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  • Question 1 - A 35-year-old woman who has given birth before is experiencing advanced labour at...

    Incorrect

    • A 35-year-old woman who has given birth before is experiencing advanced labour at 37 weeks gestation. An ultrasound reveals that the baby is in a breech presentation. Despite pushing for one and a half hours, the buttocks are still not visible. What is the appropriate course of action in this scenario?

      Your Answer: Non-rotational forceps

      Correct Answer: Caesarean section

      Explanation:

      A vaginal delivery is expected to be challenging due to the foetal presentation and station. Singleton pregnancies are not recommended for breech extraction, which also demands expertise. Hence, it is advisable to opt for a Caesarean section.

      Breech presentation occurs when the caudal end of the fetus is in the lower segment, and it is more common at 28 weeks than near term. Risk factors include uterine malformations, placenta praevia, and fetal abnormalities. Management options include spontaneous turning, external cephalic version (ECV), planned caesarean section, or vaginal delivery. The RCOG recommends informing women that planned caesarean section reduces perinatal mortality and early neonatal morbidity, but there is no evidence that the long-term health of babies is influenced by how they are born. ECV is contraindicated in certain cases, such as where caesarean delivery is required or there is an abnormal cardiotocography.

    • This question is part of the following fields:

      • Obstetrics
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  • Question 2 - A 28-year-old woman visits the antenatal clinic. What should be included in the...

    Incorrect

    • A 28-year-old woman visits the antenatal clinic. What should be included in the standard infection screening?

      Your Answer: Toxoplasmosis

      Correct Answer: Human Immunodeficiency Virus (HIV)

      Explanation:

      It is recommended that HIV testing be included as a standard part of antenatal screening.

      Antenatal Screening Policy

      Antenatal screening is an important aspect of prenatal care that helps identify potential health risks for both the mother and the developing fetus. The National Screening Committee (NSC) has recommended a policy for antenatal screening that outlines the conditions for which all pregnant women should be offered screening and those for which screening should not be offered.

      The NSC recommends that all pregnant women should be offered screening for anaemia, bacteriuria, blood group, Rhesus status, and anti-red cell antibodies, Down’s syndrome, fetal anomalies, hepatitis B, HIV, neural tube defects, risk factors for pre-eclampsia, syphilis, and other conditions depending on the woman’s medical history.

      However, there are certain conditions for which screening should not be offered, such as gestational diabetes, gestational hypertension, and preterm labor. These conditions are typically managed through regular prenatal care and monitoring.

      It is important for pregnant women to discuss their screening options with their healthcare provider to ensure that they receive appropriate care and support throughout their pregnancy. By following the NSC’s recommended policy for antenatal screening, healthcare providers can help identify potential health risks early on and provide appropriate interventions to ensure the best possible outcomes for both mother and baby.

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      • Obstetrics
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  • Question 3 - A 32-year-old pregnant woman comes for a routine check at 28 weeks gestation....

    Incorrect

    • A 32-year-old pregnant woman comes for a routine check at 28 weeks gestation. During the examination, her symphysis-fundal height measures 23 cm. What is the most crucial investigation to confirm these findings?

      Your Answer: Urinalysis

      Correct Answer: Ultrasound

      Explanation:

      The symphysis-fundal height measurement in centimetres should correspond to the foetal gestational age in weeks with an accuracy of 1 or 2 cm from 20 weeks gestation. Hence, it can be deduced that the woman is possibly experiencing fetal growth restriction. Therefore, it is crucial to conduct an ultrasound to verify if the foetus is indeed small for gestational age.

      The symphysis-fundal height (SFH) is a measurement taken from the pubic bone to the top of the uterus in centimetres. It is used to determine the gestational age of a fetus and should match within 2 cm after 20 weeks. For example, if a woman is 24 weeks pregnant, a normal SFH would be between 22 and 26 cm. Proper measurement of SFH is important for monitoring fetal growth and development during pregnancy.

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      • Obstetrics
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  • Question 4 - A 28-year-old woman has been diagnosed with gestational diabetes mellitus and is referred...

    Correct

    • A 28-year-old woman has been diagnosed with gestational diabetes mellitus and is referred to the joint antenatal and diabetic clinic. She is currently 25 weeks pregnant and this is her first pregnancy. Her family has no history of pregnancy-related problems, but her father has type 1 diabetes mellitus. On examination, her BMI is 32 kg/m² and otherwise normal. What diagnostic test would confirm her condition?

      Your Answer: Fasting plasma glucose >= 5.6 mmol/L

      Explanation:

      Gestational diabetes can be diagnosed if the patient has a fasting glucose level of 5.6 mmol/L or higher, or a 2-hour glucose level of 7.8 mmol/L or higher. This diagnosis is typically made during an oral glucose tolerance test around 24 weeks into the pregnancy for women with risk factors, such as a high BMI or a first-degree relative with diabetes mellitus. In this patient’s case, she was diagnosed with gestational diabetes mellitus during her first pregnancy due to her risk factors. Therefore, the correct answer is a fasting plasma glucose level above 5.6 mmol/L. It is important to note that a 2-hour glucose level above 5.6 mmol/L is not diagnostic of gestational diabetes mellitus, and random plasma glucose tests are not used for diagnosis. Glucose targets for women with gestational diabetes mellitus include a 2-hour glucose level of 6.4 mmol/L after mealtime and a 1-hour glucose level of 7.8 mmol/L after mealtime.

      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 woman who is 28 weeks pregnant arrives at the emergency department after...

    Correct

    • A woman who is 28 weeks pregnant arrives at the emergency department after experiencing painless leakage of fluid from her vagina. She reports an initial gush two hours ago, followed by a steady drip. During examination with a sterile speculum, the fluid is confirmed as amniotic fluid. The woman also discloses a severe allergy to penicillin. What is the optimal approach to minimize the risk of infection?

      Your Answer: 10 days erythromycin

      Explanation:

      All women with PPROM should receive a 10-day course of erythromycin. This is the recommended treatment for this condition. Piperacillin and tazobactam (tazocin) is not appropriate due to the patient’s penicillin allergy. Nitrofurantoin is used for urinary tract infections, while vancomycin is typically used for anaerobic GI infections.

      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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      • Obstetrics
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  • Question 6 - A woman gives birth via normal vaginal delivery. The midwife notices the baby...

