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  • Question 1 - A 29-year-old primiparous woman presented to Labour Ward triage at 34+1/40 with upper...

    Correct

    • A 29-year-old primiparous woman presented to Labour Ward triage at 34+1/40 with upper back/chest pain and a headache. The pregnancy had been uncomplicated up to this point, with only some lower back pain over the past 2 weeks.
      Obs: blood pressure 151/102, respiratory rate 18, sats 100% room air, heart rate 60 bpm, afebrile. On examination, she appeared well – PERL. Heart sounds were normal, chest was clear, and there was no shortness of breath (SOB). Her abdomen and uterus were soft and non-tender (SNT), and her calves were also SNT. Reflexes were normal. A urine dip showed nitrate +, leukocytes +, protein 1+. Electrocardiography (ECG) and cardiotocography (CTG) were both normal. Blood tests were taken, and results were pending.
      Considering the likely diagnosis, what would be your first step in management?

      Your Answer: Start po labetalol and admit for monitoring

      Explanation:

      Management of Pre-eclampsia with Hypertension in Pregnancy

      Pre-eclampsia is a common condition affecting pregnant women, with hypertension and proteinuria being the main clinical features. The first line of management for hypertension is oral labetalol, with close monitoring of blood pressure. In cases of mild hypertension, induction of labor is not necessary. However, admission for monitoring and commencement of labetalol is recommended. IV magnesium sulfate may be needed later on, but not initially. Discharge home is not appropriate for women with pre-eclampsia. Early recognition and management of pre-eclampsia is crucial for the well-being of both the mother and the baby.

    • This question is part of the following fields:

      • Obstetrics
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  • Question 2 - A 28-year-old woman who is 35 weeks pregnant presents to the Emergency Department...

    Correct

    • A 28-year-old woman who is 35 weeks pregnant presents to the Emergency Department with fever, abdominal pain, and anxiety. She reports experiencing night sweats for the past few days and has a history of uterine fibroids. She has been sexually active throughout her pregnancy. During the examination, there is significant uterine tenderness and a foul-smelling brown vaginal discharge is observed. The patient's blood pressure is 134/93 mmHg, and her heart rate is 110 beats per minute. Her white blood cell count is 18.5 * 109/l. The fetal heart rate is 170 beats per minute. What is the most likely diagnosis?

      Your Answer: Chorioamnionitis

      Explanation:

      The patient’s symptoms suggest an infectious process, as evidenced by her fever, rapid heartbeat, and elevated levels of neutrophils (which are already higher than normal during pregnancy). Chorioamnionitis is a clinical diagnosis that may be indicated by uterine tenderness and a foul-smelling discharge, and the presence of a baseline fetal tachycardia supports this diagnosis. The likely cause of the infection is prolonged premature rupture of membranes. Although the patient has a history of uterine fibroids, this is not relevant to her current condition, as fibroids typically cause symptoms earlier in pregnancy. Acute placental abruption would cause sudden abdominal pain, which is not present in this case. While pyelonephritis is a possible differential diagnosis, the absence of dysuria makes it less likely.

      Understanding Chorioamnionitis

      Chorioamnionitis is a serious medical condition that can affect both the mother and the foetus during pregnancy. It is caused by a bacterial infection that affects the amniotic fluid, membranes, and placenta. This condition is considered a medical emergency and can be life-threatening if not treated promptly. It is more likely to occur when the membranes rupture prematurely, but it can also happen when the membranes are still intact.

      Prompt delivery of the foetus is crucial in treating chorioamnionitis, and a cesarean section may be necessary. Intravenous antibiotics are also administered to help fight the infection. This condition affects up to 5% of all pregnancies, and it is important for pregnant women to be aware of the symptoms and seek medical attention immediately if they suspect they may have chorioamnionitis.

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      • Obstetrics
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  • Question 3 - A 28-year-old woman who is 20 weeks pregnant comes to you with worries....

    Correct

    • A 28-year-old woman who is 20 weeks pregnant comes to you with worries. She recently had contact with her friend's child who has been diagnosed with chickenpox. She cannot remember if she has had chickenpox before and is not experiencing any symptoms of infection at the moment.
      Varicella Zoster Antibodies Negative
      What steps should you take in this situation?

      Your Answer: Commence varicella-zoster immunoglobulin (VZIG)

      Explanation:

      If a pregnant woman is exposed to chickenpox before 20 weeks of pregnancy and is not immune, she should be given VZIG to prevent fetal varicella syndrome. This condition can cause serious birth defects such as microcephaly, cataracts, and limb hypoplasia. Chickenpox can also lead to severe illness in the mother, including varicella pneumonia. It is important to test for varicella antibodies if the woman is unsure if she has had chickenpox before. Without PEP, the risk of developing a varicella infection is high for susceptible contacts.

      Chickenpox exposure in pregnancy can pose risks to both the mother and fetus, including fetal varicella syndrome. Post-exposure prophylaxis (PEP) with varicella-zoster immunoglobulin (VZIG) or antivirals should be given to non-immune pregnant women, with timing dependent on gestational age. If a pregnant woman develops chickenpox, specialist advice should be sought and oral acyclovir may be given if she is ≥ 20 weeks and presents within 24 hours of onset of the rash.

    • This question is part of the following fields:

      • Obstetrics
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  • Question 4 - A 30-year-old healthy pregnant woman is about to give birth to her first...

    Correct

    • A 30-year-old healthy pregnant woman is about to give birth to her first child at 9-months gestation. The obstetrician decides to perform a caesarean section.
      Which of the following abdominal surgical incisions will the obstetrician most likely use to perform the procedure?

