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  • Question 1 - A 23-year-old woman, G1PO comes to your clinic at 12 week of pregnancy....

    Correct

    • A 23-year-old woman, G1PO comes to your clinic at 12 week of pregnancy. She is complaining of mild vaginal bleeding for the past 12 hours, along with bouts of mild cramping lower abdominal pain. On vaginal examination, the cervical os is closed with mild discharge containing blood clots and an ultrasonography confirms the presence of a live fetus with normal heart rate. Which among of the following is the most likely diagnosis?

      Your Answer: Threatened abortion

      Explanation:

      Uterine bleeding in the presence of a closed cervix along with sonographic visualization of an intrauterine pregnancy with detectable fetal cardiac activity are diagnostic of threatened abortion.

      Abortion does not always follow a uterine bleeding in early pregnancy, sometimes not even after repeated episodes or large amounts of bleeding, that is why the term “threatened” is used in this case. In about 90 to 96% cases, the pregnancy continues after vaginal bleeding if occured in the presence of a closed os and a detectable fetal heart rate. Also as the gestational age advances its less likely the condition will end in miscarriage.

      In cases of inevitable abortion, there will be dilatation of cervix along with progressive uterine bleeding and painful uterine contractions. The gestational tissue can be either felt or seen through the cervical os and the passage of this tissue occurs within a short time.

      In case were the membranes have ruptured, partly expelling the products of conception with a significant amounts of placental tissue left in the uterus is called as incomplete abortion. During the late first and early second trimesters this will be the most common presentation of an abortion. Examination findings of this includes an open cervical os with gestational tissues observed in the cervix and a uterine size smaller than expected for gestational age and a partially contracted uterus. The amount of bleeding will vary but can be severe enough to cause hypovolemic shock, with painful contractions and an ultrasound revealing tissues in the uterus.

      An in utero death of the embryo or fetus prior to 20 weeks of gestation is called as a missed abortion. In this case the women may notice that the symptoms associated with early pregnancy like nausea, breast tenderness, etc have disappeared and they don’t ‘feel pregnant’ anymore. Vaginal bleeding may occur but the cervix remains closed and the ultrasound done reveals an intrauterine gestational sac with or without an embryonic/fetal pole, but no embryonic/fetal cardiac activity will be noticed.

      In case of complete abortion, miscarriage occurs before the 12th week and the entire contents of conception will be expelled out of uterus. If this case, the physical examination will show a small and well contracted uterus with an open or closed cervix. There is scant vaginal bleeding with only mild cramping and ultrasound will reveal an empty uterus without any extra-uterine pregnancy.

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      • Obstetrics
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  • Question 2 - A 22-year-old primigravid woman present to the emergency department. She is at 40...

    Correct

    • A 22-year-old primigravid woman present to the emergency department. She is at 40 weeks gestation and complains of a 24-hour history of no fetal movements. On auscultation, fetal heart beats are clearly audible with a measurement of 140/min. On diagnostic testing, the cardiotocograph (CTG) is normal and reactive. On physical examination, her cervix is 2cm dilated and fully effaced. She is reassured and allowed to return home. 24 hours later, she calls to complain she has still felt no fetal movements, adding up to a 48 hour history. What is the best next step in management?

      Your Answer: Admit for induction of labour.

      Explanation:

      Labour induction is indicated as no fetal movements have been felt for 24 hours, with a normal cardiotocograph (CTG) and the pregnancy is at near/full term with a favourable cervix.

      Amniotic fluid volume assessment would have been indicated 24 hours earlier as, if it was low, induction would have been indicated then, despite a normal CTG.

      Ultrasound examination of the foetus is not indicated as it is necessary to expedite delivery.

      Carrying out another CTG, with or without oxytocin challenge, is not indicated, although MG monitoring during induced labour would be mandatory.

      Delivery immediately by Caesarean section is not indicated unless the lack of fetal movements is due to fetal hypoxia. This can result in fetal distress during labour, necessitating an emergency Caesarean section if the cervix is not fully dilated.

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      • Obstetrics
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  • Question 3 - A women in her 21-weeks of pregnancy, complaints of palpitations, sweating of palms,...

    Correct

    • A women in her 21-weeks of pregnancy, complaints of palpitations, sweating of palms, and increased nervousness. Along with TSH what other investigations should be done for this patient?

      Your Answer: Free T4

      Explanation:

      Patient mentioned in the case has developed thyrotoxicosis during pregnancy. TSH level should be tested, and if the result shows any suppressed or elevated TSH level, then it is mandatory to check for free T4 level.

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      • Obstetrics
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  • Question 4 - An ultrasound in the 1st trimester of pregnancy is done for? ...

    Correct

    • An ultrasound in the 1st trimester of pregnancy is done for?

      Your 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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      • Obstetrics
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  • Question 5 - A 28-year-old primigravid woman at 18 weeks of gestation comes to office for...