    Incorrect

    • A woman gives birth via normal vaginal delivery. The midwife notices the baby has an umbilical hernia, a large, protruding tongue, flattened face, and low muscle tone. What is the most probable outcome of this woman's combined screening test at 13-weeks-pregnant with this child?

      Your Answer: ↓ HCG, ↓ PAPP-A, normal nuchal translucency

      Correct Answer: ↑ HCG, ↓ PAPP-A, thickened nuchal translucency

      Explanation:

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

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      • Obstetrics
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  • Question 7 - A 22-year-old woman who is 36 weeks pregnant presents to the Emergency Department...

    Incorrect

    • A 22-year-old woman who is 36 weeks pregnant presents to the Emergency Department (ED) with a 2-day history of worsening headache despite taking painkillers. She has no significant medical history. Her pregnancy has been uneventful, but she reports increasing swelling in her hands and feet over the past week. Her blood pressure at her last prenatal visit two weeks ago was 120/80 mmHg. On examination, her blood pressure is 162/110 mmHg, heart rate 108 beats per minute, and temperature 37.2°C. Urine dipstick reveals protein ++++. What is the most appropriate medication to manage her condition?

      Your Answer: Ramipril

      Correct Answer: Magnesium sulphate

      Explanation:

      Management of Severe Pre-eclampsia: Medications to Consider and Avoid

      Severe pre-eclampsia, characterized by high blood pressure and proteinuria, can lead to eclamptic seizures and other complications. To prevent seizures, magnesium sulphate is administered as a loading dose followed by an infusion. Labetalol is the first-line medication for controlling blood pressure, but nifedipine and methyldopa can be used if labetalol is contraindicated. Ramipril, an ACE inhibitor, and amlodipine, a calcium channel blocker, are not recommended in pregnancy due to their teratogenic effects. Atenolol, a beta blocker, is not the agent of choice for pre-eclampsia management. Aspirin may be given prophylactically to women at risk of pre-eclampsia. Delivery of the fetus is the only definitive treatment for severe pre-eclampsia.

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      • Obstetrics
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  • Question 8 - A 28-year-old woman enters the delivery room. Upon examination, the midwife notes that...

    Incorrect

    • A 28-year-old woman enters the delivery room. Upon examination, the midwife notes that the head has reached the level of the ischial spine. What is the term used to describe the position of the head in relation to the ischial spine?

      Your Answer: Engagement

      Correct Answer: Station

      Explanation:

      The position of the head in relation to the ischial spine is referred to as the station. When the head is at the same level as the ischial spines, the station is considered to be ‘0’. If the station is described as ‘-2’, it means that the head is 2 cm above the ischial spines, while a station of ‘+2’ indicates that the head is 2 cm below the ischial spine.

      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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      • Obstetrics
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  • Question 9 - A 35-year-old G1P0 woman is brought to the hospital at 39 weeks of...

    Incorrect

    • A 35-year-old G1P0 woman is brought to the hospital at 39 weeks of gestation by her husband because she is experiencing strong uterine contractions. She delivers a healthy baby with an Apgar score of 8, 5 min after birth. However, she experiences significant bleeding with an estimated blood loss of six litres and is hypotensive with a BP of 60/24 mmHg despite aggressive resuscitation. The placenta appears to be adherent to the uterine wall and the surgeons are unable to separate it. It is noted that she was treated with ceftriaxone for a gonococcal infection 5 years ago, although she had lower abdominal pain for some time after.
      What is the definitive treatment for this patient’s present condition?

      Your Answer: Dinoprostone

      Correct Answer: Hysterectomy

      Explanation:

      The patient is suffering from placenta accreta, a pregnancy complication where the placenta attaches to the myometrium wall. This condition is often caused by past Caesarean sections, Asherman syndrome, or pelvic inflammatory disease, which the patient had due to a previous infection with Neisseria gonorrhoeae. To prevent co-transmission with Chlamydia trachomatis, doxycycline is given with a third-generation cephalosporin. The patient’s placenta accreta is likely due to scarring from pelvic inflammatory disease, and a total hysterectomy may be necessary if the patient’s condition worsens. While the patient may require a large blood transfusion, immediate transfusion is not the definitive treatment. Oxytocin may be used as a first-line treatment, but a hysterectomy is the definitive treatment if bleeding persists. Phenylephrine, a vasoconstrictor, may decrease bleeding but is not a definitive treatment for placenta accreta. Dinoprostone, a prostaglandin E2 analogue, is not indicated for placenta accreta.

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      • Obstetrics
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  • Question 10 - A 29-year-old woman comes in for her 20-week anomaly scan. This is also...

    Incorrect

    • A 29-year-old woman comes in for her 20-week anomaly scan. This is also her first pregnancy, but she found out she was pregnant at 12 weeks’ gestation. The sonographer alerts the consultant in the room, as she has detected spina bifida. The patient mentions that her cousin had a baby with the same condition a few years ago.
      Based on the information provided, what folic acid dosage would be advised for this patient in subsequent pregnancies?

      Your Answer: Commence folic acid 400 μg daily in the preconception period and continue until week 12 of gestation

      Correct Answer: Commence folic acid 5 mg daily in the preconception period and continue until week 12 of gestation

      Explanation:

      Folic Acid Supplementation for Neural Tube Defect Prevention

      Explanation:
      Folic acid supplementation is recommended for women who are trying to conceive in order to reduce the risk of neural tube defects and congenital abnormalities in their babies. The recommended dose is 400 μg daily in the preconception period and until the 12th week of gestation. However, women who are identified to be at high risk of having a baby with a neural tube defect should take a higher dose of 5 mg daily, ideally starting in the preconception period and continuing until the 12th week of gestation. It is important to note that folic acid supplementation should be discontinued after the first trimester. Side-effects of folic acid treatment may include abdominal distension, reduced appetite, nausea, and exacerbation of pernicious anaemia. High risk factors for neural tube defects include a family history of neural tube defects, a previous pregnancy affected by a neural tube defect, personal history of neural tube defect, and chronic conditions such as epilepsy and diabetes mellitus.

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      • Obstetrics
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  • Question 11 - A 26-year-old female patient visits her GP complaining of vaginal bleeding. She is...