      Your Answer: Suprapubic incision

      Explanation:

      Different Types of Incisions for Surgical Procedures

      There are various types of incisions used for different surgical procedures. Here are some common types of incisions and their uses:

      1. Suprapubic Incision: Also known as the Pfannenstiel incision, this is the most common incision used for Gynaecological and obstetric operations like Caesarean sections. It is made at the pubic hairline.

      2. Transverse Incision just below the Umbilicus: This incision is usually too superior for a Caesarean section because the scar would be visible and does not provide direct access to the uterus as the Pfannenstiel incision.

      3. Right Subcostal Incision: This incision is used to access the gallbladder and biliary tree.

      4. Median Longitudinal Incision: This incision is not commonly used because of cosmetic scarring, as well as the fact that the linea alba is relatively avascular and can undergo necrosis if the edges are not aligned and stitched properly.

      5. McBurney’s Point Incision: This incision is used to access the vermiform appendix and is made at the McBurney’s point, which is approximately one-third of the distance of a line, the spino-umbilical line, starting at the right anterior superior iliac spine and ending at the umbilicus.

      In conclusion, the type of incision used for a surgical procedure depends on the specific needs of the operation and the surgeon’s preference.

    • This question is part of the following fields:

      • Obstetrics
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  • Question 5 - A 32-year-old primiparous woman attends her first health visitor appointment. She is currently...

    Correct

    • A 32-year-old primiparous woman attends her first health visitor appointment. She is currently exclusively breastfeeding, but she complains of sore, cracked nipples. Despite using nipple shields, her symptoms have not improved. The woman is also concerned that her baby is not feeding enough, as she frequently has to stop the feed due to tenderness.
      During nipple examination, you observe small surface cracks, but no exudate or erythema.
      What is the initial step in managing this patient's condition?

      Your Answer: Advise the patient to consider expressing breast milk and feeding the baby from the bottle until the cracks heal

      Explanation:

      Managing Nipple Cracks During Breastfeeding

      Breastfeeding can be a challenging experience for new mothers, especially when they develop nipple cracks. To manage this condition, it is important to observe the breastfeeding technique and ensure correct positioning and latch. If the cracks persist, expressing breast milk and feeding the baby from a bottle may be necessary until the skin heals. Topical fusidic acid should be prescribed for bacterial infections, while miconazole cream is used for Candida infections. Nipple shields and breast shells should be avoided, and reducing the duration of feeds is not recommended. By following these guidelines, mothers can successfully manage nipple cracks and continue to breastfeed their babies.

    • This question is part of the following fields:

      • Obstetrics
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  • Question 6 - A 29-year-old woman comes in for her 20-week anomaly scan. This is also...

    Correct

    • 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 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.

    • This question is part of the following fields:

      • Obstetrics
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  • Question 7 - A 35-year-old woman who is 30 weeks pregnant presents with malaise, headaches and...

    Correct

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

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

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

      Your Answer: HELLP syndrome

      Explanation:

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

      Liver Complications During Pregnancy

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

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

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

    • This question is part of the following fields:

      • Obstetrics
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  • Question 8 - A 31-year-old woman arrives at the obstetric department in the initial stages of...

    Correct

    • A 31-year-old woman arrives at the obstetric department in the initial stages of labour. She is 36+4 weeks pregnant and has been experiencing polyhydramnios during this pregnancy. During examination, the foetal head is palpable on the right side of the maternal pelvis, while the buttocks are palpable on the left side. The amniotic sac remains intact. What is the best course of action for managing this patient?

      Your Answer: Offer external cephalic version

      Explanation:

      The recommended course of action for a patient in early labour with a transverse foetal lie and intact amniotic sac is to offer external cephalic version (ECV) before considering other management options. Conservative management is not appropriate as it poses a high risk of maternal and foetal death. Offering an elective caesarean section is also not the first choice, as ECV should be attempted first. An immediate caesarean section is not necessary if there are no contraindications to ECV.

      Understanding Transverse Lie in Foetal Presentation

      Foetal lie refers to the position of the foetus in relation to the longitudinal axis of the uterus. There are three types of foetal lie: longitudinal, oblique, and transverse. Transverse lie is a rare abnormal foetal presentation where the foetal longitudinal axis is perpendicular to the long axis of the uterus. This means that the foetal head is on the lateral side of the pelvis, and the buttocks are opposite. Transverse lie is more common in women who have had previous pregnancies, have fibroids or other pelvic tumours, are pregnant with twins or triplets, have prematurity, polyhydramnios, or foetal abnormalities.

      Transverse lie can be detected during routine antenatal appointments through abdominal examination or ultrasound scan. Complications of transverse lie include preterm rupture membranes, cord-prolapse, and compound presentation. Management options for transverse lie depend on the gestational age of the foetus. Before 36 weeks gestation, no management is required as most foetuses will spontaneously move into longitudinal lie during pregnancy. After 36 weeks gestation, active management through external cephalic version (ECV) or elective caesarian section is necessary. ECV should be offered to all women who would like a vaginal delivery, while caesarian section is the management for women who opt for it or if ECV is unsuccessful or contraindicated. The decision to perform caesarian section over ECV will depend on various factors, including the risks to the mother and foetus, the patient’s preference, and co-morbidities.

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      • Obstetrics
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  • Question 9 - A 27-year-old woman is eight weeks pregnant in her first pregnancy. She has...

    Correct

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

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

      Explanation:

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

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

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

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

      Perform Thyroid Function Tests in the First and Second Trimesters

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

      Continue on the Same Dose of Levothyroxine at Present if Euthyroid

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

      Return to Pre-Pregnancy Dosing Immediately Post-Delivery

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

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

    • This question is part of the following fields:

      • Obstetrics
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  • Question 10 - A 28-year-old woman presents to the antenatal clinic for a routine visit and...

