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  • Question 1 - A 27-year-old woman is eight weeks pregnant in her first pregnancy. She has...

    Correct

    • A 27-year-old woman is eight weeks pregnant in her first pregnancy. She has had clinical hypothyroidism for the past four years and takes 50 micrograms of levothyroxine daily. She reports feeling well and denies any symptoms. You order thyroid function tests, which reveal the following results:
      Free thyroxine (fT4) 20 pmol/l (11–22 pmol/l)
      Thyroid-stimulating hormone (TSH) 2.1 μu/l (0.17–3.2 μu/l)
      What is the most appropriate next step in managing this patient?

      Your Answer: Increase levothyroxine by 25 mcg and repeat thyroid function tests in two weeks

      Explanation:

      Managing Hypothyroidism in Pregnancy: Importance of Levothyroxine Dosing and Thyroid Function Tests

      Hypothyroidism is a common condition in pregnancy that requires careful management to ensure optimal fetal development and maternal health. Levothyroxine is the mainstay of treatment for hypothyroidism, and its dosing needs to be adjusted during pregnancy to account for the physiological changes that occur. Here are some key recommendations for managing hypothyroidism in pregnancy:

      Increase Levothyroxine by 25 mcg and Repeat Thyroid Function Tests in Two Weeks

      As soon as pregnancy is confirmed, levothyroxine treatment should be increased by 25 mcg, even if the patient is currently euthyroid. This is because women without thyroid disease experience a physiological increase in serum fT4 until the 12th week of pregnancy, which is not observed in patients with hypothyroidism. Increasing levothyroxine dose mimics this surge and ensures adequate fetal development. Thyroid function tests should be repeated two weeks later to ensure a euthyroid state.

      Perform Thyroid Function Tests in the First and Second Trimesters

      Regular thyroid function tests should be performed in pregnancy, starting in the preconception period if possible. Tests should be done at least once per trimester and two weeks after any changes in levothyroxine dose.

      Continue on the Same Dose of Levothyroxine at Present if Euthyroid

      If the patient is currently euthyroid, continue on the same dose of levothyroxine. However, as soon as pregnancy is confirmed, increase the dose by 25 mcg as described above.

      Return to Pre-Pregnancy Dosing Immediately Post-Delivery

      After delivery, thyroid function tests should be performed 2-6 weeks postpartum, and levothyroxine dose should be adjusted to return to pre-pregnancy levels based on the test results.

      In summary, managing hypothyroidism in pregnancy requires careful attention to levothyroxine dosing and regular thyroid function testing. By following these recommendations, we can ensure the best outcomes for both mother and baby.

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      • Obstetrics
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  • Question 2 - A 20-year-old woman presents for her first antenatal appointment following a positive pregnancy...

    Incorrect

    • A 20-year-old woman presents for her first antenatal appointment following a positive pregnancy test. She has no significant medical or family history and reports no smoking or alcohol consumption. Her BMI is 30.9kg/m², blood pressure is within normal limits, and a urine dipstick is unremarkable. What tests should be offered to her?

      Your Answer: Immediate capillary blood glucose test

      Correct Answer: Oral glucose tolerance test (OGTT) at 24-28 weeks

      Explanation:

      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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      • Obstetrics
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  • Question 3 - A 26-year-old female arrives at the emergency department complaining of sporadic abdominal pain...

    Incorrect

    • A 26-year-old female arrives at the emergency department complaining of sporadic abdominal pain and vaginal bleeding. She believes her last menstrual cycle was 8 weeks ago but is uncertain. She has no prior gynecological history and has never been pregnant before. Her vital signs are stable, with a blood pressure of 130/85 mmHg and a pulse rate of 79 bpm. A pregnancy test conducted in the department is positive, and a transvaginal ultrasound confirms a pregnancy in the adnexa with a fetal heartbeat present. What is the most appropriate course of action in this scenario?

      Your Answer: Methotrexate

      Correct Answer: Surgical management - salpingectomy or salpingostomy

      Explanation:

      The patient has a confirmed ectopic pregnancy, which requires definitive treatment even though there is no evidence of rupture. While expectant management may be an option for those without acute symptoms and decreasing beta-HCG levels, close monitoring is necessary and intervention is recommended if symptoms arise or beta-HCG levels increase. If a fetal heartbeat is present, conservative and medical management are unlikely to be successful and may increase the risk of rupture, which is a medical emergency. Therefore, surgical removal of the ectopic is the most appropriate option. If the opposite tube is healthy, salpingectomy may be the preferred choice. However, if the opposite tube is damaged, salpingostomy may be considered to preserve the functional tube and reduce the risk of future infertility.

      Understanding Ectopic Pregnancy

      Ectopic pregnancy occurs when a fertilized egg implants outside the uterus. This condition is characterized by lower abdominal pain and vaginal bleeding, typically occurring 6-8 weeks after the start of the last period. The pain is usually constant and may be felt on one side of the abdomen due to tubal spasm. Vaginal bleeding is usually less than a normal period and may be dark brown in color. Other symptoms may include shoulder tip pain, pain on defecation/urination, dizziness, fainting, or syncope. Breast tenderness may also be reported.

      During examination, abdominal tenderness and cervical excitation may be observed. However, it is not recommended to examine for an adnexal mass due to the risk of rupturing the pregnancy. Instead, a pelvic examination to check for cervical excitation is recommended. In cases of pregnancy of unknown location, serum bHCG levels >1,500 may indicate an ectopic pregnancy. It is important to seek medical attention immediately if ectopic pregnancy is suspected as it can be life-threatening.

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      • Obstetrics
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  • Question 4 - A 32-year-old woman visits your clinic in the third trimester as her foetus...

    Correct

    • A 32-year-old woman visits your clinic in the third trimester as her foetus is larger than expected for the gestational age. She has pre-existing type 2 diabetes and is taking medication to manage her blood glucose levels. She wants to know which medication is safe to take while breastfeeding.

      Which of the following medications can she continue taking?

      Your Answer: Metformin

      Explanation:

      Breastfeeding mothers should avoid taking sulfonylureas (such as gliclazide) as there is a potential risk of causing hypoglycemia in newborns. Similarly, exenatide, liraglutide, and sitagliptin should also be avoided during breastfeeding. However, it is safe to use metformin while breastfeeding.

      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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      • Obstetrics
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  • Question 5 - A 30-year-old woman, mother of three, presents on day eight postpartum with difficulties...

    Incorrect

    • A 30-year-old woman, mother of three, presents on day eight postpartum with difficulties breastfeeding. She has exclusively breastfed her other two children. She tells you her baby has problems latching, is feeding for a long time and is always hungry. She has sore nipples as a result of the poor latch.
      On examination, you notice that the baby cannot bring his tongue past the lower lip and there is restriction in movement. On lifting the tongue, it acquires a heart shape with a central notch, but you cannot visualise the frenulum.
      Which of the following is the most likely diagnosis?

      Your Answer: Anterior tongue tie

      Correct Answer: Posterior tongue tie

      Explanation:

      Common Oral Abnormalities in Infants: Tongue Tie, Upper Lip Tie, Cleft Lip, and Cleft Palate

      Tongue tie, also known as ankyloglossia, is a condition that affects up to 10% of live births, more commonly in boys than girls. It is characterized by a short, thickened frenulum attaching the tongue to the floor of the mouth, limiting tongue movements and causing difficulties with breastfeeding. Mothers may report that their infant takes a long time to feed, is irritable, and experiences nipple injury. Examination findings include limited tongue movements, inability to lift the tongue high or move it past the lower lip, and a characteristic heart-shaped notch when attempting to lift the tongue. Tongue tie can be anterior or posterior, with the latter being deeper in the mouth and more difficult to see.

      Upper lip tie is a similar condition, with a frenulum attaching the upper lip to the gum line. This can also cause difficulties with breastfeeding due to limited movement of the upper lip.

