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  • Question 1 - You encounter a 36-year-old woman during her antenatal check-up. She has recently undergone...

    Incorrect

    • You encounter a 36-year-old woman during her antenatal check-up. She has recently undergone an anomaly scan and is undergoing a routine review. During the consultation, she expresses her concern about not feeling any fetal movement yet, despite experiencing it by 18 weeks gestation in her previous pregnancies.
      At what point in her gestation would it be appropriate to refer her to the maternal fetal medicine unit for further evaluation?

      Your Answer: 20 weeks

      Correct Answer: 24 weeks

      Explanation:

      Referral to a maternal fetal medicine unit is recommended if fetal movements have not been felt by 24 weeks, as reduced movements can be a sign of fetal distress and hypoxia. While most women feel their babies move around 18-20 weeks, it can happen earlier in some cases. Although singular episodes of reduced movements may not be harmful, they can also indicate stillbirths and restricted growth. The absence of movements is particularly concerning and requires further investigation. The RCOG has set the 24 week cut off as a guideline.

      Understanding Reduced Fetal Movements

      Introduction:
      Reduced fetal movements can indicate fetal distress and are a response to chronic hypoxia in utero. This can lead to stillbirth and fetal growth restriction. It is believed that placental insufficiency may also be linked to reduced fetal movements.

      Physiology:
      Quickening is the first onset of fetal movements, which usually occurs between 18-20 weeks gestation and increases until 32 weeks gestation. Multiparous women may experience fetal movements sooner. Fetal movements should not reduce towards the end of pregnancy. There is no established definition for what constitutes reduced fetal movements, but less than 10 movements within 2 hours (in pregnancies past 28 weeks gestation) is an indication for further assessment.

      Epidemiology:
      Reduced fetal movements affect up to 15% of pregnancies, with 3-5% of pregnant women having recurrent presentations with RFM. Fetal movements should be established by 24 weeks gestation.

      Risk factors for reduced fetal movements:
      Posture, distraction, placental position, medication, fetal position, body habitus, amniotic fluid volume, and fetal size can all affect fetal movement awareness.

      Investigations:
      Fetal movements are usually based on maternal perception, but can also be objectively assessed using handheld Doppler or ultrasonography. Investigations are dependent on gestation at onset of RFM. If concern remains, despite normal CTG, urgent (within 24 hours) ultrasound can be used.

      Prognosis:
      Reduced fetal movements can represent fetal distress, but in 70% of pregnancies with a single episode of reduced fetal movement, there is no onward complication. However, between 40-55% of women who suffer from stillbirth experience reduced fetal movements prior to diagnosis. Recurrent RFM requires further investigations to consider structural or genetic fetal abnormalities.

    • This question is part of the following fields:

      • Obstetrics
      41.4
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  • Question 2 - A 30-year-old, 16 week pregnant, female arrives at the emergency department complaining of...

    Incorrect

    • A 30-year-old, 16 week pregnant, female arrives at the emergency department complaining of abdominal pain that has been persistent for the last 2 hours. She denies any vaginal bleeding. What are the risk factors linked to an elevated chance of placental abruption?

      Your Answer: Maternal trauma, nulliparity and increased maternal age

      Correct Answer: Maternal trauma, multiparity and increased maternal age

      Explanation:

      Placental abruption is more likely to occur in older mothers, those who have had multiple pregnancies, and those who have experienced maternal trauma. Pre-eclampsia, characterized by protein in the urine and high blood pressure, is also a risk factor.

      Placental Abruption: Causes, Symptoms, and Risk Factors

      Placental abruption is a condition that occurs when the placenta separates from the uterine wall, leading to maternal bleeding into the space between them. Although the exact cause of this condition is unknown, certain factors have been associated with it, including proteinuric hypertension, cocaine use, multiparity, maternal trauma, and increasing maternal age. Placental abruption is not a common occurrence, affecting approximately 1 in 200 pregnancies.

      The clinical features of placental abruption include shock that is disproportionate to the visible blood loss, constant pain, a tender and tense uterus, and a normal lie and presentation of the fetus. The fetal heart may be absent or distressed, and there may be coagulation problems. It is important to be aware of other conditions that may present with similar symptoms, such as pre-eclampsia, disseminated intravascular coagulation (DIC), and anuria.

      In summary, placental abruption is a serious condition that can have significant consequences for both the mother and the fetus. Understanding the risk factors and symptoms of this condition is important for early detection and appropriate management.

    • This question is part of the following fields:

      • Obstetrics
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  • Question 3 - A 35-year-old woman is seen in the epilepsy clinic. She has been effectively...

    Correct

    • A 35-year-old woman is seen in the epilepsy clinic. She has been effectively managing her epilepsy with carbamazepine 400 mg twice daily. She is expecting a baby girl soon and is eager to breastfeed. What guidance should be provided to the patient?

      Your Answer: No changes required

      Explanation:

      There is no need to increase the dose of medication as the patient’s epilepsy is well controlled on the current regimen. Switching from carbamazepine to lamotrigine is also unnecessary and not safer.

      Pregnancy and breastfeeding can be a concern for women with epilepsy. It is generally recommended that women continue taking their medication during pregnancy, as the risks of uncontrolled seizures outweigh the potential risks to the fetus. However, it is important for women to take folic acid before pregnancy to reduce the risk of neural tube defects. The use of antiepileptic medication during pregnancy can increase the risk of congenital defects, but this risk is still relatively low. It is recommended to aim for monotherapy and there is no need to monitor drug levels. Sodium valproate is associated with neural tube defects, while carbamazepine is considered the least teratogenic of the older antiepileptics. Phenytoin is associated with cleft palate, and lamotrigine may require a dose increase during pregnancy. Breastfeeding is generally safe for mothers taking antiepileptics, except for barbiturates. Pregnant women taking phenytoin should be given vitamin K in the last month of pregnancy to prevent clotting disorders in the newborn.

      A warning has been issued about the use of sodium valproate during pregnancy and in women of childbearing age. New evidence suggests a significant risk of neurodevelopmental delay in children following maternal use of this medication. Therefore, it should only be used if clearly necessary and under specialist neurological or psychiatric advice. It is important for women with epilepsy to discuss their options with their healthcare provider and make informed decisions about their treatment during pregnancy and breastfeeding.

    • This question is part of the following fields:

      • Obstetrics
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  • Question 4 - A 35-year-old woman presents to the gynaecology department with a recent diagnosis of...

    Correct

    • A 35-year-old woman presents to the gynaecology department with a recent diagnosis of cervical cancer. Upon staging, it was found that she has a small malignant tumour that is only visible under a microscope and measures 6mm in width. The depth of the tumour is 2.5mm, and there is no evidence of nodal or distant metastases, classifying her disease as stage IA1. She expresses a desire to preserve her fertility as she has not yet started a family.

      What treatment option would be most appropriate for this patient?

      Your Answer: Cone biopsy and close follow-up

      Explanation:

      If a woman with stage IA cervical cancer wants to maintain her fertility, a cone biopsy with negative margins and close follow-up may be considered as the best option. Hysterectomy with or without lymph node clearance would not preserve fertility. Radical trachelectomy, which involves removing the cervix, upper part of the vagina, and surrounding tissues, and checking for cancer spread in the pelvis, is an option for IA2 tumors that also preserves fertility.

      Management of Cervical Cancer Based on FIGO Staging

      Cervical cancer management is determined by the FIGO staging and the patient’s desire to maintain fertility. The FIGO staging system categorizes cervical cancer into four stages based on the extent of the tumor’s spread. Stage IA and IB tumors are confined to the cervix, with IA tumors only visible under a microscope and less than 7 mm wide. Stage II tumors have spread beyond the cervix but not to the pelvic wall, while stage III tumors have spread to the pelvic wall. Stage IV tumors have spread beyond the pelvis or involve the bladder or rectum.

      The management of stage IA tumors involves a hysterectomy with or without lymph node clearance. For patients who want to maintain fertility, a cone biopsy with negative margins can be performed, but close follow-up is necessary. Stage IB tumors are managed with radiotherapy and concurrent chemotherapy for B1 tumors and radical hysterectomy with pelvic lymph node dissection for B2 tumors.

      Stage II and III tumors are managed with radiation and concurrent chemotherapy, with consideration for nephrostomy if hydronephrosis is present. Stage IV tumors are treated with radiation and/or chemotherapy, with palliative chemotherapy being the best option for stage IVB. Recurrent disease is managed with either surgical treatment followed by chemoradiation or radiotherapy followed by surgical therapy.

      The prognosis of cervical cancer depends on the FIGO staging, with higher survival rates for earlier stages. Complications of treatments include standard surgical risks, increased risk of preterm birth with cone biopsies and radical trachelectomy, and ureteral fistula with radical hysterectomy. Complications of radiotherapy include short-term symptoms such as diarrhea and vaginal bleeding and long-term effects such as ovarian failure and fibrosis of various organs.

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      • Obstetrics
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  • Question 5 - A 25-year-old woman has undergone an artificial rupture of membranes to speed up...

    Correct

    • A 25-year-old woman has undergone an artificial rupture of membranes to speed up a labor that is progressing slowly. While her partner is assisting her in changing positions for comfort, she suddenly becomes breathless and collapses from the bed. She is now unresponsive and unconscious, with a blood pressure of 82/50 mmHg and a heart rate of 134 beats per minute. What is the probable diagnosis?

      Your Answer: Amniotic fluid embolism

      Explanation:

      The sudden collapse that occurred shortly after the rupture of membranes suggests the possibility of amniotic fluid embolism. The patient’s condition is too severe to be attributed to a simple vasovagal event. While amniotic fluid emboli can indirectly cause myocardial infarctions, it is difficult to diagnose a primary myocardial infarction without any mention of preceding chest pain. Typically, occult bleeding and hypovolemic shock would develop gradually. Although postural orthostatic tachycardia syndrome is more prevalent in women of reproductive age, it would not cause the significant hypotension observed in this case.