    Correct

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

      Your Answer: Nifedipine

      Explanation:

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

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

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      • Obstetrics
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  • Question 11 - A 27-year-old female patient arrives at 38 weeks gestation with a 4-day history...

    Correct

    • A 27-year-old female patient arrives at 38 weeks gestation with a 4-day history of headaches and swelling in her lower limbs. Upon examination, her heart rate is 80 bpm, her blood pressure is 168/86 mmHg, and a urine dipstick reveals proteinuria. While being examined, she experiences a generalized tonic-clonic seizure that resolves on its own. An emergency C-section is planned, and another seizure occurs. What is the best course of action for her treatment?

      Your Answer: Magnesium sulfate until 24 hours after last seizure or 24 hours after delivery

      Explanation:

      Magnesium sulfate should be continued for at least 24 hours after delivery or the last seizure in the management of eclampsia. This patient’s condition has progressed to eclampsia, and the primary concern is preventing seizures and delivering the baby. Magnesium sulfate is the preferred agent for managing seizures and providing neuroprotection to the baby. Stopping magnesium sulfate immediately after the last seizure still poses a risk of another seizure occurring, so it should be continued for another 24 hours. Correcting hypertension alone is unlikely to resolve the seizures, so antihypertensive therapy should be given in addition to magnesium sulfate.

      Understanding Eclampsia and its Treatment

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

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

    • This question is part of the following fields:

      • Obstetrics
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  • Question 12 - You are called to see a 27-year-old primiparous woman who has just delivered...

    Incorrect

    • You are called to see a 27-year-old primiparous woman who has just delivered via spontaneous vaginal delivery. She had an active third stage of labour with 10 mg of Syntocinon® administered intramuscularly. The placenta was delivered ten minutes ago and appears complete. The midwife has called you, as there is a continuous small stream of fresh red blood loss. It is estimated that the patient has lost 1050 ml of blood so far. You palpate the abdomen, and you cannot feel any uterine contractions.
      Observations:
      Heart rate (HR) 107 bpm
      Blood pressure (BP) 158/105 mmHg
      Temperature 37.1 °C
      Respiratory rate (RR) 18 breaths per minute
      Oxygen saturations 98% on air
      Which of the following is the next step in this patient’s management?

      Your Answer: Hysterectomy

      Correct Answer: Uterine massage and oxytocin infusion

      Explanation:

      Management of Postpartum Hemorrhage: Conservative and Pharmacological Methods

      Postpartum hemorrhage is a common complication of childbirth and can be life-threatening if not managed promptly. The causes of postpartum hemorrhage fall under four categories, known as the 4Ts: tissue problems, tone problems, trauma, and thrombin. In cases of uterine atony, which is the most common cause of postpartum hemorrhage, conservative and pharmacological methods should be employed first.

      The initial assessment should include securing two large-bore cannulae, sending blood for urgent full blood count, group and save, clotting and crossmatch of four units of blood, and commencing intravenous fluids. Uterine massage of the fundus, as well as an oxytocin infusion, should be the first step in management. If pharmacological methods fail to arrest the bleeding, then an intrauterine balloon can be employed as second line. If this still fails, the patient should be transferred to theatre for exploration and hysterectomy if necessary.

      Ergometrine is contraindicated in women with hypertension, and therefore, should not be used in patients with a raised blood pressure. Hysterectomy is a last resort in women with massive postpartum hemorrhage where mechanical and pharmacological methods have failed to stop the bleeding and the patient is haemodynamically compromised. Intrauterine balloon tamponade is an effective mechanical method to stop postpartum hemorrhage in cases where other methods have failed.

      It is important to ensure that blood is available if necessary, but transfusion should not be treated lightly due to the potential for severe complications. An up-to-date hemoglobin level should be obtained, and the patient should be fluid-resuscitated and monitored before any decision for transfusion. Overall, prompt and appropriate management of postpartum hemorrhage is crucial for ensuring positive maternal outcomes.

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      • Obstetrics
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  • Question 13 - A 26-year-old woman with type 1 diabetes mellitus visits her General Practitioner (GP)...

    Correct

    • A 26-year-old woman with type 1 diabetes mellitus visits her General Practitioner (GP) with her partner to seek advice on nutritional supplementation as they plan to start trying for a baby. She is not using any contraception and her diabetes is well managed, with her latest HbA1c level at 32 mmol/mol (recommended by the Royal College of Obstetricians and Gynaecologists < 48 mmol/mol). What is the most suitable recommendation for folic acid supplementation?

      Your Answer: Commence folic acid 5 mg daily now and continue until week 12 of gestation

      Explanation:

      Folic Acid Supplementation in Pregnancy

      Explanation: Folic acid supplementation is recommended for all women who are trying to conceive and during pregnancy to reduce the risk of neural tube defects and other congenital abnormalities. The recommended dose is 400 micrograms daily from the preconception period until the 12th week of gestation. However, women with certain high-risk factors, such as diabetes, a family history of neural tube defects, or obesity, are advised to take a higher dose of 5 mg daily from the preconception period until the 12th week of gestation. It is important to continue folic acid supplementation until the end of the first trimester to ensure proper formation of the brain and other major organs in the body. Side-effects of folic acid treatment may include abdominal distension, reduced appetite, nausea, and exacerbation of pernicious anaemia.

    • This question is part of the following fields:

      • Obstetrics
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  • Question 14 - A 26-year-old woman presents with significant vaginal bleeding and is diagnosed with a...