      Cleft lip and cleft palate are congenital malformations that occur when the facial structures fail to fuse properly during development. Cleft lip presents as a gap in the upper lip, while cleft palate is a gap in the roof of the mouth. Both can cause difficulties with feeding and require surgical intervention.

      It is important for healthcare providers to be aware of these common oral abnormalities in infants and provide appropriate management and referrals to ensure optimal feeding and development.

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      • Obstetrics
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  • Question 6 - A 32-year-old woman who is 32 weeks pregnant presents with vaginal bleeding and...

    Correct

    • A 32-year-old woman who is 32 weeks pregnant presents with vaginal bleeding and is diagnosed with placenta accreta. What is the primary risk factor associated with this condition?

      Your Answer: Previous caesarean sections

      Explanation:

      Understanding Placenta Accreta

      Placenta accreta is a condition where the placenta attaches to the myometrium instead of the decidua basalis, which can lead to postpartum hemorrhage. This condition is caused by a defective decidua basalis. There are three types of placenta accreta, which are categorized based on the degree of invasion. The first type is accreta, where the chorionic villi attach to the myometrium. The second type is increta, where the chorionic villi invade into the myometrium. The third type is percreta, where the chorionic villi invade through the perimetrium.

      There are certain risk factors that increase the likelihood of developing placenta accreta, such as having a previous caesarean section or placenta previa. It is important for healthcare providers to be aware of these risk factors and monitor patients closely during pregnancy and delivery. Early detection and management of placenta accreta can help prevent complications and ensure the best possible outcome for both the mother and baby.

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      • Obstetrics
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  • Question 7 - A 27-year-old woman presents at 18 weeks’ gestation, seeking advice. She was collecting...

    Correct

    • A 27-year-old woman presents at 18 weeks’ gestation, seeking advice. She was collecting her son from school the other day when the teacher alerted the parents that a few children had developed ‘slapped cheek syndrome’. One of those children was at her house with his parents for dinner over the weekend.
      She is concerned she may have been infected and is worried about her baby. She had all her paediatric vaccinations, as per the National Health Service (NHS) schedule.
      Which of the following should be the next step in the investigation of this patient?

      Your Answer: Parvovirus B19 immunoglobulin G (IgG) and immunoglobulin M (IgM) serology

      Explanation:

      Serology Testing for Parvovirus B19 and Rubella During Pregnancy

      During pregnancy, it is important to investigate exposure to certain viruses, such as parvovirus B19 and rubella, as they can have detrimental effects on the fetus. Serology testing for immunoglobulin G (IgG) and immunoglobulin M (IgM) antibodies is used to determine if a patient has had a previous infection or if there is a recent or acute infection.

      Parvovirus B19 is a DNA virus that commonly affects children and can cause slapped cheek syndrome. If a patient has had significant exposure to parvovirus B19, IgG and IgM serology testing is performed. A positive IgG and negative IgM result indicates an old infection, while a negative IgG and IgM result requires repeat testing in one month. A positive IgM result indicates a recent infection, which requires further confirmation and referral to a specialist center for fetal monitoring.

      Varicella IgG serology is performed if there was exposure to chickenpox during pregnancy. A positive result indicates immunity to the virus, and no further investigation is required.

      Rubella IgG and IgM serology is used to investigate exposure to rubella during pregnancy. A positive IgG indicates previous exposure or immunity from vaccination, while a positive IgM indicates a recent or acute infection.

      In conclusion, serology testing is an important tool in investigating viral exposure during pregnancy and can help guide appropriate management and monitoring.

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      • Obstetrics
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  • Question 8 - 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.

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      • Obstetrics
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  • Question 9 - A 20-year-old woman presents with a positive pregnancy test and is diagnosed with...

    Correct

    • A 20-year-old woman presents with a positive pregnancy test and is diagnosed with an ectopic pregnancy after ruling out an intrauterine pregnancy. She is asymptomatic and her serum beta-human chorionic gonadotropin (B-hCG) level is 877 IU/L. A transvaginal ultrasound shows a 24mm adnexal mass without a heartbeat and no free fluid in the abdomen. Although expectant management is an option, she declines. What is the recommended initial treatment?

      Your Answer: Methotrexate

      Explanation:

      According to the National Institute for Health and Care Excellence (NICE), if a woman has an unruptured ectopic pregnancy measuring less than 35mm without visible heartbeat, a serum B-hCG level of less than 1500 IU/L, no intrauterine pregnancy, and no pain, the recommended first-line treatment is methotrexate, provided the patient is willing to attend follow-up appointments. However, if the woman declines expectant management, which is an option for a small number of women with low B-hCG, no symptoms, and a tubal ectopic pregnancy measuring less than 35mm without heartbeat, methotrexate is the preferred treatment option. Methotrexate is a chemotherapeutic drug that interferes with DNA synthesis and disrupts cell multiplication, preventing the pregnancy from developing. Laparoscopic salpingectomy (or salpingostomy if there is a risk of infertility) is the other treatment option, which should be offered if the ectopic pregnancy is larger than 35mm, causing severe pain, or if the B-hCG level is greater than 1500. However, there is a risk of infertility if a problem arises with the remaining Fallopian tube in the future. Misoprostol and mifepristone are not recommended for the management of ectopic pregnancy.

      Understanding Ectopic Pregnancy

      Ectopic pregnancy occurs when a fertilized egg implants outside the uterus. This condition is characterized by lower abdominal pain and vaginal bleeding, typically occurring 6-8 weeks after the start of the last period. The pain is usually constant and may be felt on one side of the abdomen due to tubal spasm. Vaginal bleeding is usually less than a normal period and may be dark brown in color. Other symptoms may include shoulder tip pain, pain on defecation/urination, dizziness, fainting, or syncope. Breast tenderness may also be reported.

      During examination, abdominal tenderness and cervical excitation may be observed. However, it is not recommended to examine for an adnexal mass due to the risk of rupturing the pregnancy. Instead, a pelvic examination to check for cervical excitation is recommended. In cases of pregnancy of unknown location, serum bHCG levels >1,500 may indicate an ectopic pregnancy. It is important to seek medical attention immediately if ectopic pregnancy is suspected as it can be life-threatening.

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      • Obstetrics
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  • Question 10 - A 34-year-old woman in her second pregnancy comes in at 11 weeks with...

    Correct

    • 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: 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 11 - 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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  • Question 12 - A 32-year-old female who is 20 weeks pregnant has a raised serum alpha-fetoprotein...

    Correct

    • A 32-year-old female who is 20 weeks pregnant has a raised serum alpha-fetoprotein (AFP) and is worried about the possible causes. What could be responsible for the elevated AFP levels in this patient?

      Your Answer: Omphalocele

      Explanation:

      A raised level of maternal serum AFP is linked to fetal abdominal wall defects such as omphalocele. Conversely, low levels of maternal AFP are associated with Down’s syndrome, maternal diabetes mellitus, Edwards syndrome, and maternal obesity.

      Alpha-fetoprotein (AFP) is a protein that is created by the fetus during development. When there is an increase in AFP levels, it may indicate the presence of certain conditions such as neural tube defects (meningocele, myelomeningocele and anencephaly), abdominal wall defects (omphalocele and gastroschisis), multiple pregnancy, Down’s syndrome, trisomy 18, and maternal diabetes mellitus. On the other hand, a decrease in AFP levels may also be significant and should be further investigated.

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  • Question 13 - A 32-year-old woman presents to your GP clinic, 6 months after giving birth....

    Correct

    • A 32-year-old woman presents to your GP clinic, 6 months after giving birth. She complains of persistent palpitations, a weight loss of 4 kg since delivery, and some tremors in her hands. She mentions that her baby is healthy and she is bottle feeding. After conducting thyroid function tests, the results are as follows:
      TSH 3.2 mU/L
      T4 21 pmol/L
      What is the most suitable treatment for the likely diagnosis?