      Amniotic fluid embolism is a rare but serious complication of pregnancy that can result in a high mortality rate. It occurs when fetal cells or amniotic fluid enter the mother’s bloodstream, triggering a reaction that leads to various signs and symptoms. While several risk factors have been associated with this condition, such as maternal age and induction of labor, the exact cause remains unclear. It is believed that exposure of maternal circulation to fetal cells or amniotic fluid is necessary for the development of an amniotic fluid embolism, but the underlying pathology is not well understood.

      The majority of cases of amniotic fluid embolism occur during labor, but they can also occur during a cesarean section or in the immediate postpartum period. Symptoms of this condition include chills, shivering, sweating, anxiety, and coughing, while signs may include cyanosis, hypotension, bronchospasms, tachycardia, arrhythmia, and myocardial infarction. Diagnosis is primarily clinical and based on exclusion, as there are no definitive diagnostic tests available.

      Management of amniotic fluid embolism requires a multidisciplinary team and critical care unit. Treatment is mainly supportive, focusing on addressing the patient’s symptoms and stabilizing their condition. Given the high mortality rate associated with this condition, prompt recognition and management are crucial for improving outcomes.

    • This question is part of the following fields:

      • Obstetrics
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  • Question 6 - A 27-year-old woman visits her GP worried about not feeling any fetal movements...

    Correct

    • A 27-year-old woman visits her GP worried about not feeling any fetal movements yet. She is currently 22 weeks pregnant and this is her first pregnancy. She is anxious because her peers who have been pregnant had already experienced their baby's movements by this stage. When should a referral to an obstetrician be made for absence of fetal movements?

      Your Answer: 24 weeks

      Explanation:

      Referral to a maternal fetal medicine unit is recommended if there are no fetal movements felt by 24 weeks. While most women feel their baby moving around 18-20 weeks, it can range from 16-24 weeks. If there is a lack of fetal movement, it could be due to various reasons, including miscarriages and stillbirth, which can be distressing. Therefore, it is important to check the fetal heartbeat and consider an ultrasound to detect any abnormalities if no fetal movements are felt by 24 weeks.

      Understanding Reduced Fetal Movements

      Introduction:
      Reduced fetal movements can indicate fetal distress and are a response to chronic hypoxia in utero. This can lead to stillbirth and fetal growth restriction. It is believed that placental insufficiency may also be linked to reduced fetal movements.

      Physiology:
      Quickening is the first onset of fetal movements, which usually occurs between 18-20 weeks gestation and increases until 32 weeks gestation. Multiparous women may experience fetal movements sooner. Fetal movements should not reduce towards the end of pregnancy. There is no established definition for what constitutes reduced fetal movements, but less than 10 movements within 2 hours (in pregnancies past 28 weeks gestation) is an indication for further assessment.

      Epidemiology:
      Reduced fetal movements affect up to 15% of pregnancies, with 3-5% of pregnant women having recurrent presentations with RFM. Fetal movements should be established by 24 weeks gestation.

      Risk factors for reduced fetal movements:
      Posture, distraction, placental position, medication, fetal position, body habitus, amniotic fluid volume, and fetal size can all affect fetal movement awareness.

      Investigations:
      Fetal movements are usually based on maternal perception, but can also be objectively assessed using handheld Doppler or ultrasonography. Investigations are dependent on gestation at onset of RFM. If concern remains, despite normal CTG, urgent (within 24 hours) ultrasound can be used.

      Prognosis:
      Reduced fetal movements can represent fetal distress, but in 70% of pregnancies with a single episode of reduced fetal movement, there is no onward complication. However, between 40-55% of women who suffer from stillbirth experience reduced fetal movements prior to diagnosis. Recurrent RFM requires further investigations to consider structural or genetic fetal abnormalities.

    • This question is part of the following fields:

      • Obstetrics
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  • Question 7 - A 32-year-old female presents with intense pruritus during pregnancy, particularly in her hands...

    Correct

    • A 32-year-old female presents with intense pruritus during pregnancy, particularly in her hands and feet, which worsens at night. She has no visible rash and has a history of a stillbirth at 36 weeks. What is the most efficient management for her condition?

      Your Answer: Ursodeoxycholic acid

      Explanation:

      The patient is likely suffering from obstetric cholestasis, which can increase the risk of premature birth and stillbirth. The main symptom is severe itching, and elevated serum bile acids are typically present. Liver function tests, including bilirubin levels, may not be reliable. The most effective treatment is ursodeoxycholic acid (UDCA), which is now mostly synthetic. While antihistamines and topical menthol creams can provide some relief, UDCA is more likely to improve outcomes.

      Intrahepatic Cholestasis of Pregnancy: Symptoms and Management

      Intrahepatic cholestasis of pregnancy, also known as obstetric cholestasis, is a condition that affects approximately 1% of pregnancies in the UK. It is characterized by intense itching, particularly on the palms, soles, and abdomen, and may also result in clinically detectable jaundice in around 20% of patients. Raised bilirubin levels are seen in over 90% of cases.

      The management of intrahepatic cholestasis of pregnancy typically involves induction of labor at 37-38 weeks, although this practice may not be evidence-based. Ursodeoxycholic acid is also widely used, although the evidence base for its effectiveness is not clear. Additionally, vitamin K supplementation may be recommended.

      It is important to note that the recurrence rate of intrahepatic cholestasis of pregnancy in subsequent pregnancies is high, ranging from 45-90%. Therefore, close monitoring and management are necessary for women who have experienced this condition in the past.

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      • Obstetrics
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  • Question 8 - A 28-year-old G3P2 woman at 32 weeks gestation presents to the emergency department...

    Correct

    • A 28-year-old G3P2 woman at 32 weeks gestation presents to the emergency department with sudden and severe lower abdominal pain that started 45 minutes ago. She reports a small amount of vaginal bleeding but her baby is still active, although movements are slightly reduced. She has had regular antenatal care and her medical history is unremarkable, except for a 10 pack-year smoking history. Her two previous children were born vaginally and are healthy at ages 4 and 6.

      The patient is alert and oriented but in significant pain. Her vital signs are within normal limits except for a blood pressure of 150/95 mmHg and a heart rate of 120 beats per minute. A cardiotocograph shows a normal baseline fetal heart rate with appropriate accelerations and no decelerations.

      What is the most likely diagnosis and what is the next appropriate step in management?

      Your Answer: Admit the mother and administer steroids

      Explanation:

      It is likely that the patient is experiencing placental abruption, which is a medical emergency. The severity of the abruption and the risks to both the mother and the baby determine the management approach. This patient has risk factors such as chronic hypertension and smoking. Steroids should be administered to assist in fetal lung development if the fetus is alive, less than 36 weeks, and not in distress. The patient’s vital signs are stable, but the volume of vaginal bleeding may not accurately reflect the severity of the bleed. The fetal status is assessed using a cardiotocograph, which indicates whether the fetus is receiving adequate blood and nutrients from the placenta. Expectant management is not appropriate, and intervention is necessary to increase the chances of a positive outcome. Immediate caesarean section is only necessary if the fetus is in distress or if the mother is experiencing significant blood loss. Vaginal delivery is only appropriate if the fetus has died in utero, which is not the case here.

      Placental Abruption: Causes, Management, and Complications

      Placental abruption is a condition where the placenta separates from the uterine wall, leading to maternal haemorrhage. The severity of the condition depends on the extent of the separation and the gestational age of the fetus. Management of placental abruption is crucial to prevent maternal and fetal complications.

      If the fetus is alive and less than 36 weeks, immediate caesarean delivery is recommended if there is fetal distress. If there is no fetal distress, close observation, administration of steroids, and no tocolysis are recommended. The decision to deliver depends on the gestational age of the fetus. If the fetus is alive and more than 36 weeks, immediate caesarean delivery is recommended if there is fetal distress. If there is no fetal distress, vaginal delivery is recommended. If the fetus is dead, vaginal delivery should be induced.

      Placental abruption can lead to various maternal complications, including shock, disseminated intravascular coagulation (DIC), renal failure, and postpartum haemorrhage (PPH). Fetal complications include intrauterine growth restriction (IUGR), hypoxia, and death. The condition is associated with a high perinatal mortality rate and is responsible for 15% of perinatal deaths.

      In conclusion, placental abruption is a serious condition that requires prompt management to prevent maternal and fetal complications. Close monitoring and timely intervention can improve the prognosis for both the mother and the baby.

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      • Obstetrics
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  • Question 9 - As a young doctor in obstetrics and gynaecology, you are assisting in the...

    Incorrect

    • As a young doctor in obstetrics and gynaecology, you are assisting in the delivery of a patient when suddenly, shoulder dystocia occurs. You quickly call for senior assistance and decide to perform McRobert's manoeuvre by hyper flexing and abducting the mother's hips, moving her onto her back and bringing her thighs towards her abdomen.

      What other action can be taken to enhance the effectiveness of the manoeuvre?

      Your Answer: Fundal pressure

      Correct Answer: Suprapubic pressure

      Explanation:

      According to the shoulder dystocia guidelines of the Royal College of Obstetrics and Gynaecology, utilizing suprapubic pressure can enhance the efficacy of the McRoberts manoeuvre.

      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 fetus. Risk factors for shoulder dystocia include fetal macrosomia, high maternal body mass index, diabetes mellitus, and prolonged labor.

      If shoulder dystocia is identified, it is important to call for senior help immediately. The McRoberts’ maneuver is often performed, which 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 maternal morbidity. Oxytocin administration is not indicated for shoulder dystocia.

      Complications of shoulder dystocia can include postpartum hemorrhage and perineal tears for the mother, and brachial plexus injury and neonatal death for the fetus. It is important to manage shoulder dystocia promptly and appropriately to minimize the risk of these complications.

    • This question is part of the following fields:

      • Obstetrics
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  • Question 10 - A 32-year-old woman who is 9 weeks pregnant visits you for her booking...

    Incorrect

    • A 32-year-old woman who is 9 weeks pregnant visits you for her booking appointment. She has a brother with Down syndrome and wants to know more about the screening program. You provide information about the combined test. What other blood markers, in addition to nuchal translucency, are measured?