    Correct

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

      Your Answer: Choriocarcinoma

      Explanation:

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

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      • Obstetrics
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  • Question 15 - A pregnant woman who is slightly older is admitted to the Emergency department...

    Correct

    • A pregnant woman who is slightly older is admitted to the Emergency department with symptoms of nausea, vomiting, and lethargy. She is in her 38th week of pregnancy and has never been pregnant before. Upon examination, she appears to be clinically jaundiced and has a temperature of 37.7ºC. Her blood pressure and heart rate are normal.

      The results of her blood tests are as follows:
      - Bilirubin: 80 µmol/l
      - ALP: 240 u/l
      - ALT: 550 u/l
      - AST: 430 u/l
      - γGT: 30 u/l
      - INR: 1.8
      - Hb: 110 g/l
      - Platelets: 331 * 109/l
      - WBC: 12.5 * 109/l

      An acute viral hepatitis screen comes back negative. An urgent US doppler liver shows steatosis with patent hepatic and portal vessels. What is the most likely diagnosis?

      Your Answer: Acute fatty liver of pregnancy

      Explanation:

      Based on the presented symptoms, the most probable diagnosis is acute fatty liver of pregnancy. This is supported by the presence of jaundice, mild fever, elevated liver function tests, increased white blood cell count, coagulopathy, and steatosis on imaging. Acute fatty liver of pregnancy typically presents with non-specific symptoms such as fatigue, malaise, and nausea, whereas cholestasis of pregnancy is characterized by severe itching. The absence of abnormalities in hemoglobin, platelet count, and viral screening makes the diagnosis of HELLP syndrome or viral hepatitis unlikely. Additionally, pre-eclampsia is characterized by hypertension and proteinuria. It is important to note that placental ALP can cause an increase in serum ALP levels during pregnancy.

      Liver Complications During Pregnancy

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

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

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

    • This question is part of the following fields:

      • Obstetrics
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  • Question 16 - A 38-year-old woman visits her GP complaining of itching symptoms. She is currently...

    Correct

    • A 38-year-old woman visits her GP complaining of itching symptoms. She is currently 29 weeks pregnant and has had no complications thus far. She reports that her palms and soles of her feet have been extremely itchy for the past few days, and the sensation has now spread to her abdomen. However, she feels otherwise healthy and denies experiencing nausea, vomiting, or abdominal pain.

      During the examination, the patient appears to be in good health, without signs of jaundice or rash. Her vital signs are normal, and her blood tests are generally unremarkable, except for a slightly elevated bilirubin level.

      Based on the likely diagnosis, what is the most appropriate topic to discuss with her regarding definitive management?

      Your Answer: Induction of labour at 37 weeks

      Explanation:

      The patient is experiencing intense pruritus and has elevated bilirubin levels, which are common symptoms of intrahepatic cholestasis of pregnancy. Due to the heightened risk of stillbirth, induction of labor at 37 weeks is typically recommended. While a caesarian section at 37 weeks may be considered, there is insufficient evidence to support this approach over induction. Induction at 34 weeks is not advisable, and reassurance with a normal delivery at term is not appropriate. Therefore, a discussion regarding induction at 37 weeks is necessary.

      Intrahepatic Cholestasis of Pregnancy: Symptoms and Management

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

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

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

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  • Question 17 - A 30-year-old woman in the delivery room experienced a primary postpartum hemorrhage (PPH)...

    Correct

    • A 30-year-old woman in the delivery room experienced a primary postpartum hemorrhage (PPH) 3 hours after delivery. Following adequate resuscitation, she was assessed and diagnosed with uterine atony as the underlying cause. Pharmacological treatment was initiated, but proved ineffective. What is the most suitable initial surgical intervention?

      Your Answer: Intrauterine balloon tamponade

      Explanation:

      The majority of cases of postpartum hemorrhage are caused by uterine atony, while trauma, retained placenta, and coagulopathy account for the rest. According to the 2009 RCOG guidelines, if pharmacological management fails to stop bleeding and uterine atony is the perceived cause, surgical intervention should be attempted promptly. Intrauterine balloon tamponade is the recommended first-line measure for most women, but other interventions may also be considered depending on the clinical situation and available expertise. These interventions include haemostatic brace suturing, bilateral ligation of uterine arteries, bilateral ligation of internal iliac (hypogastric) arteries, selective arterial embolization, and hysterectomy.

      Understanding Postpartum Haemorrhage

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

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

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

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  • Question 18 - A 27-year-old woman presents to the Emergency Department with a 5-day history of...

    Correct

    • A 27-year-old woman presents to the Emergency Department with a 5-day history of vomiting. She has vomited 6 times a day for the past 5 days. When asked about pregnancy, she states her periods are irregular. On examination, her chest is clear, heart sounds are normal and she has a non-tender but distended abdomen. Her temperature is 37ºC, oxygen saturation 98% on air, heart rate 110 beats per minute, respiratory rate 20 breaths per minute, and blood pressure 110/70 mmHg. Blood results: Hb 118 g/L Male: (135-180) Female: (115 - 160) Platelets 160 * 109/L (150 - 400) WBC 5.6 * 109/L (4.0 - 11.0) CRP 4 mg/L (< 5) βhCG 453,000 mIU/ml. What is the most likely diagnosis?

      Your Answer: Complete hydatidiform mole

      Explanation:

      The most probable diagnosis for a patient with a distended abdomen and abnormally high serum βhCG is a complete hydatidiform mole. The serum βhCG level of 453,000 mIU/ml is significantly higher than the upper limit of expected levels in an intrauterine pregnancy during weeks 9-12. Morning sickness may also be more severe in molar pregnancies. An ultrasound scan can confirm the diagnosis by showing a snowstorm appearance, and histology can be performed after evacuation.