      Your Answer: Propranolol

      Explanation:

      The individual is displaying indications of postpartum thyroiditis, an autoimmune disorder that arises as the body returns to regular immunity from the immunosuppressed state during pregnancy. This condition can manifest for up to a year after childbirth, but it typically occurs 3-4 months post-delivery. Beta blockers, not antithyroid medications, should be used to treat the hyperthyroid phase.

      Understanding Postpartum Thyroiditis: Stages and Management

      Postpartum thyroiditis is a condition that affects some women after giving birth. It is characterized by three stages: thyrotoxicosis, hypothyroidism, and normal thyroid function. During the thyrotoxicosis phase, the thyroid gland becomes overactive, leading to symptoms such as anxiety, palpitations, and weight loss. In the hypothyroidism phase, the thyroid gland becomes underactive, causing symptoms such as fatigue, weight gain, and depression. However, in the final stage, the thyroid gland returns to normal function, although there is a high recurrence rate in future pregnancies.

      Thyroid peroxidase antibodies are found in 90% of patients with postpartum thyroiditis, which suggests an autoimmune component to the condition. Management of postpartum thyroiditis depends on the stage of the condition. During the thyrotoxic phase, symptom control is the main focus, and propranolol is typically used. Antithyroid drugs are not usually used as the thyroid gland is not overactive. In the hypothyroid phase, treatment with thyroxine is usually necessary to restore normal thyroid function.

      It is important to note that many causes of hypothyroidism may have an initial thyrotoxic phase, as shown in a Venn diagram. Therefore, it is crucial to properly diagnose and manage postpartum thyroiditis to ensure the best possible outcomes for both the mother and the baby.

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  • Question 14 - A 30-year-old primiparous woman who is 10 weeks pregnant is curious about iron...

    Correct

    • A 30-year-old primiparous woman who is 10 weeks pregnant is curious about iron supplementation. Her blood tests reveal a Hb level of 110 g/L. What is the appropriate Hb cut-off for initiating treatment in this patient?

      Your Answer: 110

      Explanation:

      During pregnancy, women are checked for anaemia twice – once at the initial booking visit (usually around 8-10 weeks) and again at 28 weeks. The National Institute for Health and Care Excellence (NICE) has set specific cut-off levels to determine if a pregnant woman requires oral iron therapy. These levels are less than 110 g/L in the first trimester, less than 105 g/L in the second and third trimesters, and less than 100 g/L postpartum.

      If a woman’s iron levels fall below these cut-offs, she will be prescribed oral ferrous sulfate or ferrous fumarate. It is important to continue this treatment for at least three months after the iron deficiency has been corrected to allow the body to replenish its iron stores. By following these guidelines, healthcare professionals can help ensure that pregnant women receive the appropriate care to prevent and manage anaemia during pregnancy.

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  • Question 15 - A 28-year-old woman presents to the antenatal clinic for a routine visit and...

    Incorrect

    • A 28-year-old woman presents to the antenatal clinic for a routine visit and is found to have a blood pressure of 165/111 mmHg and ++proteinuria on urinalysis. Her doctor suspects pre-eclampsia and admits her to the obstetrics assessment unit. She has recently moved to the area and her medical records are not available. She is otherwise healthy and only uses blue and brown inhalers for her asthma, for which she recently completed a 5-day course of steroids after being hospitalized for a severe exacerbation. What medication should be used to manage her hypertension?

      Your Answer: Methyldopa

      Correct Answer: Nifedipine

      Explanation:

      Nifedipine is the recommended initial treatment for pre-eclampsia in women with severe asthma. The patient’s medical history indicates that she has severe asthma, making beta blockers like Labetalol unsuitable for her. Additionally, the use of Ramipril during pregnancy has been associated with a higher incidence of birth defects in infants.

      Pre-eclampsia is a condition that occurs during pregnancy and is characterized by high blood pressure, proteinuria, and edema. It can lead to complications such as eclampsia, neurological issues, fetal growth problems, liver involvement, and cardiac failure. Severe pre-eclampsia is marked by hypertension, proteinuria, headache, visual disturbances, and other symptoms. Risk factors for pre-eclampsia include hypertension in a previous pregnancy, chronic kidney disease, autoimmune disease, diabetes, chronic hypertension, first pregnancy, and age over 40. Aspirin may be recommended for women with high or moderate risk factors. Treatment involves emergency assessment, admission for observation, and medication such as labetalol, nifedipine, or hydralazine. Delivery of the baby is the most important step in management, with timing depending on the individual case.

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  • Question 16 - A 32-year-old primigravida woman is 41 weeks pregnant and has been offered a...

    Incorrect

    • A 32-year-old primigravida woman is 41 weeks pregnant and has been offered a vaginal examination and membrane sweeping at her antenatal visit. Despite these efforts, she has not gone into labor after 6 hours. Upon examination, her cervix is firm, 1 cm dilated, 1.5 cm in length, and in the middle position. The fetal head station is -3, but there have been no complications during the pregnancy. What should be the next appropriate step?

      Your Answer:

      Correct Answer: Vaginal prostaglandin gel

      Explanation:

      If the Bishop score is less than or equal to 6, the recommended method for inducing labor is through vaginal PGE2 or oral misoprostol. In this case, since the Bishop score was less than 5, labor is unlikely without induction. One option could be to repeat a membrane sweep, but the most appropriate course of action would be to use a vaginal prostaglandin gel.

      Induction of labour is a process where labour is artificially started and is required in about 20% of pregnancies. It is indicated in cases of prolonged pregnancy, prelabour premature rupture of the membranes, maternal medical problems, diabetic mother over 38 weeks, pre-eclampsia, obstetric cholestasis, and intrauterine fetal death. The Bishop score is used to assess whether induction of labour is necessary and includes cervical position, consistency, effacement, dilation, and fetal station. A score of less than 5 indicates that labour is unlikely to start without induction, while a score of 8 or more indicates a high chance of spontaneous labour or response to interventions made to induce labour.

      Possible methods of induction include membrane sweep, vaginal prostaglandin E2, oral prostaglandin E1, maternal oxytocin infusion, amniotomy, and cervical ripening balloon. The NICE guidelines recommend vaginal prostaglandins or oral misoprostol if the Bishop score is less than or equal to 6, while amniotomy and an intravenous oxytocin infusion are recommended if the score is greater than 6.

      The main complication of induction of labour is uterine hyperstimulation, which refers to prolonged and frequent uterine contractions that can interrupt blood flow to the intervillous space and result in fetal hypoxemia and acidemia. Uterine rupture is a rare but serious complication. Management includes removing vaginal prostaglandins and stopping the oxytocin infusion if one has been started, and considering tocolysis.

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  • Question 17 - A 28-year-old woman visits her GP's office and shares the news that she...

    Incorrect

    • A 28-year-old woman visits her GP's office and shares the news that she has recently discovered she is pregnant. She is overjoyed and eager to proceed with the pregnancy. Currently, she is 6 weeks pregnant and feels fine without symptoms. She has no significant medical history and does not take any regular medications. She is a non-smoker and does not consume alcohol. Her BMI is 34 kg/m², and her blood pressure is 110/60 mmHg. Her urine dip is negative. She has heard that taking vitamin D and folic acid supplements can increase her chances of having a healthy pregnancy. What is the most advisable regimen for her in this situation?

      Your Answer:

      Correct Answer: Vitamin D 400IU daily throughout the pregnancy, and folic acid 5mg daily for the first 12 weeks of pregnancy

      Explanation:

      Pregnant women who are obese (with a BMI greater than 30 kg/m²) should be prescribed a high dose of 5mg folic acid. It is recommended that all pregnant women take 400 IU of vitamin D daily throughout their pregnancy. Additionally, folic acid should be taken daily for the first 12 weeks of pregnancy, with the dosage depending on the presence of risk factors for neural tube defects such as spina bifida. If there are no risk factors, the dose is 400 micrograms daily, but if risk factors are present, the dose should be increased to 5 mg daily. As maternal obesity is a risk factor for neural tube defects, pregnant women with a BMI greater than 30 kg/m² should take the higher dose of folic acid.