      Your Answer: Beta-human chorionic gonadotrophin (beta-hCG) and alpha-fetoprotein (AFP)

      Correct Answer: Beta-human chorionic gonadotrophin (beta-hCG) and pregnancy associated plasma protein A (PAPP-A)

      Explanation:

      NICE updated guidelines on antenatal care in 2021, recommending the combined test for screening for Down’s syndrome between 11-13+6 weeks. The test includes nuchal translucency measurement, serum B-HCG, and pregnancy-associated plasma protein A (PAPP-A). The quadruple test is offered between 15-20 weeks for women who book later in pregnancy. Results are interpreted as either a ‘lower chance’ or ‘higher chance’ of chromosomal abnormalities. If a woman receives a ‘higher chance’ result, she may be offered a non-invasive prenatal screening test (NIPT) or a diagnostic test. NIPT analyzes cell-free fetal DNA in the mother’s blood and has high sensitivity and specificity for detecting chromosomal abnormalities. Private companies offer NIPT screening from 10 weeks gestation.

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      • Obstetrics
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  • Question 11 - A 32-year-old, G2P1, presents to the obstetrics assessment unit with vaginal bleeding and...

    Correct

    • A 32-year-old, G2P1, presents to the obstetrics assessment unit with vaginal bleeding and mild abdominal pain at 15 weeks gestation. What aspect of her medical history would raise concern for a possible miscarriage?

      Your Answer: Large cervical cone biopsy

      Explanation:

      There are several factors that can increase the risk of miscarriage, including age, previous miscarriages, chronic conditions, uterine or cervical problems (such as large cervical cone biopsies or Mullerian duct anomalies), smoking, alcohol and illicit drug use, and weight. Invasive prenatal tests like chorionic villus sampling and amniocentesis also carry a slight risk of miscarriage. It’s important to note that other options are not considered risk factors for 2nd-trimester miscarriage.

      Miscarriage: Understanding the Epidemiology

      Miscarriage, also known as abortion, refers to the expulsion of the products of conception before 24 weeks. To avoid any confusion, the term miscarriage is often used. According to epidemiological studies, approximately 15-20% of diagnosed pregnancies will end in miscarriage during early pregnancy. In fact, up to 50% of conceptions may not develop into a blastocyst within 14 days.

      Recurrent spontaneous miscarriage, which is defined as the loss of three or more consecutive pregnancies, affects approximately 1% of women. Understanding the epidemiology of miscarriage is important for healthcare providers and patients alike. It can help to identify risk factors and provide appropriate counseling and support for those who have experienced a miscarriage. By raising awareness and promoting education, we can work towards reducing the incidence of miscarriage and improving the overall health and well-being of women and their families.

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      • Obstetrics
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  • Question 12 - Sarah is a 28-year-old woman who has recently given birth to a baby...

    Correct

    • Sarah is a 28-year-old woman who has recently given birth to a baby boy 6 weeks ago. At the 6 week check, you can see from her records that she has previously been on sertraline for moderate depression, however, this was stopped before her pregnancy. She tells you that she is finding it difficult to cope and is feeling extremely low. On examination, she is tearful and has a flat affect. She denies any thoughts to harm herself or her baby but is keen to try a medication that would be safe to use with breastfeeding.
      Which of the following medications may be appropriate for her to start?

      Your Answer: Paroxetine

      Explanation:

      According to NICE guidelines, the preferred treatment for post-natal depression in breastfeeding women is either sertraline or paroxetine. Before starting treatment, it is recommended to seek advice from a specialist perinatal mental health team. Although tricyclic antidepressants like amitriptyline are an option, they are less commonly used due to concerns about maternal toxicity. Citalopram is also not the first-line choice. It is safe for the patient to take medication while breastfeeding, but the infant should be monitored for any adverse effects. The priority is to manage the patient’s mood symptoms to reduce the risk to both her and her baby.

      Understanding Postpartum Mental Health Problems

      Postpartum mental health problems can range from mild ‘baby-blues’ to severe puerperal psychosis. To screen for depression, healthcare professionals may use the Edinburgh Postnatal Depression Scale, which is a 10-item questionnaire that indicates how the mother has felt over the previous week. A score of more than 13 indicates a ‘depressive illness of varying severity’, with sensitivity and specificity of more than 90%. The questionnaire also includes a question about self-harm.

      ‘Baby-blues’ is seen in around 60-70% of women and typically occurs 3-7 days following birth. It is more common in primips, and mothers are characteristically anxious, tearful, and irritable. Reassurance and support from healthcare professionals, particularly health visitors, play a key role in managing this condition. Most women with the baby blues will not require specific treatment other than reassurance.

      Postnatal depression affects around 10% of women, with most cases starting within a month and typically peaking at 3 months. The features are similar to depression seen in other circumstances, and cognitive behavioural therapy may be beneficial. Certain SSRIs such as sertraline and paroxetine may be used if symptoms are severe. Although these medications are secreted in breast milk, they are not thought to be harmful to the infant.

      Puerperal psychosis affects approximately 0.2% of women and requires admission to hospital, ideally in a Mother & Baby Unit. Onset usually occurs within the first 2-3 weeks following birth, and features include severe swings in mood (similar to bipolar disorder) and disordered perception (e.g. auditory hallucinations). There is around a 25-50% risk of recurrence following future pregnancies. Paroxetine is recommended by SIGN because of the low milk/plasma ratio, while fluoxetine is best avoided due to a long half-life.

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      • Obstetrics
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  • Question 13 - A 35-year-old woman who is 30 weeks pregnant presents with malaise, headaches and...

    Correct

    • A 35-year-old woman who is 30 weeks pregnant presents with malaise, headaches and vomiting. She is admitted to the obstetrics ward after a routine blood pressure measurement was 190/95 mmHg. Examination reveals right upper quadrant abdominal pain and brisk tendon reflexes. The following blood tests are shown:

      Hb 85 g/l
      WBC 6 * 109/l
      Platelets 89 * 109/l
      Bilirubin 2.8 µmol/l
      ALP 215 u/l
      ALT 260 u/l
      γGT 72 u/l
      LDH 846 u/I

      A peripheral blood film is also taken which shows polychromasia and schistocytes. What is the most likely diagnosis?

      Your Answer: HELLP syndrome

      Explanation:

      The symptoms of HELLP syndrome, a severe form of pre-eclampsia, include haemolysis (H), elevated liver enzymes (EL), and low platelets (LP). A patient with this condition may experience malaise, nausea, vomiting, and headache, as well as hypertension with proteinuria and epigastric and/or upper abdominal pain. The patient in this case meets the requirements for a diagnosis of HELLP syndrome.

      Liver Complications During Pregnancy

      During pregnancy, there are several liver complications that may arise. One of the most common is intrahepatic cholestasis of pregnancy, which occurs in about 1% of pregnancies and is typically seen in the third trimester. Symptoms include intense itching, especially in the palms and soles, as well as elevated bilirubin levels. Treatment involves the use of ursodeoxycholic acid for relief and weekly liver function tests. Women with this condition are usually induced at 37 weeks to prevent stillbirth, although maternal morbidity is not typically increased.

      Another rare complication is acute fatty liver of pregnancy, which may occur in the third trimester or immediately after delivery. Symptoms include abdominal pain, nausea and vomiting, headache, jaundice, and hypoglycemia. Severe cases may result in pre-eclampsia. ALT levels are typically elevated, and support care is the primary management until delivery can be performed once the patient is stabilized.

      Finally, conditions such as Gilbert’s and Dubin-Johnson syndrome may be exacerbated during pregnancy. Additionally, HELLP syndrome, which stands for haemolysis, elevated liver enzymes, and low platelets, is a serious complication that can occur in the third trimester and requires immediate medical attention. Overall, it is important for pregnant women to be aware of these potential liver complications and to seek medical attention if any symptoms arise.

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      • Obstetrics
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  • Question 14 - A 32-year-old pregnant woman is concerned about the risk of measles, mumps, and...

    Incorrect

    • A 32-year-old pregnant woman is concerned about the risk of measles, mumps, and rubella (MMR) infection for her unborn baby. She has never been vaccinated for MMR and is currently 14 weeks pregnant. There are no sick contacts around her.

      What is the appropriate course of action in this situation?

      Your Answer: Give her the measles and mumps vaccines during her current visit, but refrain from giving the rubella vaccine at any stage of her pregnancy

      Correct Answer: Refrain from giving her any MMR vaccination now and at any stage of her pregnancy

      Explanation:

      The MMR vaccine, which contains live attenuated virus, should not be given to women who are pregnant or trying to conceive. It is recommended that women avoid getting pregnant for at least 28 days after receiving the vaccine. If a pregnant woman is not immune to MMR, she should avoid contact with individuals who have the disease. In the event that a woman receives the MMR vaccine unintentionally during the periconception period or early pregnancy, termination of pregnancy is not necessary. This information is based on the guidelines provided by the American College of Obstetricians and Gynecologists.

      Rubella and Pregnancy: Risks, Features, Diagnosis, and Management

      Rubella, also known as German measles, is a viral infection caused by the togavirus. Thanks to the introduction of the MMR vaccine, it is now rare. However, if contracted during pregnancy, there is a risk of congenital rubella syndrome, which can cause serious harm to the fetus. It is important to note that the incubation period is 14-21 days, and individuals are infectious from 7 days before symptoms appear to 4 days after the onset of the rash.

      The risk of damage to the fetus is highest in the first 8-10 weeks of pregnancy, with a risk as high as 90%. However, damage is rare after 16 weeks. Features of congenital rubella syndrome include sensorineural deafness, congenital cataracts, congenital heart disease (e.g. patent ductus arteriosus), growth retardation, hepatosplenomegaly, purpuric skin lesions, ‘salt and pepper’ chorioretinitis, microphthalmia, and cerebral palsy.