      While acute appendicitis is a possibility, the patient’s non-tender abdomen and normal CRP and white cell count make it less likely. Appendicitis would not cause high serum βhCG. Ectopic pregnancy should also be ruled out, as it is a potential diagnosis in any woman of childbearing age with abdominal pain, vaginal bleeding, or signs of shock. However, the serum βhCG level for an ectopic pregnancy is unlikely to be as high as in a molar pregnancy. An ultrasound scan can differentiate between a normal intrauterine pregnancy and a molar pregnancy.

      Characteristics of Complete Hydatidiform Mole

      A complete hydatidiform mole is a rare type of pregnancy where the fertilized egg develops into a mass of abnormal cells instead of a fetus. This condition is characterized by several features, including vaginal bleeding, an enlarged uterus size that is greater than expected for gestational age, and abnormally high levels of serum hCG. Additionally, an ultrasound may reveal a snowstorm appearance of mixed echogenicity.

      In simpler terms, a complete hydatidiform mole is a type of pregnancy that does not develop normally and can cause abnormal bleeding and an enlarged uterus. Doctors can detect this condition through blood tests and ultrasounds, which show a unique appearance of mixed echogenicity. It is important for women to seek medical attention if they experience any abnormal symptoms during pregnancy.

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  • Question 19 - A 25-year-old woman who is 16 weeks pregnant comes to her GP with...

    Correct

    • A 25-year-old woman who is 16 weeks pregnant comes to her GP with concerns of exposure to an infectious disease. Her neighbor's son has a rash and a high temperature. She has no medical history and is unsure if she had chickenpox in childhood. What is the initial step to take?

      Your Answer: Check varicella antibodies

      Explanation:

      When a pregnant woman is exposed to chickenpox, the first step is to check if she has varicella antibodies. If she is unsure whether she has had chickenpox in the past, the presence or absence of antibodies will determine the next course of action.

      If a pregnant woman is over 20 weeks gestation and does not have varicella antibodies, she should be given varicella-zoster immunoglobulin or oral acyclovir within 7-14 days of exposure. Delaying the administration of oral acyclovir can reduce the risk of developing chickenpox.

      Oral acyclovir is also recommended if a pregnant woman over 20 weeks gestation develops chickenpox. However, caution should be exercised if the patient is under 20 weeks gestation and does not have any symptoms of chickenpox.

      The varicella-zoster vaccine is not recommended for pregnant women as it is a live attenuated vaccine that can cross the placenta and cause foetal varicella syndrome. It can be given to women who have not had chickenpox and are not immune to antibody testing, but they should avoid getting pregnant for three months after receiving the vaccine.

      Varicella-zoster immunoglobulin is recommended for pregnant women who are not immune to varicella on antibody testing and can receive it within 10 days of exposure. However, it provides short-lived protection, so patients should be advised to get the varicella-zoster vaccine after their pregnancy.

      Chickenpox exposure in pregnancy can pose risks to both the mother and fetus, including fetal varicella syndrome. Post-exposure prophylaxis (PEP) with varicella-zoster immunoglobulin (VZIG) or antivirals should be given to non-immune pregnant women, with timing dependent on gestational age. If a pregnant woman develops chickenpox, specialist advice should be sought and oral acyclovir may be given if she is ≥ 20 weeks and presents within 24 hours of onset of the rash.

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  • Question 20 - A 23-year-old woman who is pregnant at 37 weeks gestation develops spontaneous labour....

    Correct

    • A 23-year-old woman who is pregnant at 37 weeks gestation develops spontaneous labour. She has a history of pre-eclampsia. Her blood pressure is 170/110 mmHg.

      Blood results are as follows:

      Hb 110 g/L
      Male: (135-180)
      Female: (115 - 160)

      Platelets 100 * 109/L
      (150 - 400)

      WBC 15.0 * 109/L
      (4.0 - 11.0)

      The medical team decides to administer magnesium sulphate to the patient. However, shortly after receiving the medication, the patient experiences respiratory depression with a respiratory rate of 6 breaths per minute.

      What is the urgent treatment required for this patient?

      Your Answer: Calcium gluconate

      Explanation:

      The patient is showing signs of severe pre-eclampsia, including high blood pressure and thrombocytopenia, and requires urgent delivery and magnesium sulphate. While magnesium sulphate is effective in preventing and treating seizures, it can also cause toxicity, which is characterized by loss of deep tendon reflexes, respiratory depression, and cardiac arrest. In this case, the patient is likely experiencing magnesium sulphate toxicity due to respiratory depression. The appropriate treatment is calcium gluconate, which is the first-line option for this condition. BiPAP and CPAP are not suitable in this situation, and intubation and ventilation should only be considered if non-invasive strategies fail.

      Understanding Eclampsia and its Treatment

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

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

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  • Question 21 - A 33-year-old pregnant woman arrives at the maternity department at 40 weeks gestation....

    Correct

    • A 33-year-old pregnant woman arrives at the maternity department at 40 weeks gestation. The medical team decides to perform an artificial rupture of the membranes, but during an examination, they discover that the umbilical cord is palpable vaginally. What position should the woman assume in this situation?