      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 18 - A 35-year-old primigravida presents for her 9-week antenatal appointment. She recently had a...

    Incorrect

    • A 35-year-old primigravida presents for her 9-week antenatal appointment. She recently had a private ultrasound which revealed dichorionic, diamniotic twins. The patient has a medical history of hypothyroidism and a BMI of 38 kg/m². Although she has been smoking during her pregnancy, she has reduced her intake from 20 to 5 cigarettes per day and is interested in trying nicotine replacement therapy. Her main concern is that both her mother and sister suffered from hyperemesis gravidarum. What factor in her history is linked to a lower likelihood of developing this condition?

      Your Answer:

      Correct Answer: Smoking

      Explanation:

      Smoking has been found to decrease the risk of hyperemesis gravidarum, which is believed to occur due to rapidly rising levels of human chorionic gonadotropin (HCG) and oestrogen. This is because smoking is considered to be anti-oestrogenic. Therefore, despite having other risk factors, the fact that the patient is a smoker may decrease her incidence of hyperemesis gravidarum. On the other hand, hypothyroidism is not a risk factor, but hyperthyroidism increases the risk of hyperemesis gravidarum. Obesity and underweight are associated with an increased risk of hyperemesis, but women with these conditions who smoked before pregnancy have been found to have no increased risk. Primigravida status is also associated with an increased risk of hyperemesis, but the reason for this is not clear. Finally, twin pregnancies carry an increased risk of hyperemesis gravidarum due to higher levels of beta-hCG released from the placenta.

      Hyperemesis gravidarum is an extreme form of nausea and vomiting of pregnancy that occurs in around 1% of pregnancies and is most common between 8 and 12 weeks. It is associated with raised beta hCG levels and can be caused by multiple pregnancies, trophoblastic disease, hyperthyroidism, nulliparity, and obesity. Referral criteria for nausea and vomiting in pregnancy include continued symptoms with ketonuria and/or weight loss, a confirmed or suspected comorbidity, and inability to keep down liquids or oral antiemetics. The diagnosis of hyperemesis gravidarum requires the presence of 5% pre-pregnancy weight loss, dehydration, and electrolyte imbalance. Management includes first-line use of antihistamines and oral cyclizine or promethazine, with second-line options of ondansetron and metoclopramide. Admission may be needed for IV hydration. Complications can include Wernicke’s encephalopathy, Mallory-Weiss tear, central pontine myelinolysis, acute tubular necrosis, and fetal growth issues.

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  • Question 19 - A 23-year-old asthmatic woman has been brought to the emergency department after experiencing...

    Incorrect

    • A 23-year-old asthmatic woman has been brought to the emergency department after experiencing seizures during her pregnancy. She is currently 35 weeks pregnant and has been diagnosed with gestational hypertension by her doctor. She is taking oral medication to manage her condition. Upon examination, her urine test shows proteinuria (3+) and her blood pressure is elevated at 170/115 mmHg. As a result, the baby is delivered and the patient's seizures have ceased. What is the most appropriate treatment option for her seizures after delivery, given her probable diagnosis?

      Your Answer:

      Correct Answer: Magnesium sulphate for 24 hours after delivery/last seizure

      Explanation:

      The correct answer is that magnesium sulphate treatment should continue for 24 hours after delivery or the last seizure. This treatment is used to prevent and treat seizures in mothers with eclampsia. In this case, the patient is showing signs of eclampsia due to high protein levels in her urine, pregnancy-induced hypertension, and seizures. Therefore, she needs to be admitted and continue magnesium treatment for 24 hours after delivery or the last seizure. Magnesium helps prevent seizures by relaxing smooth muscle tissues and slowing uterine contractions. Labetalol is not the correct answer as it is used for long-term treatment of hypertension, which may not be necessary for this patient after delivery. Nifedipine with hydralazine may be more suitable for her hypertension as she is asthmatic. Magnesium sulphate treatment for 12 or 48 hours after delivery or the last seizure is not recommended according to guidelines, which suggest 24 hours is the appropriate duration.

      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 20 - You are asked to assess a middle-aged woman in the maternity ward who...

    Incorrect

    • You are asked to assess a middle-aged woman in the maternity ward who is 5 days post-partum and reporting persistent vaginal bleeding with clots. You reassure her that lochia is a normal part of the post-partum period, but advise her that further investigation with ultrasound may be necessary if the bleeding continues beyond what time frame?

      Your Answer:

      Correct Answer: 6 weeks

      Explanation:

      If lochia continues for more than 6 weeks, an ultrasound should be performed.

      During the puerperium, which is the period of around 6 weeks after childbirth when the woman’s reproductive organs return to their normal state, lochia is the discharge of blood, mucous, and uterine tissue that occurs. It is expected to stop after 4-6 weeks. However, if it persists beyond this time, an ultrasound is necessary to investigate the possibility of retained products of conception.

      Lochia refers to the discharge that is released from the vagina after childbirth. This discharge is composed of blood, mucous, and uterine tissue. It is a normal occurrence that can last for up to six weeks following delivery. During this time, the body is working to heal and recover from the physical changes that occurred during pregnancy and childbirth. It is important for new mothers to monitor their lochia and report any unusual changes or symptoms to their healthcare provider.

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  • Question 21 - A 35-year-old woman with hypertension is considering pregnancy and seeks pre-pregnancy planning. She...

    Incorrect

    • A 35-year-old woman with hypertension is considering pregnancy and seeks pre-pregnancy planning. She is currently taking losartan 50 mg daily and her BP measures 130/88 mmHg. What guidance should be provided to this patient in this scenario?

      Your Answer:

      Correct Answer: She should switch losartan to labetolol and ensure her BP is well controlled prior to attempting to get pregnant

      Explanation:

      Safe antihypertensive Medications for Pregnancy

      Explanation:
      When planning to get pregnant, it is important to ensure that any medications being taken are safe for the developing fetus. In the case of hypertension, switching to a safe medication prior to conception is recommended. Labetalol is the best-studied antihypertensive in pregnancy and is considered safe. Losartan, on the other hand, is contraindicated as it may affect renal development. Simply reducing the dosage of losartan is not enough to mitigate the risks of fetal maldevelopment. It is also important to maintain good blood pressure control prior to conception. Stopping antihypertensive medications abruptly is not recommended as it may lead to uncontrolled hypertension, which is associated with increased fetal loss. By taking these precautions, women can increase their chances of carrying a healthy fetus to term.

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  • Question 22 - A 32-year-old woman who is 36 weeks pregnant visits her GP complaining of...

    Incorrect

    • A 32-year-old woman who is 36 weeks pregnant visits her GP complaining of intense itching on the soles of her hands and feet, particularly at night, which is disrupting her sleep. Due to abnormal liver function tests (LFTs), she is referred to the obstetric team. The team prescribes medication that greatly alleviates her pruritus symptoms.
      What is the probable medication that the obstetric team has prescribed to this patient based on the given information?

      Your Answer:

      Correct Answer: Ursodeoxycholic acid

      Explanation:

      Ursodeoxycholic acid is the recommended initial medical treatment for intrahepatic cholestasis of pregnancy. The patient’s symptoms and abnormal liver function tests, along with her pregnancy status, suggest obstetric cholestasis. The Royal College of Obstetricians and Gynaecologists recommends ursodeoxycholic acid to alleviate pruritus and improve liver function in women with obstetric cholestasis. Cetirizine is not effective for pruritic symptoms during pregnancy, while cholestyramine is the preferred treatment for cholestatic pruritus but is not typically used for obstetric cholestasis. Dexamethasone is not the first-line therapy for obstetric cholestasis. Rifampicin may be used as an alternative treatment for pruritus, but caution should be exercised in patients with pre-existing liver disease due to potential hepatotoxicity, and it is not indicated for obstetric cholestasis.