    Incorrect

    • A 26-year-old female patient visits her GP complaining of vaginal bleeding. She is currently 6 weeks pregnant and denies experiencing any abdominal pain, dizziness, or shoulder tip pain. She reports passing less than a teaspoon of blood without any clots. The patient has no history of ectopic pregnancy. During examination, her heart rate is 85 beats per minute, blood pressure is 130/80 mmHg, and her abdomen is soft and non-tender. As per the current NICE CKS guidelines, what is the next appropriate step in managing this patient?

      Your Answer: Refer the patient urgently to gynaecology for same day admission

      Correct Answer: Monitor expectantly and advise to repeat pregnancy test in 7 days. If negative, this confirms miscarriage. If positive, or continued or worsening symptoms, refer to the early pregnancy assessment unit

      Explanation:

      Conduct a blood test to measure the levels of beta-human chorionic gonadotropin (hCG) in the serum, and then repeat the test after 120 hours.

      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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      • Obstetrics
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  • Question 12 - A 28-year-old woman presents to the clinic for her lab results. She is...

    Incorrect

    • A 28-year-old woman presents to the clinic for her lab results. She is currently 20 weeks pregnant and has undergone a glucose tolerance test. The findings are as follows:
      - Fasting glucose 6.9 mmol/L
      - 2-hour glucose 8.5 mmol/L

      What is the best course of action to take next?

      Your Answer: Repeat the test

      Correct Answer: Insulin

      Explanation:

      Immediate insulin (with or without metformin) should be initiated if the fasting glucose level is >= 7 mmol/l at the time of gestational diabetes diagnosis. In this case, the patient has gestational diabetes and requires prompt insulin therapy. The diagnosis of gestational diabetes is based on a fasting plasma glucose level of > 5.6 mmol/L or a 2-hour plasma glucose level of >/= 7.8 mmol/L. Although dietary advice is important, insulin therapy is necessary when the fasting glucose level is greater than 7 mmol/L. Gliclazide is not recommended for pregnant women due to the risk of neonatal hypoglycaemia. Metformin can be used in gestational diabetes, but insulin is the most appropriate next step when the fasting glucose level is >=7 mmol/L. Insulin and metformin can be used together to manage gestational diabetes. There is no need to repeat the test as the results are conclusive for gestational diabetes.

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

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      • Obstetrics
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  • Question 13 - A 32-year-old primiparous woman is 33+6 weeks pregnant. At her last antenatal appointment,...

    Incorrect

    • A 32-year-old primiparous woman is 33+6 weeks pregnant. At her last antenatal appointment, she had a blood pressure reading of 152/101 mmHg. She mentions experiencing some swelling in her hands and feet but denies any other symptoms. Her urinalysis shows no protein. She has a history of asthma, which she manages with a salbutamol inhaler as needed, and depression, for which she discontinued her medication upon becoming pregnant. What is the optimal course of action?

      Your Answer: Oral methyldopa

      Correct Answer: Oral nifedipine

      Explanation:

      Gestational hypertension is a condition where a woman develops high blood pressure after 20 weeks of pregnancy, without significant protein in the urine. This woman has moderate gestational hypertension, with her systolic blood pressure ranging between 150-159 mmHg and diastolic blood pressure ranging between 100-109 mmHg.

      Typically, moderate gestational hypertension does not require hospitalization and can be treated with oral labetalol. However, as this woman has a history of asthma, labetalol is not recommended. Instead, NICE guidelines suggest nifedipine or methyldopa as alternatives. Methyldopa is not recommended for patients with depression, so the best option for this woman is oral nifedipine, which is a calcium channel blocker.

      In cases of eclampsia, IV magnesium sulphate is necessary. It’s important to note that lisinopril, an ACE inhibitor, is not safe for use during pregnancy.

      Hypertension during pregnancy is a common occurrence that requires careful management. In normal pregnancies, blood pressure tends to decrease in the first trimester and then gradually increase to pre-pregnancy levels by term. However, in cases of hypertension during pregnancy, the systolic blood pressure is usually above 140 mmHg or the diastolic blood pressure is above 90 mmHg. Additionally, an increase of more than 30 mmHg systolic or 15 mmHg diastolic from the initial readings may also indicate hypertension.

      There are three categories of hypertension during pregnancy: pre-existing hypertension, pregnancy-induced hypertension (PIH), and pre-eclampsia. Pre-existing hypertension refers to a history of hypertension before pregnancy or elevated blood pressure before 20 weeks gestation. PIH occurs in the second half of pregnancy and resolves after birth. Pre-eclampsia is characterized by hypertension and proteinuria, and may also involve edema.

      The management of hypertension during pregnancy involves the use of antihypertensive medications such as labetalol, nifedipine, and hydralazine. In cases of pre-existing hypertension, ACE inhibitors and angiotensin II receptor blockers should be stopped immediately and alternative medications should be prescribed. Women who are at high risk of developing pre-eclampsia should take aspirin from 12 weeks until the birth of the baby. It is important to carefully monitor blood pressure and proteinuria levels during pregnancy to ensure the health of both the mother and the baby.

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  • Question 14 - A 28-year-old woman is on day one postpartum, following a normal vaginal delivery....

    Incorrect

    • A 28-year-old woman is on day one postpartum, following a normal vaginal delivery. She has called the midwife, as she is struggling to establish breastfeeding and correct positioning of the baby to the breast. She reports pain when the baby is breastfeeding.
      Which of the following is a feature of a poor latch?

      Your Answer: The baby’s lips are rolled out

      Correct Answer: Clicking noises are heard

      Explanation:

      Understanding the Signs of a Good Latch for Successful Breastfeeding

      Latching on the breast is crucial for successful breastfeeding, but many women struggle with it. A poor latch can lead to pain and frustration, causing some women to give up on breastfeeding altogether. However, there are clear signs of a good latch that can help mothers and babies achieve successful breastfeeding.

      One indicator of a poor latch is clicking noises, which can be painful for the mother and indicate that the baby is chewing on the nipple. In contrast, a good latch is associated with visible and audible swallowing, a rhythmic suck, and relaxed arms and hands of the infant. The baby’s chin should touch the breast, with the nose free, and the lips should be rolled out, not turned in. The mouth should be open wide, and the tongue positioned below the nipple, with the latter touching the palate of the baby’s mouth.

      Another sign of a good latch is that less areola should be visible below the chin than above the nipple. This indicates that the baby is taking in not only the nipple but also the areola, which is essential for effective milk expression and feeding. By understanding these signs of a good latch, mothers can ensure successful breastfeeding and a positive experience for both themselves and their babies.

