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Question 1
Correct
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A 32-year-old lady is two weeks postpartum and in good health. She has painful defecation that is accompanied by some new blood on the toilet paper. Which of the following diagnoses is the most likely?
Your Answer: Acute anal fissure.
Explanation:The history of acutely painful defecation associated with spotting of bright blood is very suggestive of an acute anal fissure. Typically, the patient reports severe pain during a bowel movement, with the pain lasting several minutes to hours afterward. The pain recurs with every bowel movement, and the patient commonly becomes afraid or unwilling to have a bowel movement, leading to a cycle of worsening constipation, harder stools, and more anal pain. Approximately 70% of patients note bright-red blood on the toilet paper or stool. Occasionally, a few drops may fall in the toilet bowl, but significant bleeding does not usually occur with an anal fissure.. After gently spreading the buttocks, a close check of the anal verge can typically confirm the diagnosis.
Rectal inspection is excruciatingly painful and opposed by sphincter spasm; however, if the fissure can be seen, it is not necessary to make the diagnosis at first.A perianal abscess, which presents as a sore indurated area lateral to the anus, or local trauma linked with anal intercourse or a foreign body, are two more painful anorectal disorders to rule out.
Anal fistulae do not appear in this way, but rather with perianal discharge, and the diagnosis is based on determining the external orifice of the fistula.
Although first-degree haemorrhoids bleed, they do not cause defecation to be unpleasant.
Although carcinoma of the anus or rectum can cause painful defecation, it would be exceptional in this situation.
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This question is part of the following fields:
- Obstetrics
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Question 2
Correct
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All of the following statements is considered incorrect regarding the management of deep vein thrombosis in pregnancy, except:
Your Answer: Warfarin therapy is contraindicated throughout pregnancy but safe during breast feeding
Explanation:Anticoagulant therapy is the standard treatment for deep vein thrombosis (DVT) but is mostly used in non-pregnant patients. In pregnancy, unfractionated heparin (UFH) and low molecular weight heparin (LMWH) are commonly used. Warfarin therapy is generally avoided in pregnancy because of its fetal toxicity.
Warfarin is contraindicated during pregnancy, but is safe to use postpartum and is compatible with breastfeeding. Low-molecular-weight heparin has largely replaced unfractionated heparin for prophylaxis and treatment in pregnancy.
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This question is part of the following fields:
- Obstetrics
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Question 3
Correct
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A 19-year-old primigravid woman, 34 weeks of gestation, came in for a routine blood test. Her platelet count is noted at 75x109/L (normal range is 150-400) . Which of the following can best explain the thrombocytopenia of this patient?
Your Answer: Incidental thrombocytopaenia of pregnancy.
Explanation:Incidental thrombocytopenia of pregnancy is the most common cause of thrombocytopenia in an otherwise uncomplicated pregnancy. The platelet count finding in this case is of little concern unless it falls below 50×109/L.
Immune thrombocytopenia is a less common cause of thrombocytopenia in pregnancy. The anti-platelet antibodies cam cross the placenta and pose a problem both to the mother and the foetus. Profound thrombocytopenia in the baby is a common finding of this condition.
Thrombocytopenia can occur in patients with severe pre-eclampsia. However, it is usually seen concurrent with other signs of severe disease.
Maternal antibodies that target the baby’s platelets can rarely cause thrombocytopenia in the mother. Instead, it can lead to severe coagulation and bleeding complications in the baby as a result of profound thrombocytopenia.
Systemic lupus erythematosus is unlikely to explain the thrombocytopenia in this patient.
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This question is part of the following fields:
- Obstetrics
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Question 4
Correct
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APGAR's score includes all the following, EXCEPT:
Your Answer: Blood pH
Explanation:Elements of the Apgar score include colour, heart rate, reflexes, muscle tone, and respiration. Apgar scoring is designed to assess for signs of hemodynamic compromise such as cyanosis, hypoperfusion, bradycardia, hypotonia, respiratory depression or apnoea. Each element is scored 0 (zero), 1, or 2. The score is recorded at 1 minute and 5 minutes in all infants with expanded recording at 5-minute intervals for infants who score 7 or less at 5 minutes, and in those requiring resuscitation as a method for monitoring response. Scores of 7 to 10 are considered reassuring.
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This question is part of the following fields:
- Obstetrics
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Question 5
Incorrect
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A 33-year -old G2Pl woman who is at 10 weeks gestation presented to the medical clinic for antenatal visit. It was revealed that she has a twin pregnancy. She was known to have had a complicated previous pregnancy with placental abruption at 34 weeks. Which of the following is considered the next step in best managing the patient in addition to routine antenatal care?
Your Answer: Serial CTGs after 34 weeks
Correct Answer: Increased iron and folic acid supplementation
Explanation:Twin pregnancies are at risk for iron deficiency due to significant maternal, fetal, and placental demands. Recommendations regarding the optimal iron dose in twin pregnancies are based on clinical expert opinions, advocating doubling the dose of iron from 30 mg of elemental iron to 60 mg routinely during the second and third trimester, regardless of maternal iron stores.
If pregnant with twins, patient should take the same prenatal vitamins she would take for any pregnancy, but a recommendation of extra folic acid and iron will be made. The additional folic acid and extra iron will help ward off iron-deficiency anaemia, which is more common when patient is pregnant with multiples.
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This question is part of the following fields:
- Obstetrics
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Question 6
Incorrect
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A 33-year-old 'grand multiparous' woman, who has previously delivered seven children by normal vaginal delivery, spontaneously delivers a live baby weighing 4750gm one hour ago after a three-hour long labour period. Shortly after, an uncomplicated third stage of labour, she goes into shock (pulse 140/min, BP 80/50 mmHg). At the time of delivery, total blood loss was noted at 500mL, and has not been excessive since then. What is the most probable diagnosis of this patient?