      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 23 - A 29-year-old woman presents to the clinic with concerns about her pregnancy. She...

    Incorrect

    • A 29-year-old woman presents to the clinic with concerns about her pregnancy. She is currently at 30 weeks gestation and reports that her pregnancy has been going smoothly thus far. However, over the past few days, she has noticed a decrease in fetal movement. She denies any recent illnesses or feeling unwell and has no significant medical history. On obstetric abdominal examination, there are no notable findings and the patient appears to be in good health. What is the recommended initial management in this case?

      Your Answer:

      Correct Answer: Handheld Doppler

      Explanation:

      When a pregnant woman reports reduced fetal movements after 28 weeks of gestation, the first step recommended by the RCOG guidelines is to use a handheld Doppler to confirm the fetal heartbeat. If the heartbeat cannot be detected, an ultrasound should be offered immediately. However, if a heartbeat is detected, cardiotocography should be used to monitor the heart rate for 20 minutes. Fetal blood sampling is not necessary in this situation. Referral to a fetal medicine unit would only be necessary if no movements had been 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.

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  • Question 24 - A 35-year-old pregnant woman visits antenatal clinic with complaints of headaches and sudden...

    Incorrect

    • A 35-year-old pregnant woman visits antenatal clinic with complaints of headaches and sudden swelling of her ankles within the past 3 days. She is currently 30+4 weeks pregnant, with a history of diabetes mellitus type II that is managed through lifestyle changes. During the examination, it was observed that the fundal height is measuring small for her gestational age. Consequently, an ultrasound scan was ordered, which revealed oligohydramnios. What is the most probable cause of oligohydramnios in this patient?

      Your Answer:

      Correct Answer: Pre-eclampsia

      Explanation:

      Oligohydramnios can be caused by pre-eclampsia, which leads to inadequate blood flow to the placenta. Polyhydramnios, on the other hand, is associated with anencephaly, diabetes mellitus, twin pregnancies, and oesophageal atresia. Twin-to-twin transfusion syndrome is usually the cause of polyhydramnios in twin pregnancies. Foetal hyperglycaemia in diabetic mothers leads to foetal polyuria. In cases of oesophageal atresia and anencephaly, the foetus is unable to swallow the amniotic fluid.

      Oligohydramnios is a condition characterized by a decrease in the amount of amniotic fluid present in the womb. The definition of oligohydramnios varies, but it is generally considered to be present when there is less than 500ml of amniotic fluid at 32-36 weeks of gestation or an amniotic fluid index (AFI) that falls below the 5th percentile.

      There are several potential causes of oligohydramnios, including premature rupture of membranes, Potter sequence, bilateral renal agenesis with pulmonary hypoplasia, intrauterine growth restriction, post-term gestation, and pre-eclampsia. These conditions can all contribute to a reduction in the amount of amniotic fluid present in the womb, which can have significant implications for fetal development and health. It is important for healthcare providers to monitor amniotic fluid levels and identify any potential causes of oligohydramnios in order to provide appropriate care and support for both the mother and the developing fetus.

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  • Question 25 - A 24-year-old primigravida is brought to the Emergency Department by her husband at...

    Incorrect

    • A 24-year-old primigravida is brought to the Emergency Department by her husband at 33 weeks of gestation after experiencing a generalised tonic–clonic seizure. Examination reveals blood pressure of 160/90 mmHg, temperature of 37 °C and 2+ pitting oedema in the lower extremities. She appears lethargic but responds to simple commands. What is the definitive treatment for this patient's condition?

      Your Answer:

      Correct Answer: Immediate delivery

      Explanation:

      Eclampsia: Symptoms and Treatment

      Eclampsia is a serious medical condition that can occur during pregnancy, characterized by pre-eclampsia and seizure activity. Symptoms may include hypertension, proteinuria, mental status changes, and blurred vision. Immediate delivery is the only definitive treatment for eclampsia, but magnesium can be given to reduce the risk of seizures in women with severe pre-eclampsia who are delivering within 24 hours. Eclampsia is more common in younger women with their first pregnancy and those with underlying vascular disorders. Hydralazine can be used to manage hypertension in pregnant women, but it is not the definitive treatment for eclampsia. Conservative management, such as salt and water restriction, bed rest, and close monitoring of blood pressure, is not appropriate for patients with eclampsia and associated seizure and mental state changes. ACE inhibitors are contraindicated during pregnancy, and labetalol is the first-line antihypertensive in pregnancy. Diazepam and magnesium sulfate can reduce seizures in eclampsia, but they are not the definitive treatment.

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  • Question 26 - A 25-year-old female patient visits her GP complaining of severe lower abdominal pain...

    Incorrect

    • A 25-year-old female patient visits her GP complaining of severe lower abdominal pain that is not relieved by painkillers. She has no significant medical history. During the evaluation, her GP conducts a pregnancy test, which comes back positive. The patient is immediately referred to the hospital, where a transvaginal ultrasound confirms an ectopic pregnancy in the left tube. What is the best course of action for management?

      Your Answer:

      Correct Answer: Salpingectomy

      Explanation:

      If a patient has an ectopic pregnancy, the treatment plan will depend on various factors such as the size and location of the pregnancy, the patient’s overall health, and the potential impact on their fertility. If the pregnancy is small and the patient’s health is stable, they may be able to receive medication to dissolve the pregnancy. However, if the pregnancy is larger or causing severe symptoms, surgery may be necessary.

      In cases where surgery is required, the surgeon may attempt to preserve the affected fallopian tube if possible. However, if the tube is severely damaged or the patient has other factors that may affect their fertility, such as age or previous fertility issues, the surgeon may opt to remove the tube completely. This decision will also depend on the patient’s desire for future fertility and the likelihood of requiring further treatment with methotrexate or a salpingectomy. If the patient’s contralateral tube is unaffected, complete removal of the affected tube may be the most appropriate course of action.

      Ectopic pregnancy is a serious condition that requires prompt investigation and management. Women who are stable are typically investigated and managed in an early pregnancy assessment unit, while those who are unstable should be referred to the emergency department. The investigation of choice for ectopic pregnancy is a transvaginal ultrasound, which will confirm the presence of a positive pregnancy test.

      There are three ways to manage ectopic pregnancies: expectant management, medical management, and surgical management. The choice of management will depend on various criteria, such as the size of the ectopic pregnancy, whether it is ruptured or not, and the patient’s symptoms and hCG levels. Expectant management involves closely monitoring the patient over 48 hours, while medical management involves giving the patient methotrexate and requires follow-up. Surgical management can involve salpingectomy or salpingostomy, depending on the patient’s risk factors for infertility.

      Salpingectomy is the first-line treatment for women without other risk factors for infertility, while salpingostomy should be considered for women with contralateral tube damage. However, around 1 in 5 women who undergo a salpingostomy require further treatment, such as methotrexate and/or a salpingectomy. It is important to carefully consider the patient’s individual circumstances and make a decision that will provide the best possible outcome.

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  • Question 27 - A 32-year-old woman is 38 weeks pregnant and has arrived at the hospital...

    Incorrect

    • A 32-year-old woman is 38 weeks pregnant and has arrived at the hospital due to experiencing contractions. She has expressed her desire for a vaginal birth. Despite being in good health, alert, and stable, her cardiotocography indicates that the baby's heart rate has increased from 164/min to 170/min after 10 minutes. As the woman is at full term, the obstetrician has decided to perform a caesarean section. What classification of caesarean section is this considered to be?

      Your Answer:

      Correct Answer: Category 2

      Explanation:

      Category 2 caesarean sections are performed when there is a non-immediate life-threatening emergency concerning the mother or the baby. This may include an abnormality detected by cardiotocography that requires an emergency caesarean section within 75 minutes of the decision being made. It is not immediately life-threatening to either the mother or the baby.

      Category 1 caesarean sections are performed in immediately life-threatening situations, such as haemodynamic instability of the mother.