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  • Question 15 - A 29-year-old woman who is 36 weeks pregnant arrives at the Emergency Department...

    Incorrect

    • A 29-year-old woman who is 36 weeks pregnant arrives at the Emergency Department with a complaint of her 'waters breaking'. She reports experiencing a sudden release of clear fluid from her vagina, which has now reduced to a trickle, and she feels some pressure in her pelvis. What is the most suitable test to conduct next?

      Your Answer: Fetal blood sample

      Correct Answer: Speculum examination

      Explanation:

      The initial investigation for preterm prelabour rupture of the membranes is a thorough speculum examination to check for the accumulation of amniotic fluid in the posterior vaginal vault. It is recommended to avoid bimanual examination to minimize the risk of infection. While cardiotocography can be used to assess foetal wellbeing, it is not the preferred first-line investigation. Foetal blood sampling is not the recommended initial investigation due to the potential risks of infection and miscarriage.

      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 16 - A 27-year-old woman is in the second stage of labour. The fetal head...

    Incorrect

    • A 27-year-old woman is in the second stage of labour. The fetal head is not descending, and the obstetrician decides to perform a ventouse extraction. He injects local anaesthetic into a nerve that crosses the ischial spine. This nerve then passes along the lateral wall of the ischiorectal fossa embedded in the obturator internus fascia in Alcock’s canal.
      Which of the following is this nerve?

      Your Answer: Genital branch of the genitofemoral nerve

      Correct Answer: Pudendal nerve

      Explanation:

      Nerve Pathways in the Pelvic Region

      The pelvic region contains several important nerves that play a crucial role in the functioning of the lower body. Here are some of the key nerve pathways in this area:

      Pudendal Nerve: This nerve exits the pelvis through the greater sciatic foramen and re-enters via the lesser sciatic foramen. It passes through Alcock’s canal and is responsible for the sensation and movement of the perineum.

      Sciatic Nerve: The sciatic nerve emerges from the pelvis through the greater sciatic foramen and descends between the femur and ischial tuberosity. It is prone to injury during deep intramuscular injections.

      Perineal Branch of S4: This nerve passes between the levator ani and coccygeus muscles and supplies the perianal skin.

      Genital Branch of the Genitofemoral Nerve: This nerve descends on the psoas major muscle and supplies the cremaster muscle and labial or scrotal skin.

      Obturator Nerve: The obturator nerve emerges from the psoas major muscle and runs along the lateral wall of the true pelvis. It exits the pelvis through the superior aspect of the obturator foramen to enter the thigh.

      Understanding these nerve pathways is important for medical professionals who work in the pelvic region, as it can help them diagnose and treat various conditions related to these nerves.

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  • Question 17 - A diabetic woman attends for an ultrasound scan during her third trimester of...

    Incorrect

    • A diabetic woman attends for an ultrasound scan during her third trimester of pregnancy. The physician reporting the scan calculates an amniotic index >95th centile and diagnoses polyhydramnios.
      What volume of amniotic fluid is considered to be consistent with polyhydramnios?

      Your Answer: >1–2 l of amniotic fluid

      Correct Answer: >2–3 l of amniotic fluid

      Explanation:

      Understanding Polyhydramnios: Excess Amniotic Fluid in Pregnancy

      Polyhydramnios is a condition in which there is an excess of amniotic fluid in the second and third trimesters of pregnancy. This excess fluid is produced by the fetal kidneys and is normally swallowed by the fetus. Diagnosis of polyhydramnios is made by ultrasound assessment of the amount of fluid. If the deepest vertical pool is greater than 8 cm or if the amniotic fluid index (AFI) is greater than the 95th percentile for the corresponding gestational age, polyhydramnios is diagnosed.

      Polyhydramnios occurs in approximately 2% of all pregnancies and is associated with maternal diabetes and fetal anomalies resulting in gastrointestinal obstruction, such as esophageal atresia and poor fetal swallowing.

      It is important to note that normal amniotic fluid varies and increases with gestational age, peaking at around 1 liter. An excess of 2 liters or more is considered consistent with polyhydramnios. Understanding this condition can help healthcare providers monitor and manage pregnancies for the best possible outcomes.

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  • Question 18 - The technician performed an ultrasonographic examination on a pregnant woman and obtained a...

    Incorrect

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

      Your Answer: Greatest length

      Correct Answer: Crown–rump length

      Explanation:

      Choosing the Appropriate Measurement for Estimating Embryonic Age

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

    • This question is part of the following fields:

      • Obstetrics
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  • Question 19 - John is a 28-year-old man who comes to see you for a follow-up...

    Incorrect

    • John is a 28-year-old man who comes to see you for a follow-up visit. You initially saw him 1 month ago for low mood and referred him for counselling. He states he is still feeling low and his feelings of anxiety are worsening. He is keen to try medication to help.
      John has a 5-month-old baby and is breastfeeding.
      Which of the following is the most appropriate medication for John to commence?

      Your Answer: Venlafaxine

      Correct Answer: Sertraline

      Explanation:

      Breastfeeding women can safely take sertraline or paroxetine as their preferred SSRIs. These medications are known to have minimal to low levels of exposure to infants through breast milk, and are not considered harmful to them. Therefore, if a mother is diagnosed with postnatal depression and requires antidepressant treatment, she should not be advised to stop breastfeeding.

      Understanding Postpartum Mental Health Problems

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

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

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

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

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      • Obstetrics
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  • Question 20 - You are evaluating a 23-year-old female who is 8 weeks pregnant and experiencing...

    Correct

    • You are evaluating a 23-year-old female who is 8 weeks pregnant and experiencing severe vomiting, making it difficult for her to retain fluids. What is the best method to determine the severity of her symptoms?

      Your Answer: Pregnancy-Unique Quantification of Emesis (PUQE) scoring system

      Explanation:

      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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      • Obstetrics
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  • Question 21 - A 35-year-old woman presents with a two-week history of morning sickness. She is...

    Incorrect

    • A 35-year-old woman presents with a two-week history of morning sickness. She is 10 weeks pregnant. She can keep down oral fluid but has vomited twice in the previous 24 hours. There are no acid reflux symptoms, abdominal pain, vaginal bleeding or urinary symptoms.

