased risk of neural tube defects; however, the recommendation regarding higher doses of folic acid supplementation is often, but not always, broadened to include women taking any anticonvulsant, including lamotrigine.
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This question is part of the following fields:
- Obstetrics
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