      Category 3 caesarean sections are not immediately life-threatening to the mother but are necessary for the non-immediate life-threatening condition of the baby, such as distress.

      Category 4 caesarean sections are elective and may be chosen by the mother or recommended based on past medical history.

      Caesarean Section: Types, Indications, and Risks

      Caesarean section, also known as C-section, is a surgical procedure that involves delivering a baby through an incision in the mother’s abdomen and uterus. In recent years, the rate of C-section has increased significantly due to an increased fear of litigation. There are two main types of C-section: lower segment C-section, which comprises 99% of cases, and classic C-section, which involves a longitudinal incision in the upper segment of the uterus.

      C-section may be indicated for various reasons, including absolute cephalopelvic disproportion, placenta praevia grades 3/4, pre-eclampsia, post-maturity, IUGR, fetal distress in labor/prolapsed cord, failure of labor to progress, malpresentations, placental abruption, vaginal infection, and cervical cancer. The urgency of C-section may be categorized into four categories, with Category 1 being the most urgent and Category 4 being elective.

      It is important for clinicians to inform women of the serious and frequent risks associated with C-section, including emergency hysterectomy, need for further surgery, admission to intensive care unit, thromboembolic disease, bladder injury, ureteric injury, and death. C-section may also increase the risk of uterine rupture, antepartum stillbirth, placenta praevia, and placenta accreta in subsequent pregnancies. Other complications may include persistent wound and abdominal discomfort, increased risk of repeat C-section, readmission to hospital, haemorrhage, infection, and fetal lacerations.

      Vaginal birth after C-section (VBAC) may be an appropriate method of delivery for pregnant women with a single previous C-section delivery, except for those with previous uterine rupture or classical C-section scar. The success rate of VBAC is around 70-75%.

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  • Question 28 - A 24-year-old woman, gravidity 2 and parity 1, at 37 weeks gestation presents...

    Incorrect

    • A 24-year-old woman, gravidity 2 and parity 1, at 37 weeks gestation presents with severe abdominal pain after fainting. Her blood pressure is 92/58 mmHg and heart rate is 132/min. Upon examination, she appears cold and her fundal height measures 37 cm. The cervical os is closed and there is no vaginal bleeding. What is the most suitable diagnosis?

      Your Answer:

      Correct Answer: Placental abruption

      Explanation:

      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.

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  • Question 29 - During her prenatal appointment, a mother informs her obstetrician that she was previously...

    Incorrect

    • During her prenatal appointment, a mother informs her obstetrician that she was previously diagnosed with immune thrombocytopenic purpura (ITP). What is the procedure that poses the highest risk of bleeding in the newborn?

      Your Answer:

      Correct Answer: Prolonged ventouse delivery

      Explanation:

      During pregnancies, immune thrombocytopenia (ITP) can become a complication if maternal antiplatelet antibodies pass through the placenta. In such cases, ventouse delivery can cause bleeding in the neonate due to the high vacuum pressure. This can worsen conditions like cephalohaematoma or subgaleal haemorrhage, especially if the neonate has thrombocytopenia. While forceps and fetal blood sampling can be used with caution, they are not as risky.

      Understanding the Difference between Gestational Thrombocytopenia and Immune Thrombocytopenia (ITP)

      Gestational thrombocytopenia and immune thrombocytopenia (ITP) are two conditions that affect platelet count during pregnancy. Gestational thrombocytopenia is a common condition that results from a combination of factors such as dilution, decreased production, and increased destruction of platelets. On the other hand, ITP is an autoimmune condition that is usually associated with acute purpuric episodes in children, but a chronic relapsing course may be seen more frequently in women.

      Differentiating between the two conditions can be challenging and often relies on a careful history. Gestational thrombocytopenia may be considered more likely if the platelet count continues to fall as pregnancy progresses, but this is not a reliable sign. If the patient becomes dangerously thrombocytopenic, she will usually be treated with steroids, and a diagnosis of ITP assumed. Pregnant women found to have low platelets during a booking visit or those with a previous diagnosis of ITP may need to be tested for serum antiplatelet antibodies for confirmation.

      It is important to note that gestational thrombocytopenia does not affect the neonate, but ITP can do if maternal antibodies cross the placenta. Depending on the degree of thrombocytopenia in the newborn, platelet transfusions may be indicated. Serial platelet counts can also be performed to see whether there is an inherited thrombocytopenia. Understanding the difference between these two conditions is crucial in ensuring proper diagnosis and management during pregnancy.

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  • Question 30 - A 26-year-old woman presents to the Emergency Department with minimal vaginal bleeding. She...

    Incorrect

    • A 26-year-old woman presents to the Emergency Department with minimal vaginal bleeding. She reports her last menstrual period as having been 4 weeks ago. She denies pain but reports severe nausea and vomiting. She has no significant past medical history and her last check-up 6 months ago did not reveal any abnormalities. On examination, her blood pressure is 160/110 mmHg and her uterus measures 12 weeks’ size. A serum beta human chorionic gonadotropin (β-HCG) level is drawn and found to be in excess of 300 000 iu. An ultrasound does not identify any foetal parts. What is this patient at risk of developing?

      Your Answer:

      Correct Answer: Pulmonary metastasis and thyroid dysfunction

      Explanation:

      Diagnosing Gestational Trophoblastic Disease: Differential Diagnosis

      Gestational trophoblastic disease is a rare condition that can present with symptoms similar to other pregnancy-related complications. When evaluating a patient with suspected gestational trophoblastic disease, it is important to consider the differential diagnosis and rule out other potential causes.

      One common misdiagnosis is occlusion of the coronary vessels, as there is no association between gestational trophoblastic disease and coronary artery disease. Rupture of the fallopian tube may be a possibility if the patient had an ectopic pregnancy, but the history and examination are not suggestive of this. Septic miscarriage is also a possibility, but the symptoms and examination findings in this scenario are more typical of gestational trophoblastic disease.

      Twin or triplet pregnancy is unlikely due to the absence of foetal parts and the elevated blood pressure. Instead, gestational trophoblastic disease should be considered when a patient presents with bleeding in early pregnancy, severe hyperemesis, new-onset hypertension prior to 20 weeks’ gestation, and a uterus that is larger than expected. An extremely elevated β-HCG and a classical ultrasound appearance resembling a ‘snow storm’ are also indicative of gestational trophoblastic disease.

      It is important to note that gestational trophoblastic disease is strongly associated with thyroid dysfunction and that the lungs are among the first sites of metastatic disease. By considering the differential diagnosis and conducting appropriate testing, healthcare providers can accurately diagnose and treat gestational trophoblastic disease.

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  • Question 31 - A 29-year-old woman presents to the emergency department with her partner. She is...

    Incorrect

    • A 29-year-old woman presents to the emergency department with her partner. She is currently 36 weeks pregnant and G2P1. Her pregnancy has been progressing normally without concerns raised at her antenatal appointments. However, she experienced a sudden gush of fluid earlier today, which soaked her trousers. On examination, fluid is seen pooling in the posterior vaginal fornix, and a swab of the fluid returns a positive partosure. The patient is afebrile and has no other abnormal vital signs. What is the most appropriate management for this likely diagnosis?

      Your Answer:

      Correct Answer: IM corticosteroids

      Explanation:

      Antenatal corticosteroids should be given in cases of preterm prelabour rupture of membranes to reduce the risk of respiratory distress syndrome in the neonate. IM corticosteroids are the appropriate form of administration for this purpose. Cervical cerclage is not recommended in this scenario as it is contraindicated in cases of preterm prelabour rupture of membranes. Expectant management is also not the best option as it increases the risk of intraamniotic infection. Indomethacin tocolysis is not recommended as it can cause complications such as ductus arteriosus closure and oligohydramnios. Nifedipine is the preferred medication for delaying labour in this scenario.

