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Question 1
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A 30 year old primigravida with diabetes suffered a post partum haemorrhage following a vaginal delivery. Her uterus was well contracted during labour. Her baby's weight is 4.4 kg. Which of the following is the most likely cause for her post partum haemorrhage?
Your Answer: Cervical/vaginal trauma
Explanation:A well contracted uterus excludes an atonic uterus. Delivery of large baby by a primigravida can cause cervical +/- vaginal tears which can lead to PPH.
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This question is part of the following fields:
- Obstetrics
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Question 2
Correct
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A 22-year-old female is at her second trimester of pregnancy and she presented to the medical clinic to receive human papillomavirus vaccination. Which of the following is considered the best step to do?
Your Answer: Postpone vaccination until after delivery
Explanation:Genital HPV is a common virus that is passed from one person to another through direct skin-to-skin contact during sexual activity. Most HPV types cause no symptoms and go away on their own, but some types can cause cervical cancer in women and other less common cancers — like cancers of the anus, penis, vagina, and vulva and oropharynx. Other types of HPV can cause warts in the genital areas of men and women, called genital warts.
HPV vaccination is recommended for 11 and 12 year-old girls. It is also recommended for girls and women age 13 through 26 years of age who have not yet been vaccinated or completed the vaccine series; HPV vaccine can also be given to girls beginning at age 9 years. CDC recommends 11 to 12 year olds get two doses of HPV vaccine to protect against cancers caused by HPV.
The vaccine is not recommended for pregnant women. Studies show that the HPV vaccine does not cause problems for babies born to women who were vaccinated while pregnant, but more research is still needed. A pregnant woman should not get any doses of the HPV vaccine until her pregnancy is completed.
Getting the HPV vaccine when pregnant is not a reason to consider ending a pregnancy. If a woman realizes that she got one or more shots of an HPV vaccine while pregnant, she should wait until after her pregnancy to finish any remaining HPV vaccine doses.
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This question is part of the following fields:
- Obstetrics
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Question 3
Correct
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A 24-year-old primigravida at 16 weeks of gestation, presented with a history of vaginal pressure, vaginal spotting and lower back pain. Transvaginal ultrasound finding shows cervical shortening to 2 cm, cervical dilation, and protrusion of fetal membranes into the cervical canal. Which among the following risk factors is not related to the development of this condition?
Your Answer: Alcohol abuse
Explanation:This woman has developed non-specific symptoms of cervical insufficiency, is a painless dilation of cervix resulting in the delivery of a live fetus during the 2nd trimester or premature delivery.
The following has been identified as the risk factors associated with increased incidence of cervical insufficiency:
– Congenital disorders of collagen synthesis like Ehlers-Danlos syndrome.
– Prior cone biopsies.
– Prior deep cervical lacerations, which is secondary to vaginal or cesarean delivery.
-Müllerian duct defects like bicornuate or septate uterus.
– More than three prior fetal losses during the 2nd trimesterFrom the given options, alcohol abuse is the only one not associated with increased incidence of cervical insufficiency.
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This question is part of the following fields:
- Obstetrics
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Question 4
Incorrect
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A 31-year-old woman at her 18th week of pregnancy presented to the emergency department with complaints of fishy, thin, white homogeneous vaginal discharge accompanied with an offensive odour. The presence of clue cells was noted during a microscopic test on the discharge. All of the following statements are considered false regarding her condition, except:
Your Answer: Metronidazole is contraindicated in this patient
Correct Answer: Relapse rate > 50 percent within 3 months
Explanation:Bacterial vaginosis (BV) affects women of reproductive age and can either be symptomatic or asymptomatic. Bacterial vaginosis is a condition caused by an overgrowth of normal vaginal flora. Most commonly, this presents clinically with increased vaginal discharge that has a fish-like odour. The discharge itself is typically thin and either grey or white.
Although bacterial vaginosis is not considered a sexually transmitted infection, women have an increased risk of acquiring other sexually transmitted infections (STI), and pregnant women have an increased risk of early delivery.
Though effective treatment options do exist, metronidazole or clindamycin, these methods have proven not to be effective long term.
BV recurrence rates are high, approximately 80% three months after effective treatment.
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This question is part of the following fields:
- Obstetrics
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Question 5
Correct
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A 30-year-old lady at 16 weeks of gestation who had histories of second-trimester pregnancy losses, presented with backache and pre-menstrual-like cramping along with increased vaginal discharge for the past one week. Pelvic examination shows that her cervix is dilated by 4 cm and effaced 80%. What will be the most likely diagnosis in this case?
Your Answer: Cervical insufficiency
Explanation:This woman has signs and symptoms suggestive of cervical insufficiency, whose clinical features include pelvic pressure, premenstrual-like cramping and backache with increased vaginal discharge. Usually these symptoms will persist for several days to weeks.
Cervical insufficiency is seen between 14 – 20 weeks of gestation, which is presented as soft effaced cervix, with minimal dilation on physical examination and a 4 cm dilated and more than 80% effaced cervix will be the clinical presentation in a more advanced case.Placental abruption presents with painful vaginal bleeding, whereas Placenta Previa presents as painless vaginal bleeding. Both cases will lead to shock but will not show any features of cervical insufficiency.
Anaemia, polyhydramnios, large for gestational age uterus and severe hyperemesis gravidarum are the commonly associated symptoms of a twin pregnancies.