      She takes folic acid and is not on any other medications.

      On examination, her temperature is 36.8ºC. Blood pressure is 100/60 mmHg and heart rate is 80/min. Her abdomen is soft and non-tender. Urine B-HCG is positive and urine dipstick shows 1+ ketone only. There is no weight loss.

      What is the most appropriate management option for this patient?

      Your Answer: Commence on oral omeprazole

      Correct Answer: Commence on oral cyclizine

      Explanation:

      The recommended first-line treatment for nausea and vomiting in pregnancy or hyperemesis gravidarum is antihistamines, specifically oral cyclizine. Second-line options include ondansetron and domperidone. Hospital admission may be necessary if the patient cannot tolerate oral medications or fluids, or if symptoms are not controlled with primary care management. There is no indication for oral omeprazole in this case as the patient has not reported any dyspeptic symptoms.

      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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      • Obstetrics
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  • Question 22 - A 32-year-old woman comes in with a positive urine pregnancy test. Lifestyle advice...

    Incorrect

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

      What supplementation would you recommend for this patient?

      Your Answer: Vitamin B12 daily

      Correct Answer: Folic acid 5mg daily

      Explanation:

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

      Folic Acid: Importance, Deficiency, and Prevention

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

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

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

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      • Obstetrics
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  • Question 23 - A 30-year-old woman who is 26 weeks’ pregnant presents to the Emergency Department...

    Incorrect

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

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

      Your Answer: She should have an ultrasound scan (USS) of her biliary tree as her high ALP signifies biliary obstruction

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

      Explanation:

      Understanding Pre-eclampsia and HELLP Syndrome in Pregnancy

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

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

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

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

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      • Obstetrics
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  • Question 24 - A 28-year-old patient presents to the Emergency Department with fresh red vaginal bleeding...

    Incorrect

    • A 28-year-old patient presents to the Emergency Department with fresh red vaginal bleeding and lower abdominal pain.
      The patient is at 36 weeks gestation and gravida 3, para 2. She is rhesus positive and a current smoker. Access to her current maternity notes is unavailable. She tells you she has pre-eclampsia for which she takes labetalol.
      Maternal observations are normal and there are no concerns with foetal movements. A cardiotocograph (CTG) demonstrates that the foetal heart rate is 140 beats/min, variability is 15 beats/min, accelerations are present and there are no decelerations noted.
      On examination, the uterus is hard and tender to palpation. The doctor suspects that the foetus may be in a transverse lie. The patient's pad is partially soaked but there is no active bleeding noted on a quick inspection.
      What would the most appropriate first course of action be in this scenario?

      Your Answer: Administer anti-D antibodies and perform a Kleihauer test

      Correct Answer: Administer corticosteroids and arrange admission to the ward

      Explanation:

      When a pregnant patient presents with painful bleeding and a hard, tender uterus, it may indicate placental abruption. In this case, the patient has risk factors such as being a smoker, having pre-eclampsia, and a transverse lie. The management of placental abruption depends on the gestation, maternal condition, and fetal condition. In this scenario, the patient is stable, at 34 weeks gestation, and the fetus is not showing signs of distress. Therefore, the appropriate plan is to admit the patient and administer steroids for observation.

      Administering anti-D and performing a Kleihauer test is unnecessary as the patient is already known to be rhesus positive. Induction of labor is not indicated as the fetus has not matured to term. Emergency caesarean section would only be necessary if fetal distress was present. Performing a sterile speculum examination is not appropriate as it could cause or worsen hemorrhage, especially if the patient has placenta previa. The best course of action is to admit the patient to the ward until access to notes becomes available or an ultrasound is performed.

      Placental Abruption: Causes, Management, and Complications

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

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

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

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

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  • Question 25 - You receive a call from a 27-year-old woman who is 8-weeks pregnant with...

    Incorrect

    • You receive a call from a 27-year-old woman who is 8-weeks pregnant with twins. Last week she had severe nausea and vomiting despite a combination of oral cyclizine and promethazine. She continued to vomit and was admitted to the hospital briefly where she was started on metoclopramide and ondansetron which helped control her symptoms.

      Today she tells you she read a pregnancy forum article warning about the potential risks of ondansetron use in pregnancy. She is concerned and wants advice on whether she should continue taking it.

      How would you counsel this woman regarding the use of ondansetron during pregnancy?

      Your Answer: There is a small but significant risk of spontaneous miscarriage in twin pregnancies

      Correct Answer: There is a small increased risk of cleft lip/palate in the newborn if used in the first trimester

      Explanation:

      The use of ondansetron during pregnancy has been associated with an increased risk of 3 oral clefts per 10,000 births, according to a study. However, this risk is not included in the RCOG guideline on nausea and vomiting of pregnancy, and there is currently no official NICE guidance on the matter. A draft of NICE antenatal care guidance, published in August 2021, acknowledges the increased risk of cleft lip or palate with ondansetron use, but notes that there is conflicting evidence regarding the drug’s potential to cause heart problems in babies. It is important to note that the risk of spontaneous miscarriage in twin pregnancies is not supported by evidence, and there is no established risk of severe congenital heart defects in newborns associated with ondansetron use.

      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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      • Obstetrics
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  • Question 26 - 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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  • Question 27 - A 26-year-old woman who is 25 weeks pregnant with her second child is...

    Incorrect

    • A 26-year-old woman who is 25 weeks pregnant with her second child is scheduled for a blood glucose check at the antenatal clinic due to her history of gestational diabetes during her first pregnancy. After undergoing the oral glucose tolerance test, her fasting glucose level is found to be 7.2mmol/L and her 2hr glucose level is 8 mmol/L. What is the best course of action for management?

      Your Answer: Glibenclamide

      Correct Answer: Insulin

      Explanation:

      The correct answer for the management of gestational diabetes is insulin. If the fasting glucose level is equal to or greater than 7 mmol/L at the time of diagnosis, insulin should be initiated. Diet and exercise/lifestyle advice alone is not sufficient for managing gestational diabetes and medication is necessary. Empagliflozin and glibenclamide are not appropriate treatments for gestational diabetes. Glibenclamide may only be considered if the patient has declined insulin.

      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 28 - A 30-year-old pregnant woman presents with a complaint of dyspnoea that has been...