      If a suspected case of rubella in pregnancy arises, it should be discussed immediately with the local Health Protection Unit (HPU) as type/timing of investigations may vary. IgM antibodies are raised in women recently exposed to the virus. It should be noted that it is very difficult to distinguish rubella from parvovirus B19 clinically. Therefore, it is important to also check parvovirus B19 serology as there is a 30% risk of transplacental infection, with a 5-10% risk of fetal loss.

      If a woman is tested at any point and no immunity is demonstrated, they should be advised to keep away from people who might have rubella. Non-immune mothers should be offered the MMR vaccination in the post-natal period. However, MMR vaccines should not be administered to women known to be pregnant or attempting to become pregnant.

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      • Obstetrics
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  • Question 15 - The technician performed an ultrasonographic examination on a pregnant woman and obtained a...

    Correct

    • The technician performed an ultrasonographic examination on a pregnant woman and obtained a median scan of the 7-week-old embryo. Using the ultrasound machine, the technician marked the most superior point of the embryo's head and the most inferior point of the embryo. The technician then measured the distance between the marks. What is the calculation that the technician made?

      Your Answer: Crown–rump length

      Explanation:

      Choosing the Appropriate Measurement for Estimating Embryonic Age

      When estimating the age of an embryo, it is important to choose the appropriate measurement based on the anatomy and timing of the scan. In the case of a scan taken at 7 weeks post-fertilisation, the crown-rump length is the most appropriate measurement to use. The greatest width is not used for estimating embryonic age, while the greatest length is only suitable for early embryos in the third and early fourth weeks. Crown-heel length may be used for 8-week-old embryos, but requires visibility of the lower limb. Crown-elbow length is not applicable in this case as the limbs cannot be visualised. It is important to consider the specific circumstances of the scan when choosing the appropriate measurement for estimating embryonic age.

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      • Obstetrics
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  • Question 16 - You are asked to review a 32-year-old woman, who is breastfeeding on day...

    Incorrect

    • You are asked to review a 32-year-old woman, who is breastfeeding on day two post-emergency Caesarean section, because her wound is tender. On examination, you notice that the skin surrounding the wound is erythematosus, with a small amount of yellow discharge. There is no wound dehiscence. The area is tender on examination. Observations are stable, and the patient is apyrexial. You send a swab from the wound for culture. She has an allergy to penicillin.
      Which of the following is the best next step in this patient’s management?

      Your Answer: Intravenous antibiotics

      Correct Answer: Oral erythromycin

      Explanation:

      Treatment of Cellulitis in Post-Caesarean Section Patient

      Cellulitis around the Caesarean wound site requires prompt treatment to prevent the development of sepsis, especially in postpartum women. The initial steps include wound swab for culture and sensitivities, marking the area of cellulitis, and analgesia. Flucloxacillin is the first-line antibiotic for cellulitis, but oral erythromycin is recommended for patients with penicillin allergy. The dose of erythromycin is 500 mg four times a day orally for five to seven days, and it is safe during breastfeeding. Topical treatment is not as effective as systemic treatment, and analgesia is necessary to manage pain. Antibiotics should not be delayed until culture sensitivities are available, and intravenous antibiotics are not indicated unless the patient’s condition deteriorates. Close monitoring of symptoms, observations, and inflammatory markers should guide treatment.

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      • Obstetrics
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  • Question 17 - A 29-year-old woman presents with hypertension at 12 weeks into her pregnancy. She...

    Correct

    • A 29-year-old woman presents with hypertension at 12 weeks into her pregnancy. She has no history of hypertension. She complains of headache and tenderness in the right lower quadrant. An ultrasound of her pelvis reveals multiple cysts in both ovaries. There are no signs of hirsutism or virilism. What is the most probable diagnosis?

      Your Answer: Molar pregnancy

      Explanation:

      Possible Causes of Hirsutism in Women: A Differential Diagnosis

      Hirsutism, the excessive growth of hair in women in a male pattern, can be caused by various underlying conditions. Here are some possible causes and their distinguishing features:

      Molar Pregnancy: This condition is characterized by hypertension in the first trimester of pregnancy. Excessive stimulation of ovarian follicles by high levels of gonadotrophins or human chorionic gonadotrophin (hCG) can lead to the formation of multiple theca lutein cysts bilaterally.

      Congenital Adrenal Hyperplasia: This disease, which is mostly found in women, can present with gradual onset of hirsutism without virilization. It is caused by a deficiency of 21-hydroxylase and is characterized by an elevated serum concentration of 17-hydroxyprogesterone.

      Luteoma of Pregnancy: This benign, solid ovarian tumor develops during pregnancy and disappears after delivery. It may be associated with excess androgen production, leading to hirsutism and virilization.

      Adrenal Tumor: Androgen-secreting adrenal tumors can cause rapid onset of severe hirsutism, with or without virilization. Amenorrhea is found in almost half of the patients, and testosterone and dihydrotestosterone sulfate concentrations are elevated.

      Polycystic Ovary Syndrome: Women with this condition are at higher risk of developing pre-eclampsia. However, the development of hypertension in the first trimester of pregnancy makes it more likely that there is a molar pregnancy present, with theca lutein cysts seen on ultrasound.

      In summary, hirsutism in women can be caused by various conditions, and a differential diagnosis is necessary to determine the underlying cause and appropriate treatment.

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      • Obstetrics
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  • Question 18 - A 32-year-old pregnant woman with pre-eclampsia experienced an eclamptic seizure at 11 am...

    Incorrect

    • A 32-year-old pregnant woman with pre-eclampsia experienced an eclamptic seizure at 11 am today. Magnesium was administered, and the baby was delivered an hour later at midday. However, she had another eclamptic seizure at 2 pm. Both the mother and baby have been stable since then. What is the appropriate time to discontinue the magnesium infusion?

      Your Answer: Until blood pressure returns to less than 140/90 mmHg

      Correct Answer: 24 hours after last seizure

      Explanation:

      The administration of magnesium should be initiated in women who are at high risk of severe pre-eclampsia or those who have eclampsia. It is important to continue the treatment for 24 hours after delivery or the last seizure, whichever occurs later. Therefore, the correct answer is 24 hours after the last seizure.

      Understanding Eclampsia and its Treatment

      Eclampsia is a condition that occurs when seizures develop in association with pre-eclampsia, a pregnancy-induced hypertension that is characterized by proteinuria and occurs after 20 weeks of gestation. To prevent seizures in patients with severe pre-eclampsia and treat seizures once they develop, magnesium sulphate is commonly used. However, it is important to note that this medication should only be given once a decision to deliver has been made. In cases of eclampsia, an IV bolus of 4g over 5-10 minutes should be given, followed by an infusion of 1g/hour. During treatment, it is crucial to monitor urine output, reflexes, respiratory rate, and oxygen saturations. Respiratory depression can occur, and calcium gluconate is the first-line treatment for magnesium sulphate-induced respiratory depression. Treatment should continue for 24 hours after the last seizure or delivery, as around 40% of seizures occur post-partum. Additionally, fluid restriction is necessary to avoid the potentially serious consequences of fluid overload.

      In summary, understanding the development of eclampsia and its treatment is crucial in managing this potentially life-threatening condition. Magnesium sulphate is the primary medication used to prevent and treat seizures, but it should only be given once a decision to deliver has been made. Monitoring vital signs and urine output is essential during treatment, and calcium gluconate should be readily available in case of respiratory depression. Finally, fluid restriction is necessary to avoid complications associated with fluid overload.

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  • Question 19 - A 35-year-old woman who has never given birth is in labour at 37...

    Correct

    • A 35-year-old woman who has never given birth is in labour at 37 weeks gestation. During examination, the cervix is found to be dilated at 7 cm, the head is in direct Occipito-Anterior position, the foetal station is at -1, and the head is palpable at 2/5 ths per abdomen. The cardiotocogram reveals late decelerations and a foetal heart rate of 100 beats/min, which persist for 15 minutes. What is the appropriate course of action in this scenario?

      Your Answer: Caesarian section

      Explanation:

      The cardiotocogram shows late decelerations and foetal bradycardia, indicating the need for immediate delivery. Instrumental delivery is not possible and oxytocin and vaginal prostaglandin are contraindicated. The safest approach is an emergency caesarian section.

      Cardiotocography (CTG) is a medical procedure that measures pressure changes in the uterus using either internal or external pressure transducers. It is used to monitor the fetal heart rate, which normally ranges between 100-160 beats per minute. There are several features that can be observed during a CTG, including baseline bradycardia (heart rate below 100 beats per minute), which can be caused by increased fetal vagal tone or maternal beta-blocker use. Baseline tachycardia (heart rate above 160 beats per minute) can be caused by maternal pyrexia, chorioamnionitis, hypoxia, or prematurity. Loss of baseline variability (less than 5 beats per minute) can be caused by prematurity or hypoxia. Early deceleration, which is a decrease in heart rate that starts with the onset of a contraction and returns to normal after the contraction, is usually harmless and indicates head compression. Late deceleration, on the other hand, is a decrease in heart rate that lags behind the onset of a contraction and does not return to normal until after 30 seconds following the end of the contraction. This can indicate fetal distress, such as asphyxia or placental insufficiency. Variable decelerations, which are independent of contractions, may indicate cord compression.

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      • Obstetrics
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  • Question 20 - A 35-year-old woman presents at 12 weeks’ gestation to see the clinician. Her...

    Correct

    • A 35-year-old woman presents at 12 weeks’ gestation to see the clinician. Her risk of developing Down syndrome was calculated as 1 in 8, and she was offered a diagnostic test. Amniocentesis confirms Down syndrome. Following long discussions with her and her partner, she decides on termination of the pregnancy.
      Which of the following is the most appropriate management option for this patient?

      Your Answer: Oral mifepristone followed by vaginal misoprostol as an inpatient

      Explanation:

      Medical and Surgical Management of Termination of Pregnancy

      Medical and surgical management are two options for termination of pregnancy. Medical management involves the use of oral mifepristone followed by vaginal misoprostol. This method is recommended for termination of pregnancy before 13 weeks’ gestation and can be performed in an inpatient setting. The patient is administered the medication in hospital and will stay in the clinic or hospital to pass the pregnancy. Appropriate analgesia and antiemetics are given to take home, as required. The patient should be advised that there is a possibility medical management will fail and surgical management will need to take place.