      Your Answer: On all fours

      Explanation:

      The recommended position for women with cord prolapse is on all fours, with their knees and elbows on the ground. It is important to avoid pushing the cord back in, but to keep it warm and moist. This position helps to prevent compression of the presenting part of the fetus. However, immediate preparations for a caesarian section should also be made. The Trendelenburg position, which involves tilting the head end of the bed downwards, is not recommended for cord prolapse. The Lloyd Davis position, which involves separating the legs, is also not recommended. The McRoberts manoeuvre, which involves hyper-flexing the legs tightly to the abdomen, is used for shoulder dystocia during vaginal delivery and is not appropriate for cord prolapse. The lithotomy position, which involves raising the legs in stirrups, is commonly used in obstetrics and gynaecology but is not recommended for cord prolapse.

      Understanding Umbilical Cord Prolapse

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

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

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

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  • Question 22 - A 28-year-old woman presents to the antenatal clinic at 12 weeks gestation for...

    Correct

    • A 28-year-old woman presents to the antenatal clinic at 12 weeks gestation for Down's syndrome screening. She undergoes a screening test and the results show an increased b-hCG, decreased PAPP-A, and thickened nuchal translucency on ultrasound. The chance of Down's syndrome is calculated to be 1/80. The patient expresses her concern about the safety of the testing options for her and her baby. She has no significant medical history. What is the most appropriate next step in managing this patient?

      Your Answer: Offer non-invasive prenatal screening test (NIPT)

      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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  • Question 23 - A 29-year-old woman, who is 12 weeks pregnant, visits her midwife for a...

    Correct

    • A 29-year-old woman, who is 12 weeks pregnant, visits her midwife for a check-up. She has a BMI of 33 kg/m² and no other medical conditions. The patient is anxious about gestational diabetes, which she believes is common in larger women. She has one child previously, a boy, who was born after a complicated and prolonged delivery. He weighed 4.6kg at birth and required no additional post-natal care. There is no family history of any pregnancy-related issues. What is the most appropriate test to address her concerns and medical history?

      Your Answer: Oral glucose tolerance test at 24-28 weeks

      Explanation:

      The preferred method for diagnosing gestational diabetes is still the oral glucose tolerance test.

      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 24 - A 35-year-old woman presents with a significant obstetric hemorrhage due to uterine atony....

    Correct

    • A 35-year-old woman presents with a significant obstetric hemorrhage due to uterine atony. What is the initial medical management after stabilization and general measures?

      Your Answer: Syntocinon

      Explanation:

      To treat postpartum haemorrhage caused by uterine atony, medical options include oxytocin, ergometrine, carboprost, and misoprostol.

      The leading cause of primary postpartum haemorrhage is uterine atony. The RCOG has issued guidelines (Green-top Guideline No.52) for managing primary PPH due to uterine atony. The first-line treatment recommended is 5U of IV Syntocinon (oxytocin), followed by 0.5 mg of ergometrine.

      Understanding Postpartum Haemorrhage

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

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

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

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  • Question 25 - A 28-year-old woman gives birth vaginally at 38 weeks gestation to a healthy...

    Correct

    • A 28-year-old woman gives birth vaginally at 38 weeks gestation to a healthy baby girl weighing 4.2 kg. This is her third delivery. However, she experiences ongoing bleeding even after the placenta is removed, resulting in a loss of approximately 900 ml of blood. Upon examination, her heart rate is 98 bpm, her blood pressure is 100/60 mmHg, and her oxygen saturation is 97% on room air. The medical team immediately takes an ABCDE approach and notifies senior members to become involved. What is the most likely underlying factor that has contributed to her presentation?

      Your Answer: Failure of adequate uterine contractions

      Explanation:

      The primary cause of postpartum haemorrhage (PPH) is the failure of adequate uterine contractions, also known as uterine atony. This is evident in a patient who has lost more than 500 ml of blood within 24 hours following a vaginal delivery. Other causes of PPH include trauma (e.g. perineal tear), tissue (e.g. retained placenta), and thrombin (e.g. coagulopathy), which are collectively referred to as the 4 Ts. While it was previously believed that multiparity was a risk factor for PPH, recent studies suggest that nulliparity is a stronger risk factor. Nonetheless, uterine atony remains the most common cause of PPH. Uterine hyperstimulation, which is characterized by excessively frequent uterine contractions, is rare and typically seen following induced labor, but it is not a common cause of PPH.

      Understanding Postpartum Haemorrhage

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

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

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

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  • Question 26 - A patient 16/40 gestation contacts your clinic via phone. This is her first...

    Correct

    • A patient 16/40 gestation contacts your clinic via phone. This is her first pregnancy and she is worried about not experiencing any foetal movements yet. You provide reassurance that foetal movements can be felt between 16-20 weeks gestation in first pregnancies. When should further investigation be considered if no foetal movements are felt by this time?

      Your Answer: 24 weeks

      Explanation:

      According to RCOG guidelines, women typically feel fetal movements by 20 weeks of gestation. However, if no movements are felt by 24 weeks, it is recommended to refer the woman to a maternal fetal medicine unit to assess for potential neuromuscular conditions.

      Understanding Reduced Fetal Movements

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

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

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

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

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

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

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  • Question 27 - A woman is in labour with her first child. The midwife becomes concerned...

    Correct

    • A woman is in labour with her first child. The midwife becomes concerned that the cardiotocograph is showing late decelerations. She is reviewed by the obstetrician on-call who states that there is fetal compromise, but no immediate risk to life. A category two caesarean section is planned.

      What is the timeframe for the delivery to be performed?

      Your Answer: Within 75 minutes

      Explanation:

      Category 2 caesarean sections must be carried out within 75 minutes of the decision being made. This category is used when there is fetal or maternal compromise that is not immediately life-threatening. The delivery should be planned as soon as possible, but the target time is within 60-75 minutes. Category 1 caesarean section, on the other hand, is used when there is an immediate threat to the life of the woman or fetus, and the procedure should be performed within 30 minutes.