    Correct

    • A 28-year-old primigravid woman at 18 weeks of gestation comes to office for a routine prenatal visit and anatomy ultrasound. Patient feels well generally and has no concerns, also has no chronic medical conditions, and her only daily medication is a prenatal vitamin. She is accompanied by her mother as her husband was unable to get off work. Ultrasound shows a cephalic singleton fetus measuring at <10th percentile consistent with severe growth restriction.There are bilateral choroid plexus cysts, clenched fists, and a large ventricular septal defect. Amniotic fluid level is normal with a posterior and fundal placenta. Which of the following statements is the most appropriate initial response by the physician?

      Your Answer: There are some things about your ultrasound that I need to discuss with you; is it okay to do that now?

      Explanation:

      SPIKES protocol for delivering serious news to patients includes:
      – Set the stage includes arranging for a private, comfortable setting space, introduce patient/family & team members, maintain eye contact & sit at the same level and schedule appropriate time interval & minimize space for interruptions.
      – Perception: Use open-ended questions to assess the patient’s/family’s perception of the medical situation.
      – Invitation: should ask patient/family how much information they would like to know and remain cognizant of their cultural, educational & religious issues.
      – Knowledge:
      Warn the patient/family that serious news is coming, Speak in simple & straightforward terms, stop & check whether they are understanding.
      – Empathy: Express understanding & give support when responding to emotions
      – Summary & strategy: Summarize & create follow-through plan, including end-of-life discussions if applicable.

      The ultrasound findings of severe growth restriction, bilateral choroid plexus cysts, clenched fists, and a large ventricular septal defect are consistent with trisomy 18, the second most common autosomal trisomy, which results in fetal loss or neonatal death in the majority of cases.  In this case, the physician is to deliver a very serious news to the patient who is presenting for a routine visit, believing her pregnancy was normal.  When serious news is unexpected, it is especially important to prepare the patient and determine how the patient would like to receive the results.
      The physician is supposed to provide a comfortable setting and must ask patient’s permission to share the results. This allows the patient to respond with her preference and avoids making assumptions about whom, if anyone, she would like to be present with.  For example, some patients may prefer to defer discussion of the results until a major support person (eg, husband, mother) is present. In addition to establish patient’s preferred setting, physician should determine how much information the patient would like to receive. Some patients will prefer a detailed medical information about diagnosis and prognosis, whereas others may prefer to have time to process the news emotionally and receive further information later.  The SPIKES protocol (Setting the stage, Perception, Invitation, Knowledge, Empathy, and Summary/strategy) is a six-step model that can guide physicians in delivering serious news to patients.

      These statements do not allow the patient to choose how she receives the results and assume that she does not want her mother present.

      This statement fails to prepare the patient for serious news and prematurely jumps to sharing results using technical, medical terminology that may be difficult for the patient to comprehend. This approach could also be upsetting to a patient undergoing a routine ultrasound who is not expecting anything abnormal.

      This statement inappropriately determines when and with whom the patient should receive the results. Instead the patient should be asked how she prefers to receive the results.

      While delivering unexpected, serious news, physicians should prepare the patient and determine how the patient prefers to receive the information.

    • This question is part of the following fields:

      • Obstetrics
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  • Question 6 - A 41-year-old woman (gravida 2, para 1) presents at eight weeks gestation for...

    Correct

    • A 41-year-old woman (gravida 2, para 1) presents at eight weeks gestation for her first antenatal visit. This is her second pregnancy. She is worried about Down syndrome risk in her foetus. From the following options listed, select the safest test (i.e., the one with least risk of causing adverse consequences in the pregnancy) that will provide an accurate diagnosis regarding the presence or absence of Trisomy 21 in the foetus.

      Your Answer: Amniocentesis at 16 weeks of gestation.

      Explanation:

      Nuchal translucency scans and maternal screening tests simply aid in determining a risk percentage for the presence of Trisomy 21, but an accurate diagnosis cannot be reached.

      Chorionic villous biopsy (CVB), amniocentesis, and cordocentesis, are all prenatal diagnostic tests that can provide a definitive diagnosis regarding the presence of foetal abnormalities.

      Amniocentesis performed at 16 weeks of gestation is associated with the lowest risk for miscarriage and hence is the safest test and should be recommended to the mother (correct answer).

      The miscarriage risk from a CVB is at least double the risk following amniocentesis.

      Nowadays, cordocentesis is rarely used for sampling of foetal material to detect chromosomal abnormalities as the test poses an even higher risk of miscarriage compared to the other procedures discussed above.

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      • Obstetrics
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  • Question 7 - Which of the following is the most likely anaesthetic or analgesic causing reduced...

    Correct

    • Which of the following is the most likely anaesthetic or analgesic causing reduced variability on cardiotocograph?

      Your Answer: Intramuscular pethidine

      Explanation:

      Opiates and spinal anaesthetics reduce the variability of a CTG. Including some antihypertensives like labetalol and alpha methyl dopa.