      Mifepristone is a competitive antagonist of progesterone for the progesterone receptor. It promotes degradation of the decidualised endometrium, cervical ripening and dilation, as well as increases the sensitivity of the myometrium to the effect of prostaglandins. Misoprostol, a synthetic prostaglandin E1, in turn, binds avidly to myometrial cells, promoting contraction of the uterus, and therefore expulsion of the products of conception. If this fails to empty the uterus, then a surgical procedure to manually evacuate the uterus is the next appropriate step in the patient’s management.

      Surgical termination of pregnancy is first line for women presenting after 14 weeks’ gestation, women who have a preference over medical management and patients where medical termination has failed.

      In cases where the patient has decided to proceed with termination of pregnancy, delaying the procedure is unethical and does not benefit the patient in any way. The patient should be fully informed of the risks associated with the procedure and given the necessary support.

      Vaginal misoprostol can also be used in conjunction with mifepristone for medical termination of pregnancy or as monotherapy in medical management of miscarriage or induction of labour.

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  • Question 21 - A woman who is positive for hepatitis B serology and surface antigen gives...

    Correct

    • A woman who is positive for hepatitis B serology and surface antigen gives birth to a healthy baby girl. What treatment should be provided to the newborn?

      Your Answer: Hep B vaccine and 0.5 millilitres of HBIG within 12 hours of birth with a further hepatitis vaccine at 1-2 months and a further vaccine at 6 months

      Explanation:

      When babies are born to mothers who are hepatitis B surface antigen positive or are at high risk of developing hepatitis B, they should receive the first dose of the hepatitis B vaccine shortly after birth. Additionally, babies born to surface antigen positive mothers should receive 0.5 millilitres of hepatitis B immunoglobulin within 12 hours of birth. The second and third doses of the hepatitis B vaccine should be given at 1-2 months and 6 months, respectively.

      Hepatitis B and Pregnancy: Screening and Prevention

      During pregnancy, all women are offered screening for hepatitis B. If a mother is found to be chronically infected with hepatitis B or has had acute hepatitis B during pregnancy, it is important that her baby receives a complete course of vaccination and hepatitis B immunoglobulin. Currently, studies are being conducted to evaluate the effectiveness of oral antiviral treatment, such as Lamivudine, in the latter part of pregnancy.

      There is little evidence to suggest that a caesarean section reduces the risk of vertical transmission of hepatitis B. However, it is important to note that hepatitis B cannot be transmitted through breastfeeding, unlike HIV. It is crucial for pregnant women to undergo screening for hepatitis B to ensure the health and safety of both the mother and the baby. With proper prevention and treatment, the risk of transmission can be greatly reduced.

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  • Question 22 - A 32-year-old teacher with type II diabetes is 5-months pregnant with her first...

    Incorrect

    • A 32-year-old teacher with type II diabetes is 5-months pregnant with her first child. Following reviewing the patient in prenatal clinic, you are interested to find out more about stages of fetal development.
      During the fifth (gestational) month of human development, which organ is the most active site of formation of formed elements of the blood?

      Your Answer: Liver

      Correct Answer: Bone marrow

      Explanation:

      The Sites of Haematopoiesis in the Fetus and Adult

      Haematopoiesis, the process of blood cell formation, occurs in various sites throughout fetal development and in adults. The dominant site of haematopoiesis changes as the fetus develops and bones are formed. Here are the different sites of haematopoiesis and their significance:

      Bone Marrow: From four months into childhood and adulthood, bone marrow becomes the primary source of hematopoiesis. Red blood cells and immune effector cells are derived from pluripotent haematopoietic cells, which are first noted in blood islands of the yolk sac. By 20 weeks, almost all of these cells are produced by the bone marrow.

      Yolk Sac: Haematopoiesis begins in the yolk sac and in angiogenic cell clusters throughout the embryonic body. This involves the formation of nucleated red blood cells, which differentiate from endothelial cells in the walls of blood vessels. Yolk sac haematopoiesis peaks at about one month and becomes insignificant by three months.

      Liver: By the sixth week, the fetal liver performs haematopoiesis. This peaks at 12-16 weeks and continues until approximately 36 weeks. Haematopoietic stem cells differentiate in the walls of liver sinusoids. In adults, there is a reserve haematopoietic capacity, especially in the liver.

      Spleen: The spleen is a minor site of haematopoiesis, being active between the third and sixth months.

      Lymph Nodes: Lymph nodes are not a significant site of haematopoiesis.

      In patients with certain conditions, such as haemolytic anaemia or myeloproliferative disease, hepatic haematopoiesis may be reactivated, leading to hepatomegaly. Understanding the different sites of haematopoiesis is important for understanding blood cell formation and certain medical conditions.

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  • Question 23 - A 26-year-old woman presents with significant vaginal bleeding and is diagnosed with a...

    Correct

    • A 26-year-old woman presents with significant vaginal bleeding and is diagnosed with a hydatidiform mole. The uterus is evacuated, but she continues to feel unwell and her β-human chorionic gonadotrophin (β-HCG) levels continue to increase in the following weeks.
      What is the most probable diagnosis?

      Your Answer: Choriocarcinoma

      Explanation:

      Gestational trophoblastic disease (GTD) is a rare condition that includes hydatidiform mole, choriocarcinoma, and placental site trophoblastic tumor. GTD occurs when abnormal trophoblastic tissue forms instead of a fetus after fertilization. Hydatidiform moles are the most common form of GTD and are found in about 1 in every 1000 births. They often present with signs of early pregnancy failure, such as heavy vaginal bleeding. Treatment involves removing the abnormal tissue, and close monitoring of beta-HCG levels is necessary post-evacuation. If levels fail to drop, it may indicate an invasive mole or choriocarcinoma, which requires referral to a specialist center for further treatment. Pituitary and adrenal adenomas are other types of tumors that can produce hormones and cause various symptoms. In contrast, ectopic pregnancy is a separate condition that occurs when a fertilized egg implants outside the uterus.

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  • Question 24 - A mother brings her 5-day old daughter to see you as she is...

    Correct

    • A mother brings her 5-day old daughter to see you as she is worried about her daughter's weight loss. The baby was born at term without any complications. She is exclusively breastfed and has had a normal amount of wet nappies today. The baby is not showing any signs of distress and all observations are within normal limits. However, her birth weight was 3200g and today she weighs 2900g. What would be the best course of action to manage this infant's weight loss?

      Your Answer: Referral to midwife-led breastfeeding clinic

      Explanation:

      If the baby loses more than 10% of his birth weight in the first week, immediate measures must be taken to ensure proper feeding.

      Breastfeeding Problems and Their Management

      Breastfeeding is a natural process, but it can come with its own set of challenges. Some of the minor problems that breastfeeding mothers may encounter include frequent feeding, nipple pain, blocked ducts, and nipple candidiasis. These issues can be managed by seeking advice on proper positioning, trying breast massage, and using appropriate medication.

      Mastitis is a more serious problem that affects around 1 in 10 breastfeeding women. It is characterized by symptoms such as fever, nipple fissure, and persistent pain. Treatment involves the use of antibiotics, such as flucloxacillin, for 10-14 days. Breastfeeding or expressing milk should continue during treatment to prevent complications such as breast abscess.

      Breast engorgement is another common problem that causes breast pain in breastfeeding women. It occurs in the first few days after birth and affects both breasts. Hand expression of milk can help relieve the discomfort of engorgement. Raynaud’s disease of the nipple is a less common problem that causes nipple pain and blanching. Treatment involves minimizing exposure to cold, using heat packs, and avoiding caffeine and smoking.

      If a breastfed baby loses more than 10% of their birth weight in the first week of life, it may be a sign of poor weight gain. This should prompt consideration of the above breastfeeding problems and an expert review of feeding. Monitoring of weight should continue until weight gain is satisfactory.

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  • Question 25 - As the junior doctor on the labour ward, you are summoned to attend...

    Incorrect

    • As the junior doctor on the labour ward, you are summoned to attend a first delivery of a 26-year-old patient. The patient experienced spontaneous preterm rupture of membranes at 34 weeks, and now the umbilical cord is palpable above the level of the introitus. What is the appropriate course of action for managing this patient?

      Your Answer: The patient is advised to lie supine

      Correct Answer: The presenting part of the fetus may be pushed back into the uterus

      Explanation:

      In the event of cord prolapse, which occurs when the umbilical cord descends below the presenting part of the fetus after membrane rupture, fetal hypoxia and death can occur due to cord compression or spasm. To prevent compression, tocolytics should be administered and a Caesarean delivery should be performed. The patient should be advised to assume an all-fours position. It is important not to push the cord back into the uterus. The preferred method of delivery is an immediate Caesarean section.

      Understanding Umbilical Cord Prolapse

      Umbilical cord prolapse is a rare but serious complication that can occur during delivery. It happens when the umbilical cord descends ahead of the presenting part of the fetus, which can lead to compression or spasm of the cord. This can cause fetal hypoxia and potentially irreversible damage or death. Certain factors increase the risk of cord prolapse, such as prematurity, multiparity, polyhydramnios, twin pregnancy, cephalopelvic disproportion, and abnormal presentations like breech or transverse lie.

      Around half of all cord prolapses occur when the membranes are artificially ruptured. Diagnosis is usually made when the fetal heart rate becomes abnormal and the cord is palpable vaginally or visible beyond the introitus. Cord prolapse is an obstetric emergency that requires immediate management. The presenting part of the fetus may be pushed back into the uterus to avoid compression, and the cord should be kept warm and moist to prevent vasospasm. The patient may be asked to go on all fours or assume the left lateral position until preparations for an immediate caesarian section have been carried out. Tocolytics may be used to reduce uterine contractions, and retrofilling the bladder with saline can help elevate the presenting part. Although caesarian section is the usual first-line method of delivery, an instrumental vaginal delivery may be possible if the cervix is fully dilated and the head is low.