New menstrual cycle after an abortion is expected to be presented with cervical dilation however signs of effacement will not be present along with it.
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This question is part of the following fields:
- Obstetrics
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Question 6
Incorrect
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A 50-year-old woman comes to the clinic complaining she is “urinating all the time. It started initially as some leakage of urine with sneezing or coughing, but now she leaks while walking to the bathroom.She voids frequently during the day and several times each night, also sometimes patient feels an intense urge to urinate but passes only a small amount when she tries to void. She now wears a pad every day and plans her social outings based on bathroom access.Patient had no history of dysuria or hematuria and had 2 vaginal deliveries in her 20s.She drinks alcohol socially, takes 2 or 3 cups of coffee each morning, and “drinks lots of water throughout the day.” When asked about which urinary symptoms are the most troublesome, the patient is unsure. Among the following which is the best next step in management of this patient?
Your Answer: Cystoscopy
Correct Answer: Voiding diary
Explanation:This patient experiences a stress based mixed urinary incontinence presented as leakage of urine while sneezing or coughing and urgency which is an intense urge to urinate with small voiding volume as her symptoms. Urinary incontinence is common and may cause significant distress in some, as seen in this patient who wears a pad every day. Initial evaluation of mixed incontinence includes maintaining a voiding diary, which helps to classify the predominant type of urinary incontinence and thereby to determine an optimal treatment by tracking the fluid intake, urine output and leaking episodes.
All patients with mixed incontinence generally require bladder training along with lifestyle changes like weight loss, smoking cessation, decreased alcohol and caffeine intake and practicing pelvic floor muscle exercises like Kegels. Depending on the predominant type, patients who have limited or incomplete symptom relief with bladder training may benefit from pharmacotherapy or surgery.
In patients with urgency-predominant incontinence, timed voiding practice like urinating on a fixed schedule rather than based on a sense of urgency along with oral antimuscarinics are found to be useful.
Surgery with a mid-urethral sling is performed in patients with stress-predominant incontinence which is due to a weakened pelvic floor muscles as in cystocele.
In patients with a suspected urethral diverticulum or vesicovaginal fistula, a cystoscopy is usually indicated but is not used in initial evaluation of urinary incontinence due to its cost and invasiveness.
Urodynamic testing involves measurement of bladder filling and emptying called as cystometry, urine flow, and pressure (eg, urethral leak point). This testing is typically reserved for those patients with complicated urinary incontinence, who will not respond to treatment or to those who are considering surgical intervention.
Initial evaluation of mixed urinary incontinence is done by maintaining a voiding diary, which helps to classify predominant type of urinary incontinence into stress predominant or urgency predominant and thereby to determine the optimal treatment required like bladder training, surgical intervention, etc.
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This question is part of the following fields:
- Obstetrics
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Question 7
Correct
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A 22-year-old Asian woman with a background history of primary pulmonary hypertension attends your clinic. She is planning for a pregnancy in the next few months and feels well generally. What would be your advice?
Your Answer: Pregnancy is contraindicated in her condition
Explanation:From the options given, option A is correct as primary pulmonary hypertension is considered a contraindication to pregnancy.
The patient should be educated about the possible risks and increased maternal mortality in such cases. This restriction is due to the fact that symptoms of Pulmonary hypertension gets worse during pregnancy which results in high maternal mortality.
Termination of pregnancy may be advisable in these circumstances mostly to preserve the life of the mother.
Sudden death secondary to hypotension is also a commonly dreaded complication among patients with pulmonary hypertension during pregnancy. -
This question is part of the following fields:
- Obstetrics
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Question 8
Correct
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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: 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 9
Correct
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A 21-year-old primigravida female presents to the emergency department at 41 weeks gestation. She complains of a nine hour history of irregular painful contractions. On examination of her pelvis, her cervix is fully effaced, but only 2 - 3 cm dilated. The fetal head is at the level of the ischial spines in a left occipito-posterior (LOP) position. The membranes ruptured an hour ago. What would be the best next line of management?
Your Answer: Oxytocic (Syntocinon4) infusion.
Explanation:The best next line of management is to administer an oxytocic (Syntocinon) infusion.
This is because the progress of labour is slow, and it necessary to augment it. As the membranes have already ruptured, the next step is to increase the contractions and induce labour using an infusion of oxytocic (Syntocinon) infusion.
Extra fluid is also required, but this will be administered alongside the Syntocinon infusion.
A lumbar epidural block is indicated in patients with an occipito-posterior (OP) position. This should not be attempted until more pain relief is required and the progress of labour is reassessed.
A Caesarean section may be necessary due to obstructed labour or fetal distress, it is not indicated at this stage.
Taking blood and holding it in case cross-matching is ultimately required is common, but most patients do not have blood cross-matched prophylactically in case there is a need to be delivered by Caesarean section and require a transfusion.
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This question is part of the following fields:
- Obstetrics
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Question 10
Correct
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A pregnant female recently underwent her antenatal screening for HIV and Hepatitis B. Which of the following additional tests should she be screened for?
Your Answer: Rubella, Toxoplasma and Syphilis
Explanation:A screening blood test for the infectious diseases HIV, Syphilis, Rubella, Toxoplasmosis and Hepatitis B is offered to all pregnant females so as to reduce the chances of transmission to the neonate.
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This question is part of the following fields:
- Obstetrics
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