      Preterm prelabour rupture of the membranes (PPROM) is a condition that occurs in approximately 2% of pregnancies, but it is responsible for around 40% of preterm deliveries. This condition can lead to various complications, including prematurity, infection, and pulmonary hypoplasia in the fetus, as well as chorioamnionitis in the mother. To confirm PPROM, a sterile speculum examination should be performed to check for pooling of amniotic fluid in the posterior vaginal vault. However, digital examination should be avoided due to the risk of infection. If pooling of fluid is not observed, testing the fluid for placental alpha microglobulin-1 protein (PAMG-1) or insulin-like growth factor binding protein-1 is recommended. Ultrasound may also be useful to show oligohydramnios.

      The management of PPROM involves admission and regular observations to ensure that chorioamnionitis is not developing. Oral erythromycin should be given for ten days, and antenatal corticosteroids should be administered to reduce the risk of respiratory distress syndrome. Delivery should be considered at 34 weeks of gestation, but there is a trade-off between an increased risk of maternal chorioamnionitis and a decreased risk of respiratory distress syndrome as the pregnancy progresses. PPROM is a serious condition that requires prompt diagnosis and management to minimize the risk of complications for both the mother and the fetus.

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  • Question 32 - A 25-year-old primiparous woman attends her booking visit where she is given an...

    Incorrect

    • A 25-year-old primiparous woman attends her booking visit where she is given an appointment for her first scan at 12+4 weeks’ gestation. She wants to know what the appointment will involve.
      Regarding the 11–13 week appointment, which of the following is correct?

      Your Answer:

      Correct Answer: It can also include the ‘combined test’

      Explanation:

      Understanding Down Syndrome Screening Tests

      Down syndrome screening tests are important for pregnant women to determine the likelihood of their baby having the condition. One of the most common tests is the combined test, which is performed between 11+0 and 13+6 weeks’ gestation. This test involves a blood test and an ultrasound scan to measure serum pregnancy-associated plasma protein A (PAPP-A) and β-hCG, as well as nuchal translucency. The results are combined to give an individual risk of having a baby with Down syndrome.

      If a woman misses the window for the combined test, she can opt for the quadruple test, which is performed between weeks 15 and 16 of gestation. This test measures four serum markers: inhibin, aFP, unconjugated oestriol, and total serum hCG. Low aFP and unconjugated oestriol, as well as raised inhibin and hCG, are associated with Down syndrome.

      It is important to note that these tests are not diagnostic, but rather provide a risk assessment. Women who are classified as high risk may opt for a diagnostic test, such as amniocentesis or chorionic villous sampling, to confirm the presence of an extra chromosome. All pregnant women in the UK should be offered Down syndrome screening and given the opportunity to make an informed decision about participating in the test.

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  • Question 33 - A young girl requires an episiotomy during labour. The incision should be made:...

    Incorrect

    • A young girl requires an episiotomy during labour. The incision should be made:

      Your Answer:

      Correct Answer: Posterior to the vagina, mediolaterally into the soft tissues of the perineum and the perineal skin

      Explanation:

      Understanding the Risks of Different Episiotomy Incisions

      Episiotomy is a surgical procedure that involves making an incision in the perineum to widen the vaginal opening during childbirth. However, the location and direction of the incision can have different risks and complications. Here are some important things to know about the risks of different episiotomy incisions:

      1. Posterior to the vagina, mediolaterally into the soft tissues of the perineum and the perineal skin
      This is the most common type of episiotomy. However, cutting too close to the anus can cause damage to the anal sphincter, leading to fecal incontinence.

      2. Anterior to the vagina, straight up the mid-line so that the incision lies mid-way between the vagina and the external urethral orifice
      This type of incision can damage the external urethral orifice, leading to urinary incontinence.

      3. Posterior to the vagina, straight down the mid-line into the soft tissues of the perineum and the perineal skin
      Cutting down the midline posterior to the vagina can harm the perineal body, leading to both fecal and urinary incontinence, as well as pelvic organ prolapse.

      4. Anterior to the vagina, mediolaterally into the labium minus
      This type of incision can damage Bartholin’s glands, which can lead to pain and discomfort during sexual intercourse.

      5. One incision anterior to the vagina and one incision posterior to the vagina down the mid-line
      This type of incision can cause damage to both the urethral orifice and the perineal body, leading to both urinary and fecal incontinence.

      In conclusion, it is important to discuss the risks and benefits of episiotomy with your healthcare provider and to understand the potential complications of different types of incisions.

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  • Question 34 - A 35-year-old woman arrives at 28 weeks gestation for her third pregnancy. During...

    Incorrect

    • A 35-year-old woman arrives at 28 weeks gestation for her third pregnancy. During an ultrasound at 12 weeks, it was discovered that she was carrying dichorionic diamniotic twins. She is admitted to the hospital due to painless, bright red bleeding per vaginum. She has undergone two previous caesarian sections. What is the probable diagnosis?

      Your Answer:

      Correct Answer: Placenta praevia

      Explanation:

      Placenta praevia is a pregnancy complication characterized by the attachment of the placenta to the lower part of the uterus. The main symptom is painless bleeding occurring after the 24th week of gestation. Risk factors include a history of placenta praevia, previous caesarean section, damage to the endometrium, and multiple pregnancies. Placenta praevia frequently results in a high presenting part or abnormal lie due to the placenta’s low position.

      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 35 - A 25-year-old woman visits her GP with complaints of mild abdominal pain and...

    Incorrect

    • A 25-year-old woman visits her GP with complaints of mild abdominal pain and vaginal bleeding. She is currently 6 weeks pregnant and is otherwise feeling well. On examination, she is tender in the right iliac fossa and has a small amount of blood in the vaginal vault with a closed cervical os. There is no cervical excitation. Her vital signs are stable, with a blood pressure of 120/80 mmHg, heart rate of 80 bpm, temperature of 36.5ºC, saturations of 99% on air, and respiratory rate of 14 breaths/minute. A urine dip reveals blood only, and a urinary pregnancy test is positive. What is the most appropriate course of action?

      Your Answer:

      Correct Answer: Refer for immediate assessment at the Early Pregnancy Unit

      Explanation:

      A woman with a positive pregnancy test and abdominal, pelvic or cervical motion tenderness should be immediately referred for assessment due to the risk of an ectopic pregnancy. Arranging an outpatient ultrasound or reassuring the patient is not appropriate. Urgent investigation is necessary to prevent the risk of rupture. Expectant management may be appropriate for a woman with vaginal bleeding and no pain or tenderness, but not for this patient who has both.

      Bleeding in the First Trimester: Understanding the Causes and Management

      Bleeding in the first trimester of pregnancy is a common concern for many women. It can be caused by various factors, including miscarriage, ectopic pregnancy, implantation bleeding, cervical ectropion, vaginitis, trauma, and polyps. However, the most important cause to rule out is ectopic pregnancy, as it can be life-threatening if left untreated.

      To manage early bleeding, the National Institute for Health and Care Excellence (NICE) released guidelines in 2019. If a woman has a positive pregnancy test and experiences pain, abdominal tenderness, pelvic tenderness, or cervical motion tenderness, she should be referred immediately to an early pregnancy assessment service. If the pregnancy is over six weeks gestation or of uncertain gestation and the woman has bleeding, she should also be referred to an early pregnancy assessment service.

      A transvaginal ultrasound scan is the most important investigation to identify the location of the pregnancy and whether there is a fetal pole and heartbeat. If the pregnancy is less than six weeks gestation and the woman has bleeding but no pain or risk factors for ectopic pregnancy, she can be managed expectantly. However, she should be advised to return if bleeding continues or pain develops and to repeat a urine pregnancy test after 7-10 days and to return if it is positive. A negative pregnancy test means that the pregnancy has miscarried.

      In summary, bleeding in the first trimester of pregnancy can be caused by various factors, but ectopic pregnancy is the most important cause to rule out. Early referral to an early pregnancy assessment service and a transvaginal ultrasound scan are crucial in identifying the location of the pregnancy and ensuring appropriate management. Women should also be advised to seek medical attention if they experience any worrying symptoms or if bleeding or pain persists.