      In conclusion, umbilical cord prolapse is a rare but serious complication that requires prompt recognition and management. Understanding the risk factors and appropriate interventions can help reduce the incidence of fetal mortality associated with this condition.

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  • Question 26 - A 32-year-old woman who is 32 weeks pregnant visits her local antenatal unit...

    Correct

    • A 32-year-old woman who is 32 weeks pregnant visits her local antenatal unit for a midwife check-up. She has been diagnosed with intrahepatic cholestasis of pregnancy and is taking ursodeoxycholic acid. Additionally, she is being treated with lamotrigine for epilepsy. This is her first pregnancy, and she has not experienced any previous miscarriages. During her appointment, she expresses concern about her step-sister's recent stillbirth, as her step-sister has already had two prior stillbirths. Based on her medical history, which factor puts her at the highest risk for a similar outcome?

      Your Answer: Intrahepatic cholestasis of pregnancy

      Explanation:

      Intrahepatic cholestasis of pregnancy is known to increase the risk of stillbirth, which is why doctors usually recommend inducing labor at 37-38 weeks of gestation. Although some studies suggest that this may no longer be the case, the general consensus is that the risk of stillbirth is still relatively high. Therefore, early induction of labor is still advised.

      While advanced maternal age is a risk factor for stillbirth, being 34 years old is not considered to be in the category of older maternal age, which is defined as 35 years old or older.

      Although there may be a genetic component to stillbirths, having a step-sister with a history of stillbirth does not constitute a family history of the condition. This is because step-siblings are not biologically related, but rather connected through marriage.

      Lamotrigine is considered the safest anti-epileptic medication to use during pregnancy, and there is no evidence to suggest that it increases the risk of stillbirth.

      Intrahepatic Cholestasis of Pregnancy: Symptoms and Management

      Intrahepatic cholestasis of pregnancy, also known as obstetric cholestasis, is a condition that affects approximately 1% of pregnancies in the UK. It is characterized by intense itching, particularly on the palms, soles, and abdomen, and may also result in clinically detectable jaundice in around 20% of patients. Raised bilirubin levels are seen in over 90% of cases.

      The management of intrahepatic cholestasis of pregnancy typically involves induction of labor at 37-38 weeks, although this practice may not be evidence-based. Ursodeoxycholic acid is also widely used, although the evidence base for its effectiveness is not clear. Additionally, vitamin K supplementation may be recommended.

      It is important to note that the recurrence rate of intrahepatic cholestasis of pregnancy in subsequent pregnancies is high, ranging from 45-90%. Therefore, close monitoring and management are necessary for women who have experienced this condition in the past.

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  • Question 27 - A 35-year-old woman is 39 weeks pregnant with twins (dichorionic diamniotic). During labor,...

    Incorrect

    • A 35-year-old woman is 39 weeks pregnant with twins (dichorionic diamniotic). During labor, the midwife observes the umbilical cord protruding from the vagina. The emergency button is pressed, and the woman is rushed for an emergency C-section. What is the most probable cause of umbilical cord prolapse?

      Your Answer: Nulliparity

      Correct Answer: Artificial amniotomy

      Explanation:

      The most probable reason for umbilical cord prolapse is artificial rupture of membranes. Factors such as cephalic presentation, nulliparity, and prolonged pregnancy decrease the chances of cord prolapse. Prostaglandins do not significantly affect the risk of cord prolapse.

      Understanding Umbilical Cord Prolapse

      Umbilical cord prolapse is a rare but serious complication that can occur during delivery. It happens when the umbilical cord descends ahead of the presenting part of the fetus, which can lead to compression or spasm of the cord. This can cause fetal hypoxia and potentially irreversible damage or death. Certain factors increase the risk of cord prolapse, such as prematurity, multiparity, polyhydramnios, twin pregnancy, cephalopelvic disproportion, and abnormal presentations like breech or transverse lie.

      Around half of all cord prolapses occur when the membranes are artificially ruptured. Diagnosis is usually made when the fetal heart rate becomes abnormal and the cord is palpable vaginally or visible beyond the introitus. Cord prolapse is an obstetric emergency that requires immediate management. The presenting part of the fetus may be pushed back into the uterus to avoid compression, and the cord should be kept warm and moist to prevent vasospasm. The patient may be asked to go on all fours or assume the left lateral position until preparations for an immediate caesarian section have been carried out. Tocolytics may be used to reduce uterine contractions, and retrofilling the bladder with saline can help elevate the presenting part. Although caesarian section is the usual first-line method of delivery, an instrumental vaginal delivery may be possible if the cervix is fully dilated and the head is low.

      In conclusion, umbilical cord prolapse is a rare but serious complication that requires prompt recognition and management. Understanding the risk factors and appropriate interventions can help reduce the incidence of fetal mortality associated with this condition.

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  • Question 28 - A 34-year-old woman in her second pregnancy comes in at 11 weeks with...

    Incorrect

    • A 34-year-old woman in her second pregnancy comes in at 11 weeks with a 1-day history of vaginal bleeding. Bleeding began as a light brown discharge while wiping and was accompanied by menstrual-like cramps. Symptoms have since subsided. During the examination, the abdomen is soft and painless, the cervical os is closed, and there is some dark brown discharge in the vaginal area.
      What ultrasound results would confirm the diagnosis?

      Your Answer: An empty uterus

      Correct Answer: Gestational sac seen within the uterus; fetal heart rate present

      Explanation:

      Understanding Different Types of Miscarriage

      Miscarriage is the loss of pregnancy before 20 weeks’ gestation and can occur due to various risk factors. There are different types of miscarriage, each with its own set of symptoms and ultrasound findings.

      Threatened Miscarriage: This type presents with lower abdominal pain and light brown discharge. Ultrasound reveals an intrauterine gestational sac and fetal heart rate. Patients may experience further threatened miscarriage or proceed to a complete or full-term pregnancy.

      Inevitable Miscarriage: Active bleeding within the uterine cavity is suggestive of an ongoing miscarriage. The cervical os is open, and products of conception may be seen within the vagina. This type will inevitably progress to a miscarriage.

      Complete Miscarriage: An empty uterus is associated with a complete miscarriage. Examination reveals a closed cervical os and may or may not be associated with vaginal bleeding.

      Missed Miscarriage: A gestational sac small for dates, associated with an absent fetal heart rate, is an incidental finding. Examination is unremarkable, with a closed cervical os and no evidence of vaginal bleeding.

      Incomplete Miscarriage: Products of conception are seen within the uterus, with an absent fetal heart rate. Examination reveals an open or closed cervical os and bleeding. If this miscarriage does not proceed to a complete miscarriage, it will require surgical evacuation.

      Understanding the different types of miscarriage can help patients and healthcare providers manage the condition effectively.

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  • Question 29 - A 25-year-old patient with a history of well-controlled epilepsy visits the general practice...

    Correct

    • A 25-year-old patient with a history of well-controlled epilepsy visits the general practice with her partner. They have been attempting to conceive through regular sexual intercourse for the past 10 months. The patient is currently taking omeprazole, levetiracetam, folic acid 400 micrograms, and paracetamol as needed. What medication adjustments would be most suitable?

      Your Answer: Folic acid 5 milligrams

      Explanation:

      Women on antiepileptics trying to conceive should receive 5mg folic acid. Letrozole and clomiphene are not appropriate for this patient. Adequate control of epilepsy is important and medication changes should be made by a specialist. This patient should be started on a high dose of folic acid due to the risk of neural tube defects.

      Folic Acid: Importance, Deficiency, and Prevention

      Folic acid is a vital nutrient that is converted to tetrahydrofolate (THF) in the body. It is found in green, leafy vegetables and plays a crucial role in the transfer of 1-carbon units to essential substrates involved in the synthesis of DNA and RNA. However, certain factors such as phenytoin, methotrexate, pregnancy, and alcohol excess can cause a deficiency in folic acid. This deficiency can lead to macrocytic, megaloblastic anemia and neural tube defects.

      To prevent neural tube defects during pregnancy, it is recommended that all women take 400mcg of folic acid until the 12th week of pregnancy. Women at higher risk of conceiving a child with a neural tube defect should take 5mg of folic acid from before conception until the 12th week of pregnancy. Women are considered higher risk if they or their partner has a neural tube defect, they have had a previous pregnancy affected by a neural tube defect, or they have a family history of a neural tube defect. Additionally, women with certain medical conditions such as coeliac disease, diabetes, or thalassaemia trait, or those taking antiepileptic drugs, or who are obese (BMI of 30 kg/m2 or more) are also considered higher risk.

      In summary, folic acid is an essential nutrient that plays a crucial role in DNA and RNA synthesis. Deficiency in folic acid can lead to serious health consequences, including neural tube defects. However, taking folic acid supplements during pregnancy can prevent these defects and ensure a healthy pregnancy.

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  • Question 30 - A 29-year-old woman is being monitored with cardiotocography (CTG) during her labor. What...

    Incorrect

    • A 29-year-old woman is being monitored with cardiotocography (CTG) during her labor. What would be considered an 'abnormal' characteristic of the CTG tracings?

      Your Answer: Baseline heart rate of 160 beats/minute

      Correct Answer: A single prolonged deceleration lasting 3 minutes or more

      Explanation:

      Cardiotocography (CTG) is a medical procedure that measures pressure changes in the uterus using either internal or external pressure transducers. It is used to monitor the fetal heart rate, which normally ranges between 100-160 beats per minute. There are several features that can be observed during a CTG, including baseline bradycardia (heart rate below 100 beats per minute), which can be caused by increased fetal vagal tone or maternal beta-blocker use. Baseline tachycardia (heart rate above 160 beats per minute) can be caused by maternal pyrexia, chorioamnionitis, hypoxia, or prematurity. Loss of baseline variability (less than 5 beats per minute) can be caused by prematurity or hypoxia. Early deceleration, which is a decrease in heart rate that starts with the onset of a contraction and returns to normal after the contraction, is usually harmless and indicates head compression. Late deceleration, on the other hand, is a decrease in heart rate that lags behind the onset of a contraction and does not return to normal until after 30 seconds following the end of the contraction. This can indicate fetal distress, such as asphyxia or placental insufficiency. Variable decelerations, which are independent of contractions, may indicate cord compression.