      Caesarean Section: Types, Indications, and Risks

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

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

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

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

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  • Question 28 - A 32-year-old woman who is 13 weeks pregnant had pre-eclampsia in her previous...

    Correct

    • A 32-year-old woman who is 13 weeks pregnant had pre-eclampsia in her previous pregnancy and underwent a caesarean section at 36 weeks gestation. Her blood pressure has been normal since then and today. What intervention should be suggested to decrease the likelihood of pre-eclampsia recurrence?

      Your Answer: Low-dose aspirin

      Explanation:

      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 29 - A 35-year-old para 1+0 has arrived at term in labor. During a vaginal...

    Correct

    • A 35-year-old para 1+0 has arrived at term in labor. During a vaginal examination, the occiput is palpable posteriorly (near the sacrum). What is the appropriate course of action for managing this patient?

      Your Answer: The fetal head may rotate spontaneously to an OA position

      Explanation:

      1: The occiput posterior (OP) position during delivery is feasible, but it may result in a longer and more painful labor.
      2: If labor progress is slow, augmentation should be considered.
      3: The use of Kielland’s forceps is linked to the most favorable outcomes, but it requires specialized skills.
      4: Typically, women in the OP position will feel the urge to push earlier than those in the occiput anterior (OA) position.

      Labour is divided into three stages, with stage 2 being from full dilation to delivery of the fetus. This stage can be further divided into two categories: passive second stage, which occurs without pushing, and active second stage, which involves the process of maternal pushing. The active second stage is less painful than the first stage, as pushing can mask the pain. This stage typically lasts around one hour, but if it lasts longer than that, medical interventions such as Ventouse extraction, forceps delivery, or caesarean section may be necessary. Episiotomy, a surgical cut made in the perineum to widen the vaginal opening, may also be required during crowning. However, this stage is associated with transient fetal bradycardia, which is a temporary decrease in the fetal heart rate.

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  • Question 30 - A 28-year-old woman with a history of back pain uses paracetamol and ibuprofen...

    Correct

    • A 28-year-old woman with a history of back pain uses paracetamol and ibuprofen regularly for pain relief. She and her partner are planning to have a baby, and would like to know about the safety of analgesics during pregnancy.
      What is the best statement regarding the safety of analgesics in pregnancy?

      Your Answer: Codeine phosphate can be used at low doses if needed

      Explanation:

      Safe and Unsafe Painkillers in Pregnancy

      Pregnancy can be a challenging time for women, especially when it comes to managing pain. While some painkillers are safe to use during pregnancy, others can have harmful effects on the developing fetus. Here is a breakdown of some commonly used painkillers and their safety in pregnancy.

      Codeine phosphate: Low doses of codeine phosphate are generally safe to use during pregnancy. However, if taken closer to delivery, the neonate should be observed for signs of respiratory depression, drowsiness, or opioid withdrawal.

      Naproxen: Naproxen belongs to the family of NSAIDs and is contraindicated in pregnancy. However, it is safe to use in the postpartum period and by women who are breastfeeding.

      Ibuprofen: Ibuprofen and other NSAIDs should be avoided during pregnancy as they are associated with teratogenic effects and other congenital problems.

      Paracetamol: Paracetamol is the analgesic of choice in pregnancy and is safe to use within the recommended limits. However, patients should be cautioned against taking paracetamol and low-dose co-codamol concurrently.

      Tramadol: Tramadol should be avoided in pregnancy as it has been shown to be embryotoxic in animal models.

      In conclusion, it is important for pregnant women to consult with their healthcare provider before taking any painkillers to ensure the safety of both mother and fetus.

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  • Question 31 - A 23-year-old asthmatic woman has been brought to the emergency department after experiencing...

    Correct

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

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

      Explanation:

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

      Understanding Eclampsia and its Treatment

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

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

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      • Obstetrics
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  • Question 32 - A 28-year-old woman is on day one postpartum, following a normal vaginal delivery....

    Correct

    • 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: 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 33 - A 35-year-old woman is 32 weeks pregnant and meets with her midwife to...

    Correct

    • A 35-year-old woman is 32 weeks pregnant and meets with her midwife to discuss her birth plan. Her pregnancy has been uncomplicated with a fundal placenta seen on ultrasound scans. She has no pre-existing medical conditions. The patient had one previous pregnancy three years ago and delivered a healthy baby via low transverse caesarean section. She is eager to plan for a vaginal delivery this time around if feasible. What advice should the midwife provide to the patient?

      Your Answer: Planned vaginal delivery is an option from 37 weeks

      Explanation:

      Having had one previous caesarean section, the majority of women can have a successful vaginal delivery. A fundal placenta, which is attached at the top of the uterus away from the cervical os, is a favorable location for a placenta and does not require a caesarean section. However, a previous caesarean section does increase the risk of placenta praevia, where the placenta covers the cervical os, which may require a caesarean section. Inducing vaginal delivery at 36-37 weeks is not recommended in this case, as it is not a suitable option. While maternal age of 37 may pose some risks during pregnancy and birth, it is not a determining factor for a caesarean section unless there are other concerns.

      Caesarean Section: Types, Indications, and Risks

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

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

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

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

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  • Question 34 - A 35-year-old woman, para 2+0, is currently in the second stage of labour...

    Correct

    • A 35-year-old woman, para 2+0, is currently in the second stage of labour and has successfully delivered the anterior shoulder. She has chosen active management for the third stage of labour. During her pregnancy, she experienced mild gestational hypertension and her most recent blood pressure reading was 140/90 mmHg. What medication should be given at this point?