    Correct

    • A 30-year-old pregnant woman presents with a complaint of dyspnoea that has been worsening with physical activity for the past month. She is currently 16 weeks pregnant and has had normal prenatal testing. Upon examination, her vital signs are stable, and her lungs are clear bilaterally without cardiac murmur. Mild dependent oedema is noted in her lower extremities. What is the probable cause of her dyspnoea?

      Your Answer: Increased minute ventilation

      Explanation:

      Physiological Changes During Pregnancy and Breathlessness: Understanding the Relationship

      During pregnancy, a woman’s body undergoes numerous physiological changes that can affect her respiratory system. One of the most significant changes is an increase in tidal volume, which leads to an overall increase in minute ventilation. This increased respiratory workload can result in a feeling of breathlessness, which is experienced by up to 75% of pregnant women, particularly during the first trimester. However, it is important to note that this feeling of breathlessness is typically not indicative of any underlying cardiac or pulmonary issues.

      While some degree of dependent leg edema is normal during pregnancy, it is important to understand that other respiratory changes, such as a decrease in residual volume or a reduction in functional residual capacity, do not typically contribute to the feeling of breathlessness. Respiratory rate usually remains unchanged during pregnancy.

      Overall, understanding the physiological changes that occur during pregnancy and their impact on the respiratory system can help healthcare providers better manage and address any concerns related to breathlessness in pregnant women.

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  • Question 29 - A 38-year-old G7P3 mother presents with a show and waters breaking at 34+1...

    Correct

    • A 38-year-old G7P3 mother presents with a show and waters breaking at 34+1 weeks, following three days of fever and left flank pain. Despite hoping for a home birth, she eventually agrees to go to the hospital after three hours of convincing from the midwife. Upon arrival, continuous cardiotocography is initiated and a foetal doppler reveals foetal bradycardia. On abdominal exam, the baby is found to be in a footling breech position, but the uterus is non-tender and contracting. A speculum examination reveals an exposed cord, with a soft 8 cm cervix and an exposed left foot.

      What is the most appropriate initial management plan for this patient and her baby?

      Your Answer: Put the patient on all fours and push the foot back into the uterus

      Explanation:

      In the case of umbilical cord prolapse, the priority is to limit compression on the cord and reduce the chance of cord vasospasm. This can be achieved by pushing any presenting part of the baby back into the uterus, putting the mother on all fours, and retrofilling the bladder with saline. In addition, warm damp towels can be placed over the cord to limit handling. It is important to note that this is a complex emergency that requires immediate attention, as it can lead to foetal bradycardia and limit the oxygen supply to the baby. In this scenario, a category 1 Caesarean section would be necessary, as the pathological CTG demands it. Delivering the baby as breech immediately is not recommended, as it is a high-risk strategy that can lead to morbidity and mortality. IM corticosteroids are indicated for premature rupture of membranes, but the immediate priority is to deal with the emergency. McRobert’s manoeuvre is not appropriate in this case, as it is used to correct shoulder dystocia, which is not the issue at hand.

      Understanding Umbilical Cord Prolapse

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

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

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

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  • Question 30 - A 28-year-old G2P1 woman is admitted to the maternity ward after experiencing regular...

    Incorrect

    • A 28-year-old G2P1 woman is admitted to the maternity ward after experiencing regular contractions. During a vaginal examination, the midwife confirms that the mother is currently in the first stage of labor. When does this stage of labor typically end?

      Your Answer: 6 cm cervical dilation

      Correct Answer: 10 cm cervical dilation

      Explanation:

      The first stage of labour begins with the onset of true labour and ends when the cervix is fully dilated at 10cm. During this stage, regular contractions occur and the cervix gradually dilates. It is important to note that although 4 cm and 6cm cervical dilation occur during this stage, it does not end until the cervix is fully effaced at 10cm. The second stage of labour ends with the birth of the foetus, not the first.

      Labour is divided into three stages, with the first stage beginning from the onset of true labour until the cervix is fully dilated. This stage is further divided into two phases: the latent phase and the active phase. The latent phase involves dilation of the cervix from 0-3 cm and typically lasts around 6 hours. The active phase involves dilation from 3-10 cm and progresses at a rate of approximately 1 cm per hour. In primigravidas, this stage can last between 10-16 hours.

      During this stage, the baby’s presentation is important to note. Approximately 90% of babies present in the vertex position, with the head entering the pelvis in an occipito-lateral position. The head typically delivers in an occipito-anterior position.

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  • Question 31 - 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: Vitamin D 400 IU daily throughout the pregnancy, and folic acid 400mg daily for the first 12 weeks of pregnancy

      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 32 - A 31-year-old woman with epilepsy, associated with generalised tonic–clonic seizures, attends her regular...

    Incorrect

    • A 31-year-old woman with epilepsy, associated with generalised tonic–clonic seizures, attends her regular Epilepsy Clinic appointment with her partner. She is currently taking the combined oral contraceptive pill, but she wants to start trying for a baby. She is currently on sodium valproate and has been seizure-free for one year.
      What is the most suitable antiepileptic medication for this patient to take during the preconception period and pregnancy?

      Your Answer: Continue sodium valproate

      Correct Answer: Stop sodium valproate and commence lamotrigine

      Explanation:

      Antiepileptic Medication Options for Women of Childbearing Age

      Introduction:
      Women of childbearing age with epilepsy require careful consideration of their antiepileptic medication options due to the potential teratogenic effects on the fetus. This article will discuss the appropriate medication options for women with epilepsy who are planning to conceive or are already pregnant.

      Antiepileptic Medication Options for Women of Childbearing Age

      Stop Sodium Valproate and Commence Lamotrigine:
      Sodium valproate is a teratogenic drug and should be avoided in pregnancy. Lamotrigine and carbamazepine are recommended by the Royal College of Obstetricians and Gynaecologists (RCOG) as safer alternatives. Lamotrigine is a sodium channel blocker and has fewer side effects than carbamazepine. It is present in breast milk but has not been associated with harmful effects on the infant.

      Continue Sodium Valproate:
      Sodium valproate is a teratogenic drug and should be avoided in pregnancy. Women taking sodium valproate should be reviewed preconception to change their medication to a safer alternative. Untreated epilepsy can be a major risk factor in pregnancy, increasing maternal and fetal mortality.