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  • Question 31 - A 30-year-old woman who is 26 weeks’ pregnant presents to the Emergency Department...

    Correct

    • A 30-year-old woman who is 26 weeks’ pregnant presents to the Emergency Department (ED) with some swelling of her ankles. She has had no other pregnancy problems and this is her first child. Her blood pressure is 150/95 mmHg and she has 2+ protein in her urine. After 4 hours, her blood pressure has decreased to 130/95 mmHg. Her booking bloods and previous bloods are not available. Her results are as follows:
      Investigation Result Normal value
      Blood pressure 130/95 mmHg < 120/< 80 mmHg
      Haemoglobin (Hb) 85 g/l 115–155 g/l
      Platelets (Plts) < 210 × 109/l 150-400 × 109/l
      Alkaline phosphatase (ALP) 250 U/litre 25–250 U/litre (in pregnancy)

      Which of the following statements is most likely to be true?

      Your Answer: By definition she has pre-eclampsia and should be admitted for investigations and blood pressure (BP) control

      Explanation:

      Understanding Pre-eclampsia and HELLP Syndrome in Pregnancy

      Pre-eclampsia is a serious condition that can occur during pregnancy, characterized by high blood pressure and proteinuria. Diagnosis requires two readings of blood pressure, taken 4-6 hours apart, with a systolic reading of 140 or higher, a diastolic reading of 90 or higher, or an increase of 30 systolic or 20 diastolic from booking blood pressure in the second half of pregnancy. Proteinuria of at least 1+ on reagent stick testing is also required.

      The severity of pre-eclampsia is classified based on blood pressure readings. Mild pre-eclampsia is characterized by a systolic reading of 140-149 or a diastolic reading of 90-99. Moderate pre-eclampsia is characterized by a systolic reading of 150-159 or a diastolic reading of 100-109. Severe pre-eclampsia is diagnosed with a systolic reading of 160 or higher or a diastolic reading of 110 or higher.

      HELLP syndrome is a subtype of severe pre-eclampsia, characterized by haemolysis, elevated liver enzymes, and low platelets. Diagnosis requires a blood film showing fragmented red cells, an LDH level over 600 IU/litre, and raised bilirubin. Elevated AST or ALT levels over 70 IU/litre and platelet counts below 100 x 10^9/litre are also required.

      It is important to note that not all cases of high blood pressure in pregnancy are pre-eclampsia or HELLP syndrome. However, if a pregnant woman meets the diagnostic criteria for pre-eclampsia, it is an obstetrical emergency and requires immediate attention. Additionally, if a pregnant woman has high ALP levels, an ultrasound scan of the biliary tree may be necessary to check for biliary obstruction. It is also important to note that ALP levels are typically elevated during pregnancy due to the placenta releasing ALP.

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  • Question 32 - A 29-year-old lady who is 30 weeks pregnant with her second child presents...

    Incorrect

    • A 29-year-old lady who is 30 weeks pregnant with her second child presents in a very anxious state. She has just been at a friend’s party and has discovered that one of the children there had just developed a rash suggesting chickenpox. She is terrified the disease is going to harm her unborn child. She cannot recall if she had chickenpox as a child. Her medical record does not shed any light on the situation, and it is unclear if she has had vaccination against varicella. She does not have a rash herself and feels well. Her pregnancy has been uncomplicated to date.
      What is the most appropriate next course of action?

      Your Answer: Advise that no immediate action is needed, but she should return immediately if she develops a rash, so that varicella-zoster immunoglobulin can be administered

      Correct Answer: Urgently test for varicella antibodies (varicella-zoster IgG)

      Explanation:

      The patient’s immunity to varicella-zoster needs to be determined urgently by testing for varicella-zoster IgG antibodies in the blood, as she has had some exposure to chickenpox and is unsure of her immunity status. If antibodies are detected, she is considered immune and no further action is required, but she should seek medical care immediately if she develops a rash. Varicella-zoster immunoglobulin should only be administered to non-immune patients within 10 days of exposure. It is important to note that if the patient contracts chickenpox during pregnancy, there is a risk of fetal varicella syndrome if infected before 28 weeks’ gestation. Immunisation during pregnancy is not recommended, but the patient can receive the vaccine postpartum if found to be non-immune. It is safe to receive the vaccine while breastfeeding.

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  • Question 33 - A 27-year-old woman, who is 30 weeks pregnant, reports feeling breathless during a...

    Correct

    • A 27-year-old woman, who is 30 weeks pregnant, reports feeling breathless during a routine prenatal appointment. Upon examination, you observe that everything appears normal except for mild hyperventilation. What is the probable discovery during pregnancy?

      Your Answer: Decrease in total lung capacity

      Explanation:

      Changes in Physiological Parameters during Pregnancy

      During pregnancy, various physiological changes occur in a woman’s body to support the growing fetus. One of these changes is a decrease in total lung capacity by approximately 200 ml. This reduction is due to a decrease in residual volume caused by the fetus. However, the basal metabolic rate increases during pregnancy. Additionally, cardiac output can increase by up to 40%, while the glomerular filtration rate (GFR) normally increases. Maternal oxygen consumption also rises during pregnancy to meet the oxygen demands of the fetus, leading to an increase in minute volume. These changes in physiological parameters are essential for the healthy development of the fetus and the mother’s well-being during pregnancy.

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  • Question 34 - A 28-year-old woman who has never given birth is found to have gestational...

    Incorrect

    • A 28-year-old woman who has never given birth is found to have gestational diabetes during her current pregnancy after an oral glucose tolerance test (OGTT). She inquires about the potential impact of this diagnosis on future pregnancies.

      What is the recommended method for screening for gestational diabetes in subsequent pregnancies?

      Your Answer: OGTT at 24-28 weeks

      Correct Answer: OGTT immediately after booking, and at 24-28 weeks

      Explanation:

      Women with a history of gestational diabetes should be offered an OGTT immediately after booking and at 24-28 weeks to screen for gestational diabetes in subsequent pregnancies. No screening test is not recommended. OGTT at 24-28 weeks is the screening strategy for those with risk factors but no previous history of gestational diabetes.

      Gestational diabetes is a common medical disorder affecting around 4% of pregnancies. Risk factors include a high BMI, previous gestational diabetes, and family history of diabetes. Screening is done through an oral glucose tolerance test, and diagnostic thresholds have recently been updated. Management includes self-monitoring of blood glucose, diet and exercise advice, and medication if necessary. For pre-existing diabetes, weight loss and insulin are recommended, and tight glycemic control is important. Targets for self-monitoring include fasting glucose of 5.3 mmol/l and 1-2 hour post-meal glucose levels.

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  • Question 35 - A 33-year-old woman gives birth to a healthy baby at 38 weeks gestation...

    Correct

    • A 33-year-old woman gives birth to a healthy baby at 38 weeks gestation without any complications during delivery. Following a physiological third stage of labor, the patient experiences suspected uterine atony and loses 800 ml of blood. She has a medical history of asthma.

      An ABCDE approach is taken, and IV access is established. The obstetric consultant attempts uterine compression, but the bleeding persists. The patient's heart rate is 92 bpm, and her blood pressure is 130/80 mmHg.

      What is the next appropriate step in managing this patient?

      Your Answer: IV oxytocin

      Explanation:

      Medical treatments available for managing postpartum haemorrhage caused by uterine atony include oxytocin, ergometrine, carboprost, and misoprostol.

      The correct option for this patient is IV oxytocin. The patient is experiencing primary postpartum haemorrhage (PPH), which is characterized by the loss of more than 500 ml of blood within 24 hours of delivering the baby. Uterine atony, which occurs when the uterus fails to contract after the placenta is delivered, is the most common cause of PPH. The initial steps in managing this condition involve an ABCDE approach, establishing IV access, and resuscitation. Mechanical palpation of the uterine fundus (rubbing the uterus) is also done to stimulate contractions, but it has not been successful in this case. The next step is pharmacological management, which involves administering IV oxytocin.

      IM carboprost is not the correct option. Although it is another medical management option, it should be avoided in patients with asthma, which this patient has.

      IV carboprost is also not the correct option. Carboprost is given intramuscularly, not intravenously. Additionally, it should be avoided in patients with asthma.

      Understanding Postpartum Haemorrhage

      Postpartum haemorrhage (PPH) is a condition where a woman experiences blood loss of more than 500 ml after giving birth vaginally. It can be classified as primary or secondary. Primary PPH occurs within 24 hours after delivery and is caused by the 4 Ts: tone, trauma, tissue, and thrombin. The most common cause is uterine atony. Risk factors for primary PPH include previous PPH, prolonged labour, pre-eclampsia, increased maternal age, emergency Caesarean section, and placenta praevia.

      In managing PPH, it is important to involve senior staff immediately and follow the ABC approach. This includes two peripheral cannulae, lying the woman flat, blood tests, and commencing a warmed crystalloid infusion. Mechanical interventions such as rubbing up the fundus and catheterisation are also done. Medical interventions include IV oxytocin, ergometrine, carboprost, and misoprostol. Surgical options such as intrauterine balloon tamponade, B-Lynch suture, ligation of uterine arteries, and hysterectomy may be considered if medical options fail to control the bleeding.

      Secondary PPH occurs between 24 hours to 6 weeks after delivery and is typically due to retained placental tissue or endometritis. It is important to understand the causes and risk factors of PPH to prevent and manage this life-threatening emergency effectively.

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  • Question 36 - A 32-year-old woman comes in with a positive urine pregnancy test. Lifestyle advice...