      Your Answer: Oxytocin

      Explanation:

      The third stage of labor begins with the birth of the baby and ends with the expulsion of the placenta and membranes. To reduce the risk of post-partum hemorrhage and the need for blood transfusion after delivery, active management of this stage is recommended. This involves administering uterotonic drugs, delaying clamping and cutting of the cord for over a minute but less than five minutes, and using controlled cord traction after signs of placental separation. Guidelines recommend the use of 10 IU oxytocin by IM injection after delivery of the anterior shoulder. Ergometrine should not be given to patients with hypertension, and oxytocin is preferred as it causes less nausea and vomiting. The active management process should take less than 30 minutes.

      Understanding Labour and its Stages

      Labour is the process of giving birth, which is characterized by the onset of regular and painful contractions that are associated with cervical dilation and descent of the presenting part. Signs of labour include regular and painful uterine contractions, a show (shedding of mucous plug), rupture of the membranes (not always), and shortening and dilation of the cervix.

      Labour can be divided into three stages. The first stage starts from the onset of true labour to when the cervix is fully dilated. The second stage is from full dilation to delivery of the fetus, while the third stage is from delivery of the fetus to when the placenta and membranes have been completely delivered.

      Monitoring is an essential aspect of labour. Fetal heart rate (FHR) should be monitored every 15 minutes (or continuously via CTG), contractions should be assessed every 30 minutes, maternal pulse rate should be assessed every 60 minutes, and maternal blood pressure and temperature should be checked every 4 hours. Vaginal examination (VE) should be offered every 4 hours to check the progression of labour, and maternal urine should be checked for ketones and protein every 4 hours.

      In summary, understanding the stages of labour and the importance of monitoring can help ensure a safe and successful delivery.

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  • Question 35 - A 25-year-old woman has experienced difficulty with lactation during the first week after...

    Correct

    • A 25-year-old woman has experienced difficulty with lactation during the first week after giving birth to her second child. She successfully breastfed her first child for nine months. She delivered at full term and suffered from a significant postpartum hemorrhage six hours after delivery. She received an IV oxytocin infusion and a blood transfusion. What is the most probable location of the lesion?

      Your Answer: Anterior pituitary

      Explanation:

      Understanding Pituitary Lesions and their Symptoms

      The pituitary gland is a small gland located at the base of the brain that produces and releases hormones that regulate various bodily functions. Lesions in different parts of the pituitary gland can cause a range of symptoms.

      Anterior Pituitary: Ischaemic necrosis of the anterior pituitary can occur following post-partum haemorrhage, leading to varying symptoms of hypopituitarism. The most common initial symptom is low or absent prolactin, resulting in failure to commence lactation. Other symptoms may include amenorrhoea, hypothyroidism, glucocorticoid deficiency, and loss of genital and axillary hair. Treatment requires hormone supplementation and involvement of an endocrinologist.

      Hypothalamus: Lesions in the hypothalamus can cause hyperthermia/hypothermia, aggressive behaviour, somnolence, and Horner syndrome.

      Cerebral Cortex: Lesions in the cerebral cortex are associated with stroke or multiple sclerosis and affect different functions such as speech, movement, hearing, and sight.

      Posterior Pituitary: Lesions in the posterior pituitary are associated with central diabetes insipidus.

      Pituitary Stalk: Lesions in the pituitary stalk are associated with diabetes insipidus, hypopituitarism, and hyperprolactinaemia. The patient presents with galactorrhoea, irregular menstrual periods, and other symptoms related to hyperprolactinaemia due to the lifting of dopamine neurotransmitter release inhibition.

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  • Question 36 - A woman gives birth via normal vaginal delivery. The midwife notices the baby...

    Correct

    • 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, 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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  • Question 37 - A 28-year-old woman visits her GP's office and shares the news that she...

    Correct

    • 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 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 38 - A 25-year-old woman who is 32 weeks pregnant presents to the Emergency Department...

    Correct

    • A 25-year-old woman who is 32 weeks pregnant presents to the Emergency Department with sudden onset abdominal pain and some very light vaginal bleeding which has subsequently stopped. On examination her abdomen is tense and tender. The mother says she has not noticed any reduction in foetal movements. Her vital signs are as follows:

      HR 105 bpm
      BP 120/80 mmHg
      Temperature 37.1ºC
      Respiratory Rate 20 min-1

      Cardiotocography (CTG) was performed and showed a foetal heart rate of 140 bpm, with beat-beat variability of 5-30 bpm and 3 accelerations were seen in a 20 minute period.

      Ultrasound demonstrates normal foetal biophysical profile and liquor volume. There is a small collection of retroplacental blood.

      What is the most appropriate course of action for this patient?

      Your Answer: Admit for IV corticosteroids and monitor maternal and foetal condition

      Explanation:

      In the case of a small placental abruption without signs of foetal distress and a gestational age of less than 36 weeks, the recommended management is to admit the patient and administer steroids. While vitamin K can aid in blood clotting, it is not the optimal choice in this situation. A caesarean section is not immediately necessary as the foetus is not in distress and is under 36 weeks. Antibiotics are not indicated as there are no signs of infection and the patient is not experiencing a fever. Continuous monitoring with CTG for 24 hours is not necessary if the foetus is not displaying any distress on initial presentation and the mother has not reported a decrease in foetal movements.

      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 39 - A 35-year-old woman presents at 12 weeks’ gestation to see the clinician. Her...

    Correct

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

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

      Explanation:

      Medical and Surgical Management of Termination of Pregnancy

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

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

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

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

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

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  • Question 40 - 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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SESSION STATS - PERFORMANCE PER SPECIALTY

Obstetrics (39/40) 98%
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