      Stop Sodium Valproate and Commence Ethosuximide:
      Ethosuximide is not appropriate for this patient’s management as it is recommended for absence seizures or myoclonic seizures. Use during breastfeeding has been associated with infant hyperexcitability and sedation.

      Stop Sodium Valproate and Commence Levetiracetam:
      Levetiracetam is recommended as an adjunct medication for generalised tonic-clonic seizures that have failed to respond to first-line treatment. This patient has well-controlled seizures on first-line treatment and does not require adjunct medication. Other second-line medications include clobazam, lamotrigine, sodium valproate and topiramate.

      Stop Sodium Valproate and Commence Phenytoin:
      Phenytoin is a teratogenic drug and should be avoided in pregnancy. It can lead to fetal hydantoin syndrome, which includes a combination of developmental abnormalities.

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      • Obstetrics
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  • Question 33 - You are asked to assess a woman who has given birth to her...

    Correct

    • You are asked to assess a woman who has given birth to her third child 2 hours ago. The baby was born at term, weighed 4.2kg, and was in good health. She had a natural delivery that lasted for 7 hours, and opted for a physiological third stage. According to the nurse, she has lost around 750ml of blood, but her vital signs are stable and the bleeding seems to be decreasing. What is the leading reason for her blood loss?

      Your Answer: Uterine atony

      Explanation:

      PPH, which is the loss of 500ml or more from the genital tract within 24 hours of giving birth, is primarily caused by uterine atony. It can be classified as minor (500-1000ml) or major (>1000ml) and has a mortality rate of 6 deaths/million deliveries. The causes of PPH can be categorized into the ‘four T’s’: tone, tissue (retained placenta), trauma, and thrombin (coagulation abnormalities).

      Understanding Postpartum Haemorrhage

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

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

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

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      • Obstetrics
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  • Question 34 - A 25-year-old primigravida woman at 36 weeks gestation comes in with mild irregular...

    Incorrect

    • A 25-year-old primigravida woman at 36 weeks gestation comes in with mild irregular labor pains in the lower abdomen. Upon examination, her cervix is firm, posterior, and closed, and fetal heart tones are present. However, the pain subsides during the consultation. What would be the most suitable course of action?

      Your Answer: Magnesium sulphate

      Correct Answer: Reassure and discharge

      Explanation:

      False labor typically happens during the final month of pregnancy. It is characterized by contractions felt in the lower abdomen that are irregular and spaced out every 20 minutes. However, there are no progressive changes in the cervix.

      Labour is divided into three stages, with the first stage beginning from the onset of true labour until the cervix is fully dilated. This stage is further divided into two phases: the latent phase and the active phase. The latent phase involves dilation of the cervix from 0-3 cm and typically lasts around 6 hours. The active phase involves dilation from 3-10 cm and progresses at a rate of approximately 1 cm per hour. In primigravidas, this stage can last between 10-16 hours.

      During this stage, the baby’s presentation is important to note. Approximately 90% of babies present in the vertex position, with the head entering the pelvis in an occipito-lateral position. The head typically delivers in an occipito-anterior position.

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      • Obstetrics
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  • Question 35 - A 34-year-old woman is at eight weeks’ gestation in her first pregnancy, with...

    Incorrect

    • A 34-year-old woman is at eight weeks’ gestation in her first pregnancy, with a body mass index (BMI) of 36.5 kg/m2. She has type 2 diabetes mellitus, and her sister had pre-eclampsia in both her pregnancies. She had deep vein thrombosis (DVT), following a long-haul flight to Australia last year.
      Which of the following risk factors presenting in this patient’s history is considered a high-risk factor for the development of pre-eclampsia?

      Your Answer: Family history of a first-degree relative with pre-eclampsia

      Correct Answer: Type 2 diabetes mellitus

      Explanation:

      Pre-eclampsia Risk Factors in Pregnancy

      During the first prenatal visit, women are screened for their risk of developing pre-eclampsia during pregnancy. High-risk factors include a personal history of pre-eclampsia, essential hypertension, type 1 or 2 diabetes mellitus, chronic kidney disease, or autoimmune conditions. Moderate risk factors include a BMI of 35-39.9 kg/m2, family history of pre-eclampsia, age of ≥ 40, first pregnancy, multiple pregnancy, and an interpregnancy interval of > 10 years. If any high or moderate risk factor is present, it is recommended that the woman take 75 mg of aspirin daily from the 12th week of gestation until delivery. A personal history of DVT is not a risk factor for pre-eclampsia, but it is associated with an increased risk of thrombi during pregnancy and the puerperium.

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      • Obstetrics
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  • Question 36 - A 28-year-old female patient visits her general practitioner complaining of mild left iliac...

    Correct

    • A 28-year-old female patient visits her general practitioner complaining of mild left iliac fossa pain that has been present for three days. She reports that she discontinued her oral contraceptives seven weeks ago due to side effects and has not had a menstrual period for approximately two months. During her visit, a pregnancy test is conducted, which returns positive. The possibility of an ectopic pregnancy is suspected, and she is referred to the early pregnancy assessment unit. What is the preferred initial imaging modality to confirm an ectopic pregnancy?

      Your Answer: Transvaginal ultrasound

      Explanation:

      A transvaginal ultrasound is the preferred method of investigation for ectopic pregnancy.

      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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      • Obstetrics
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  • Question 37 - A 27-year-old G4P3 woman presents with a lump in the breast, having ceased...

    Incorrect

    • A 27-year-old G4P3 woman presents with a lump in the breast, having ceased breastfeeding her youngest child two weeks prior. Her past medical history is significant for previous episodes of mastitis when breastfeeding her older children. On examination the lump is in the right breast at the six o'clock position, 3 cm from the nipple. The lump is non-tender and the overlying skin seems unaffected. Her observations are as follows:

      Heart rate: 90,
      Respiratory rate: 14,
      Blood pressure: 112/72 mmHg,
      Oxygen saturation: 99%,
      Temperature: 37.5 Cº.

      What is the probable diagnosis, and what is the most appropriate next step in investigation?

      Your Answer: Galactocele, ultrasound imaging

      Correct Answer: Galactocele, no further investigation necessary

      Explanation:

      Galactocele and breast abscess can be distinguished based on clinical history and examination findings, without the need for further investigation.