    • This question is part of the following fields:

      • Obstetrics
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  • Question 8 - Lidiya is a 30-year-old hospital nurse in her nine weeks of pregnancy. She...

    Correct

    • Lidiya is a 30-year-old hospital nurse in her nine weeks of pregnancy. She has no history of chickenpox, but by regularly attending the facial sores of an elderly patient with herpes zoster ophthalmicus she has been significantly exposed to shingles. What would you advise her as preventive management?

      Your Answer: If she had chicken pox immunization in the past, she needs to have her Varicella-Zoster IgG antibodies checked to assure immunity

      Explanation:

      Patient in the given case is nine weeks pregnant, and she has been exposed to a herpes zoster rash because she is working as a hospital nurse and has no prior history of chickenpox.
      The most appropriate next step in this case would be checking for Varicella-Zoster IgG antibodies which assures immunity to varicella infections. If VZV IgG is present no further action is needed, but if VZV IgG antibodies are absent, then she will need Varicella Zoster Immunoglobulins within ten days from the exposure to shingles.

    • This question is part of the following fields:

      • Obstetrics
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  • Question 9 - A 21-year-old woman at 39 weeks of gestation in her second pregnancy is...

    Correct

    • A 21-year-old woman at 39 weeks of gestation in her second pregnancy is admitted in the hospital for severe abdominal pain. She notes that also has been having vaginal bleeding of about one litre and uterine contractions are present. Her previous pregnancy was a vaginal, without any complications. Her current blood pressure is 95/50 mmHg with a pulse rate of 120 beats/min. On physical examination, the uterus is palpable at the level of the xiphisternum and is firm. It is acutely tender to palpation. Fetal heart sounds cannot be heard on auscultation or with Doppler assessment. The cervix is 4 cm dilated and fully effaced. Immediate resuscitative measures are taken. Which of the following is the most appropriate next step in management for this patient?

      Your Answer: Amniotomy

      Explanation:

      This patient is presenting with a severe placental abruption causing fetal death and shock in the mother. The most appropriate initial management for the patient is to treat her shock with blood transfusions and exclude or treat any coagulation disorder resulting from the abruption. Delivery also needs to be expedited to remove the dead foetus. An amniotomy is usually all that is required to induce spontaneous labour as the uterus is usually very irritable. Spontaneous labour is likely to occur in this case, where the cervix is already 4 cm dilated and fully effaced.

      Caesarean section is rarely needed to be done when the foetus is already dead.

      Vaginal prostaglandin and an oxytocin (Syntocin®) infusion are not needed and unlikely to be required.

      Ultrasound examination to confirm the diagnosis and fetal death is also unnecessary given the clinical and Doppler findings.

    • This question is part of the following fields:

      • Obstetrics
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  • Question 10 - A 35-year-old woman presented to the medical clinic for her first prenatal visit....

    Incorrect

    • A 35-year-old woman presented to the medical clinic for her first prenatal visit. Upon history-taking, it was noted that this was her first pregnancy and based on her last menstrual period, she is pregnant for 11 weeks already. There was also no mention of a history of medical problems. Upon further observation, the uterus was palpable midway between her pubic symphysis and the umbilicus. There was also no audible fetal heart tones using the Doppler stethoscope. Which of the following is considered the best management as the next step given the case above?

      Your Answer:

      Correct Answer: Schedule an ultrasound as soon as possible to determine the gestational age and viability of the foetus.

      Explanation:

      In pregnancy, the uterus increases in size to accommodate the developing foetus. At 16 weeks gestation, the fundus of the uterus must be palpated at the midpoint between the umbilicus and the pubic symphysis but the patient’s uterus was already palpable at just 11 weeks.

      If less than seven weeks pregnant, it’s unlikely to find a heartbeat by ultrasound. Using transvaginal ultrasound, a developing baby’s heartbeat should be clearly visible by the time a woman is seven weeks pregnant. Abdominal ultrasound is considerably less sensitive, so it can take longer for the heartbeat to become visible. If past seven weeks pregnant, seeing no heartbeat may be a sign of miscarriage.

      Fetal viability is confirmed by the presence of an embryo that has cardiac activity. Cardiac activity is often present when the embryo itself measures 2 mm or greater during the 6th week of gestation. If cardiac activity is not evident, other sonographic features of early pregnancy can predict viability.

      It is recommended that all pregnant women undergo a routine ultrasound at 10 to 13 weeks of gestation to determine an accurate gestational age. Getting an accurate gestational age is highly important and pertinent for the optimal assessment of fetal growth later in pregnancy. Ultrasound is the most reliable method for establishing a true gestational age by measurement of crown-rump length, which can be measured either transabdominally or transvaginally.

    • This question is part of the following fields:

      • Obstetrics
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SESSION STATS - PERFORMANCE PER SPECIALTY

Obstetrics (9/9) 100%
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