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  • Question 36 - You are seeing a G3P1 14-weeks pregnant woman in the GP surgery. She...

    Incorrect

    • You are seeing a G3P1 14-weeks pregnant woman in the GP surgery. She is concerned about the possibility of developing postpartum psychosis again, as she had experienced it in her previous pregnancy and was hospitalized. What is the likelihood of her developing this condition once more?

      Your Answer:

      Correct Answer: 25-50 %

      Explanation:

      To monitor her throughout her pregnancy and postnatal period, this woman requires a referral to a perinatal mental health team due to her increased risk of postpartum psychosis. It would have been preferable for her to receive preconception advice before becoming pregnant. The recurrence rate is not influenced by the baby’s gender.

      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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  • Question 37 - A woman in her 12th week of pregnancy arrives at the emergency department...

    Incorrect

    • A woman in her 12th week of pregnancy arrives at the emergency department with a two-week history of intense vomiting and lack of appetite. The scent of food triggers her nausea. She hasn't consumed any food for the past four days and has only had minimal amounts of water.
      She is currently taking omeprazole and folic acid and has never smoked or consumed alcohol. What is an instance of a risk factor for this ailment?

      Your Answer:

      Correct Answer: Multiple pregnancies

      Explanation:

      Hyperemesis gravidarum is more likely to occur in women who are pregnant with multiple babies. Other factors that may increase the risk of HG include obesity, epilepsy, stress, and a family history of the condition. Treatment options may include corticosteroids like prednisolone, anti-emetic drugs such as ondansetron, and vitamins B6 and B12. While advanced maternal age can increase the risk of certain pregnancy complications, it has not been linked to an increased risk of HG. Similarly, having multiple previous pregnancies does not appear to increase the risk of HG, but a history of the condition in a previous pregnancy may be a risk factor.

      Hyperemesis gravidarum is an extreme form of nausea and vomiting of pregnancy that occurs in around 1% of pregnancies and is most common between 8 and 12 weeks. It is associated with raised beta hCG levels and can be caused by multiple pregnancies, trophoblastic disease, hyperthyroidism, nulliparity, and obesity. Referral criteria for nausea and vomiting in pregnancy include continued symptoms with ketonuria and/or weight loss, a confirmed or suspected comorbidity, and inability to keep down liquids or oral antiemetics. The diagnosis of hyperemesis gravidarum requires the presence of 5% pre-pregnancy weight loss, dehydration, and electrolyte imbalance. Management includes first-line use of antihistamines and oral cyclizine or promethazine, with second-line options of ondansetron and metoclopramide. Admission may be needed for IV hydration. Complications can include Wernicke’s encephalopathy, Mallory-Weiss tear, central pontine myelinolysis, acute tubular necrosis, and fetal growth issues.

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  • Question 38 - A 40-year-old pregnant woman is confused about why she has been advised to...

    Incorrect

    • A 40-year-old pregnant woman is confused about why she has been advised to undergo an oral glucose tolerance test. She has had four previous pregnancies, and her babies' birth weights have ranged from 3.4-4.6kg. She has no history of diabetes, but both her parents have hypertension, and her grandfather has diabetes. She is of white British ethnicity and has a BMI of 29.6kg/m². What is the reason for recommending an oral glucose tolerance test for this patient?

      Your Answer:

      Correct Answer: Previous macrosomia

      Explanation:

      It is recommended that pregnant women with a family history of diabetes undergo an oral glucose tolerance test (OGTT) for gestational diabetes between 24 and 28 weeks of pregnancy.

      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 39 - A 25-year-old primiparous female is at 39 weeks gestation. Upon examination by a...

    Incorrect

    • A 25-year-old primiparous female is at 39 weeks gestation. Upon examination by a midwife, her Bishop score is determined to be 4. What is the significance of this score?

      Your Answer:

      Correct Answer: Labour is unlikely to start spontaneously

      Explanation:

      To determine if induction is necessary, the Bishop scoring system evaluates cervical characteristics such as position, consistency, effacement, dilation, and foetal station. If the score is less than 5, induction is likely required. However, if the score is above 9, spontaneous labour is expected.

      Induction of labour is a process where labour is artificially started and is required in about 20% of pregnancies. It is indicated in cases of prolonged pregnancy, prelabour premature rupture of the membranes, maternal medical problems, diabetic mother over 38 weeks, pre-eclampsia, obstetric cholestasis, and intrauterine fetal death. The Bishop score is used to assess whether induction of labour is necessary and includes cervical position, consistency, effacement, dilation, and fetal station. A score of less than 5 indicates that labour is unlikely to start without induction, while a score of 8 or more indicates a high chance of spontaneous labour or response to interventions made to induce labour.

      Possible methods of induction include membrane sweep, vaginal prostaglandin E2, oral prostaglandin E1, maternal oxytocin infusion, amniotomy, and cervical ripening balloon. The NICE guidelines recommend vaginal prostaglandins or oral misoprostol if the Bishop score is less than or equal to 6, while amniotomy and an intravenous oxytocin infusion are recommended if the score is greater than 6.

      The main complication of induction of labour is uterine hyperstimulation, which refers to prolonged and frequent uterine contractions that can interrupt blood flow to the intervillous space and result in fetal hypoxemia and acidemia. Uterine rupture is a rare but serious complication. Management includes removing vaginal prostaglandins and stopping the oxytocin infusion if one has been started, and considering tocolysis.

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  • Question 40 - A 28-year-old woman presents at 29 weeks’ gestation very concerned as she has...

    Incorrect

    • A 28-year-old woman presents at 29 weeks’ gestation very concerned as she has not felt her baby move at all since the night before. She has a history of coeliac disease. No fetal movements can be palpated. An ultrasound scan confirms fetal death. Blood investigations were performed: thyroid-stimulating hormone (TSH) 10.5 μu/l (0.17–3.2 μu/l) and free thyroxine (fT4) 4 pmol/l (11–22 pmol/l). These were not performed at booking.
      According to the national antenatal screening programme, which of the following groups of patients should be screened for thyroid disorders in pregnancy?

      Your Answer:

      Correct Answer: Type 1 diabetes mellitus

      Explanation:

      Thyroid Screening in Pregnancy: Identifying High-Risk Patients

      Pregnancy can increase the risk of developing thyroid disorders, which can have detrimental effects on both the mother and fetus. Therefore, it is important to identify high-risk patients and screen them for thyroid function early in pregnancy. According to updated guidelines, patients with a current or previous thyroid disease, family history of thyroid disease in a first-degree relative, autoimmune conditions such as coeliac disease, type 1 and type 2 diabetes mellitus, as well as gestational diabetes are considered at higher risk. These patients should be screened by performing TSH and serum fT4 levels in the preconception period, if possible, or as soon as pregnancy is confirmed.

      Detecting hypothyroidism early is crucial, as symptoms can mimic those of a normal pregnancy, making detection harder. Hypothyroidism in the mother can lead to fetal demise, severe neurodevelopmental abnormalities, congenital malformations, and congenital hypothyroidism. Patients diagnosed with overt hypothyroidism in pregnancy should be started on levothyroxine immediately.

      There is no recommendation to screen women with a history of chronic kidney disease or hypertension for thyroid disease in pregnancy. However, chronic kidney disease is a high-risk factor for pre-eclampsia, and commencing aspirin at 12 weeks through to delivery is essential to reduce the risk of developing pre-eclampsia or any of its complications. Women who are carriers of the thalassaemia trait are not screened for thyroid disease in pregnancy, but their partner should be tested for carrier status to assess the risk to the fetus.

      In conclusion, identifying high-risk patients and screening for thyroid function early in pregnancy can help prevent adverse outcomes for both the mother and fetus.

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SESSION STATS - PERFORMANCE PER SPECIALTY

Obstetrics (11/15) 73%
Passmed