      Recent discontinuation of breastfeeding is a risk factor for both mastitis/abscess formation and galactocele formation. Galactoceles are distinguishable from breast abscesses because they are painless and non-tender upon examination, and there are no signs of infection locally or systemically.
      Although the patient’s history of mastitis increases the likelihood of a breast abscess, the clinical presentation strongly suggests a galactocele (i.e. painless lump, no localized redness, and absence of fever).

      Understanding Galactocele

      Galactocele is a condition that commonly affects women who have recently stopped breastfeeding. It occurs when a lactiferous duct becomes blocked, leading to the accumulation of milk and the formation of a cystic lesion in the breast. Unlike an abscess, galactocele is usually painless and does not cause any local or systemic signs of infection.

      In simpler terms, galactocele is a type of breast cyst that develops when milk gets trapped in a duct. It is not a serious condition and can be easily diagnosed by a doctor. Women who experience galactocele may notice a lump in their breast, but it is usually painless and does not require any treatment. However, if the lump becomes painful or infected, medical attention may be necessary. Overall, galactocele is a common and harmless condition that can be managed with proper care and monitoring.

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      • Obstetrics
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  • Question 38 - A 25 year old woman presents to her GP with breast pain. She...

    Incorrect

    • A 25 year old woman presents to her GP with breast pain. She gave birth 3 weeks ago and is exclusively breastfeeding. She reports a 4 day history of increasing pain in her left breast, which has not improved with continued feeding and expressing. During examination, she appears healthy, but her temperature is 38.5ºC. There is a small area of redness above the left nipple, which is sensitive to touch. She has no known allergies.
      What is the best course of action for management?

      Your Answer: Oral cephalexin & encourage to continue breastfeeding

      Correct Answer: Oral flucloxacillin & encourage to continue breastfeeding

      Explanation:

      Lactation mastitis is a prevalent inflammatory condition of the breast that can have infectious or non-infectious origins. The primary cause is milk stasis, which can occur due to either overproduction or insufficient removal.

      In cases of non-infectious mastitis, the accumulation of milk leads to an inflammatory response. Occasionally, an infection may develop through retrograde spread via a lactiferous duct or a traumatised nipple, with Staphylococcus aureus being the most common organism.

      Symptoms of lactation mastitis include breast pain (usually unilateral) accompanied by an erythematosus, warm, and tender area. Patients may also experience fever and flu-like symptoms.

      The first-line approach to managing lactation mastitis is conservative, involving analgesia and encouraging effective milk removal (either through continued breastfeeding or expressing from the affected side) to prevent further milk stasis. It is also crucial to ensure proper positioning and attachment during feeding.

      If symptoms do not improve after 12-24 hours of conservative management, antibiotics should be prescribed. The first-line choice is oral flucloxacillin (500 mg four times a day for 14 days), or erythromycin if the patient is allergic to penicillin. Co-amoxiclav is the second-line choice.

      In cases where conservative and antibiotic management do not improve symptoms, other more serious causes, such as inflammatory breast cancer, should be considered. (Source – CKS mastitis)

      Breastfeeding Problems and Their Management

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

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

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

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

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      • Obstetrics
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  • Question 39 - A 35-year-old woman with G4P3 at 39 weeks gestation presents to the labour...

    Incorrect

    • A 35-year-old woman with G4P3 at 39 weeks gestation presents to the labour ward following a spontaneous rupture of membranes. She delivers a healthy baby vaginally but experiences excessive bleeding and hypotension. Despite attempts to control the bleeding, the senior doctor decides to perform a hysterectomy. Upon examination, the pathologist observes that the chorionic villi have deeply invaded the myometrium but not the perimetrium.
      What is the diagnosis?

      Your Answer: Placenta accreta

      Correct Answer: Placenta increta

      Explanation:

      The correct answer is placenta increta, where the chorionic villi invade the myometrium but not the perimetrium. The patient’s age and history of multiple pregnancies increase the risk of this abnormal placentation, which can be diagnosed through pathological studies. Placenta accreta, percreta, and previa are incorrect answers, as they involve different levels of placental attachment and can cause different symptoms.

      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 40 - A 28-year-old woman is admitted to the Acute Gynaecology Ward with per vaginum...

    Incorrect

    • A 28-year-old woman is admitted to the Acute Gynaecology Ward with per vaginum bleeding. She is 14 weeks pregnant and has had a scan confirming an intrauterine pregnancy. She reports lower abdominal cramping and bleeding for the last two days, which prompted admission to await an ultrasound scan. You are an FY1 doctor and are called to see her as she has increasing pain and is crying in distress. On examination, she is sweaty and uncomfortable. Abdomen is soft in the upper region, but firm and very tender suprapubically. Observations show temperature 38.7 °C, heart rate 130 bpm, blood pressure 95/65, respiratory rate 22 and oxygen saturations 97% on air. Checking her pad shows fresh bleeding and speculum examination is difficult due to pain, but there is a smelly discharge and you think you see tissue sitting in the os. You manage to get IV access and starts fluid resuscitation.
      What is the most important next step in management?

      Your Answer:

      Correct Answer: Call your registrar

      Explanation:

      Immediate Management of Septic Miscarriage: Steps to Take

      Septic miscarriage is a life-threatening condition that requires urgent medical attention. If a patient presents with increasing pain, bleeding, and fever, along with clinical signs of sepsis, it is important to inform senior doctors immediately. Here are the steps to take:

      1. Call your registrar: Senior doctors need to know about the patient urgently, coming to review and liaising with coordinators to get the patient to theatre as soon as possible.

      2. Bloods and blood cultures: This is the most important thing to do after informing seniors. She is already shocked, so getting IV access now is essential. Bloods such as a group and crossmatch need to be sent, along with blood cultures.

      3. Transvaginal ultrasound scan: Transvaginal ultrasound scan has no place in the immediate management. The diagnosis is obvious from the history and examination.

      4. Ultrasound abdomen: Abdominal ultrasound can be performed after the patient is initially managed and is out of danger. For the current scenario, it is important to inform a senior registrar as the condition may deteriorate. After giving the call to registrar emergency management should be initiated according to A-E assessment.

      5. Give analgesia and try to repeat the speculum examination: She is already shocked, and to delay treatment to try and examine again would be dangerous.

      By following these steps, you can ensure that the patient receives the urgent care she needs to manage septic miscarriage.

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SESSION STATS - PERFORMANCE PER SPECIALTY

Obstetrics (23/39) 59%
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