    Correct

    • A 32-year-old woman comes in with a positive urine pregnancy test. Lifestyle advice is given and blood tests are ordered. She has no notable medical history. During the examination, the following are observed:
      - Heart rate: 92 beats per minute
      - Blood pressure: 126/78 mmHg
      - Oxygen saturation: 98% on room air
      - Temperature: 36.6ºC
      - Respiratory rate: 16 breaths per minute
      - BMI: 30 kg/m²

      What supplementation would you recommend for this patient?

      Your Answer: Folic acid 5mg daily

      Explanation:

      Pregnant women with a BMI greater than 30 kg/m2, regardless of their medical history, should receive a high dose of 5mg folic acid to prevent neural tube defects. Iron supplementation may be necessary for those with iron-deficiency anemia, but it is not currently indicated for this patient. Low-dose folic acid supplementation may be appropriate for non-obese pregnant women. Vitamin B12 supplementation is necessary for those with a deficiency, but it is not currently indicated for this patient. Vitamin D supplementation may be necessary for those with a deficiency, but it is not currently indicated for this patient unless she has risk factors such as dark skin and modest clothing.

      Folic Acid: Importance, Deficiency, and Prevention

      Folic acid is a vital nutrient that is converted to tetrahydrofolate (THF) in the body. It is found in green, leafy vegetables and plays a crucial role in the transfer of 1-carbon units to essential substrates involved in the synthesis of DNA and RNA. However, certain factors such as phenytoin, methotrexate, pregnancy, and alcohol excess can cause a deficiency in folic acid. This deficiency can lead to macrocytic, megaloblastic anemia and neural tube defects.

      To prevent neural tube defects during pregnancy, it is recommended that all women take 400mcg of folic acid until the 12th week of pregnancy. Women at higher risk of conceiving a child with a neural tube defect should take 5mg of folic acid from before conception until the 12th week of pregnancy. Women are considered higher risk if they or their partner has a neural tube defect, they have had a previous pregnancy affected by a neural tube defect, or they have a family history of a neural tube defect. Additionally, women with certain medical conditions such as coeliac disease, diabetes, or thalassaemia trait, or those taking antiepileptic drugs, or who are obese (BMI of 30 kg/m2 or more) are also considered higher risk.

      In summary, folic acid is an essential nutrient that plays a crucial role in DNA and RNA synthesis. Deficiency in folic acid can lead to serious health consequences, including neural tube defects. However, taking folic acid supplements during pregnancy can prevent these defects and ensure a healthy pregnancy.

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  • Question 37 - You are working at a prenatal care center. A couple comes in who...

    Correct

    • You are working at a prenatal care center. A couple comes in who are 28 weeks pregnant. They had difficulty getting pregnant naturally but were able to conceive through their second attempt at IVF. This is their first child. During their 14 week ultrasound, the sonographer expressed concern about the placement of the placenta and they have returned for a follow-up scan today, which confirms the initial finding. What is the probable anomaly?

      Your Answer: Placenta praevia

      Explanation:

      A study conducted in Norway in 2006 revealed that singleton pregnancies conceived through assisted fertilization had a six-fold higher risk of placenta praevia compared to naturally conceived pregnancies. The risk of placenta previa was also nearly three-fold higher in pregnancies following assisted fertilization for mothers who had conceived both naturally and through assisted fertilization. This abnormal placental placement is believed to be linked to the abnormal ovarian stimulation hormones that occur during IVF. Additionally, the incidence of placenta praevia is associated with previous caesarean sections, multiparity, and previous gynaecological surgeries, while the incidence of other options given increases with the number of previous caesarean sections.

      Understanding Placenta Praevia

      Placenta praevia is a condition where the placenta is located wholly or partially in the lower uterine segment. It is a relatively rare condition, with only 5% of women having a low-lying placenta when scanned at 16-20 weeks gestation. However, the incidence at delivery is only 0.5%, as most placentas tend to rise away from the cervix.

      There are several factors associated with placenta praevia, including multiparity, multiple pregnancy, and embryos implanting on a lower segment scar from a previous caesarean section. Clinical features of placenta praevia include shock in proportion to visible loss, no pain, a non-tender uterus, abnormal lie and presentation, and a usually normal fetal heart. Coagulation problems are rare, and small bleeds may occur before larger ones.

      Diagnosis of placenta praevia should not involve digital vaginal examination before an ultrasound, as this may provoke severe haemorrhage. The condition is often picked up on routine 20-week abdominal ultrasounds, but the Royal College of Obstetricians and Gynaecologists recommends the use of transvaginal ultrasound for improved accuracy and safety. Placenta praevia is classified into four grades, with grade IV being the most severe, where the placenta completely covers the internal os.

      In summary, placenta praevia is a rare condition that can have serious consequences if not diagnosed and managed appropriately. It is important for healthcare professionals to be aware of the associated factors and clinical features, and to use appropriate diagnostic methods for accurate grading and management.

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  • Question 38 - You are evaluating a 35-year-old gravida 2 para 1 woman who has presented...

    Correct

    • You are evaluating a 35-year-old gravida 2 para 1 woman who has presented for her initial prenatal visit. She is currently 12 weeks pregnant.
      During her first pregnancy, she had gestational diabetes which was managed with insulin therapy. However, her blood glucose levels are currently within normal limits. She is presently taking 400 µcg folic acid supplements and has no other medication history.
      At this clinic visit, a complete set of blood and urine samples are collected.
      What alterations would you anticipate observing in a healthy pregnant patient compared to before pregnancy?

      Your Answer: Decreased serum urea

      Explanation:

      Physiological Changes During Pregnancy

      The human body undergoes significant physiological changes during pregnancy. The cardiovascular system experiences an increase in stroke volume by 30%, heart rate by 15%, and cardiac output by 40%. However, systolic blood pressure remains unchanged, while diastolic blood pressure decreases in the first and second trimesters, returning to non-pregnant levels by term. The enlarged uterus may interfere with venous return, leading to ankle edema, supine hypotension, and varicose veins.

      The respiratory system sees an increase in pulmonary ventilation by 40%, with tidal volume increasing from 500 to 700 ml due to the effect of progesterone on the respiratory center. Oxygen requirements increase by only 20%, leading to over-breathing and a fall in pCO2, which can cause a sense of dyspnea accentuated by the elevation of the diaphragm. The basal metabolic rate increases by 15%, possibly due to increased thyroxine and adrenocortical hormones, making warm conditions uncomfortable for women.

      The maternal blood volume increases by 30%, mostly in the second half of pregnancy. Red blood cells increase by 20%, but plasma increases by 50%, leading to a decrease in hemoglobin. There is a low-grade increase in coagulant activity, with a rise in fibrinogen and Factors VII, VIII, X. Fibrinolytic activity decreases, returning to normal after delivery, possibly due to placental suppression. This prepares the mother for placental delivery but increases the risk of thromboembolism. Platelet count falls, while white blood cell count and erythrocyte sedimentation rate rise.

      The urinary system experiences an increase in blood flow by 30%, with glomerular filtration rate increasing by 30-60%. Salt and water reabsorption increase due to elevated sex steroid levels, leading to increased urinary protein losses. Trace glycosuria is common due to the increased GFR and reduction in tubular reabsorption of filtered glucose.

      Calcium requirements increase during pregnancy, especially during the third trimester and lactation. Calcium is transported actively across the placenta, while serum levels of calcium and phosphate fall with a fall in protein. Ionized levels of calcium remain stable, and gut absorption of calcium increases substantially due to increased 1,25 dihydroxy vitamin D.

      The liver experiences an increase in alkaline phosphatase by 50%,

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  • Question 39 - A 9-year-old girl presents with her daughter, who is two weeks old and...

    Incorrect

    • A 9-year-old girl presents with her daughter, who is two weeks old and was diagnosed a few days following birth with an anterior tongue tie. She is still struggling to establish enough feeding due to poor latch and a poor seal, even though she is alternating between breastfeeding and bottle feeding of expressed milk. She has been reviewed by the health visitor twice who is satisfied with her breastfeeding technique. The baby was over the 50th centile at birth and now has dropped to the 25th centile.
      Given the above, what is the next most appropriate step in the management of this child?

      Your Answer: Refer for frenotomy under general anaesthesia

      Correct Answer: Refer for frenotomy under no anaesthesia

      Explanation:

      Management of Tongue Tie in Infants: Referral for Frenotomy under No Anaesthesia

      Tongue tie is a congenital condition that affects a baby’s ability to move their tongue due to a thickened frenulum. This can cause problems with breastfeeding and bottle feeding, leading to poor weight gain and irritability. In severe cases, a referral for frenotomy is necessary. In infants under three months of age, the procedure can be performed without anaesthesia, though local anaesthesia may be used. Conservative management and support with breastfeeding should be attempted first, but if unsuccessful, a frenotomy should be performed as early as possible to give the baby and mother the best chance at successful feeding. Frenotomy under general anaesthesia is only necessary for infants over three months of age. Converting to bottle feeding is not a solution in severe cases of tongue tie.

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  • Question 40 - You are examining the blood test results of a middle-aged pregnant woman. What...

    Incorrect

    • You are examining the blood test results of a middle-aged pregnant woman. What result would suggest the requirement for regular antenatal administration of anti-D prophylaxis at 28 weeks?

      Your Answer: Rhesus negative mothers who are sensitised

      Correct Answer: Rhesus negative mothers who are not sensitised

      Explanation:

      Rhesus negative pregnancies can lead to the formation of anti-D IgG antibodies in the mother if she delivers a Rh +ve child, which can cause haemolysis in future pregnancies. Prevention involves testing for D antibodies and giving anti-D prophylaxis to non-sensitised Rh -ve mothers at 28 and 34 weeks. Anti-D immunoglobulin should be given within 72 hours in various situations. Tests should be done on all babies born to Rh -ve mothers, and affected fetuses may experience various complications and require treatment such as transfusions and UV phototherapy.

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SESSION STATS - PERFORMANCE PER SPECIALTY

Obstetrics (24/40) 60%
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