Your Answer: Uterine atony.
Correct Answer: Uterine rupture.
Explanation:The patient most likely suffered a uterine rupture. It occurs most often in multiparous women and is less often associated with external haemorrhage. Shock develops shortly after rupture due to the extent of concealed bleeding.
Uterine inversion rarely occurs when after a spontaneous and normal third stage of labour. Although it can lead to shock, it is usually associated with a history of controlled cord traction or Dublin method of placenta delivery before the uterus has contracted. This diagnosis is also strongly considered when shock is out of proportion to the amount of blood loss.
An overwhelming infection is unlikely in this case when labour occurred for a short period of time. Uterine atony and amniotic fluid embolism are more associated with excessive vaginal bleeding, which is not evident in this case.
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This question is part of the following fields:
- Obstetrics
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Question 7
Correct
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Your Answer: Endometrial biopsy
Explanation:Uncontrolled endometrial proliferation due to excess and unregulated estrogen is the reason for intermenstrual bleeding and irregular menses along with abnormal uterine bleeding (AUB) in this patient. The condition is mostly associated with an increased risk of endometrial hyperplasia
ancer.
The absolute risk of endometrial hyperplasia
ancer is very low in women aged <45, therefore they can be started on combination medication with estrogen/progestin contraception (ie, medical management) without the evaluation of endometrium. The estrogen component of medication regulates the menstrual cycle by build up the endometrium; whereas the progestin component helps in shedding of the endometrium.
However, patients who have continued irregular menstrual bleeding even while on combination contraceptives require further evaluation as they have failed to improve with medical management. In such patients, the endometrial lining will be too thick for the progestin to completely shed during menstruation and this unshed endometrium continues to undergo dysregulated proliferation, leading to an increased risk of endometrial hyperplasia
ancer. Therefore, patients age below 45 with AUB who have failed medical management require an endometrial biopsy.
AUB persistent above 6 months, obesity, and/or tamoxifen therapy are the other indications for endometrial biopsy in women age <45, as all of these will increase the amount of unopposed endometrial estrogen exposure. In patients with heavy menstrual bleeding and anemia, coagulation studies are performed to evaluate for bleeding disorders like von Willebrand disease. It is not necessary in this patient as she have a normal hemoglobin level. In patients with heavy, but regular (ovulatory) bleeding an endometrial ablation, which is a procedure used to remove the excess endometrium, can be considered as the treatment option. Endometrial ablation is contraindicated in undiagnosed cases of AUB as it prevents evaluation of the endometrium in patients with possible endometrial hyperplasia
ancer.To check for abnormalities of the uterus like didelphys or of the Fallopian tube like scarring, a hysterosalpingogram is used but it is not useful to evaluate AUB. In addition, as the procedure could spread cancerous endometrial cells into the abdominal cavity, hysterosalpingogram is contraindicated in cases of undiagnosed AUB.
To evaluate secondary amenorrhea, ie. absence of menses for >6 months in a patient with previously irregular menses, a progesterone withdrawal test is used to determine whether amenorrhea is from low estrogen level, in negative cases there will be no bleeding after progesterone. This test is not indicated or relevant in this case as patient had continued bleeding while on oral contraceptives suggestive of high estrogen levels.
Evaluation for endometrial hyperplasia
ancer with an endometrial biopsy is required for those women age <45 with abnormal uterine bleeding who have failed medical management with oral contraceptives. -
This question is part of the following fields:
- Obstetrics
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Question 8
Incorrect
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During difficult labour, mediolateral episiotomy is favoured to midline episiotomy because?
Your Answer: Reduced dyspareunia
Correct Answer: Less extension of the incision
Explanation:Mediolateral episiotomy is favoured to midline episiotomy because there is less extension of the incision and decreased chances of injury to the anal sphincter and rectum.
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This question is part of the following fields:
- Obstetrics
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Question 9
Correct
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A 20-year-old pregnant woman at 32 weeks gestation presents with a history of vaginal bleeding after intercourse. Pain is absent and upon examination, the following are found: abdomen soft and relaxed, uterus size is equal to dates and CTG reactive. What is the single most possible diagnosis?
Your Answer: Placenta previa
Explanation:Placenta previa typically presents with painless bright red vaginal bleeding usually in the second to third trimester. Although it’s a condition that sometimes resolves by itself, bleeding may result in serious complications for the mother and the baby and so it should be managed as soon as possible.
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This question is part of the following fields:
- Obstetrics
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Question 10
Correct
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All of the following are considered complications of gestational trophoblastic disease, except:
Your Answer: Infertility
Explanation:Gestational trophoblastic disease (GTD) is a group of tumours defined by abnormal trophoblastic proliferation. Trophoblast cells produce human chorionic gonadotropin (hCG).
GTD is divided into hydatidiform moles (contain villi) and other trophoblastic neoplasms (lack villi). The non-molar or malignant forms of GTD are called gestational trophoblastic neoplasia (GTN).
Hydatidiform mole (HM) is associated with abnormal gametogenesis and/or fertilization. Risk factors include extremes of age, ethnicity, and a prior history of an HM which suggests a genetic basis for its aetiology.GTD is best managed by an interprofessional team that includes nurses and pharmacists. Patients with molar pregnancies must be monitored for associated complications including hyperthyroidism, pre-eclampsia, and ovarian theca lutein cysts. Molar pregnancy induced hyperthyroidism should resolve with the evacuation of the uterus, but patients may require beta-adrenergic blocking agents before anaesthesia to reverse effects of thyroid storm. Pre-eclampsia also resolves quickly after the evacuation of the uterus. Theca lutein cysts will regress spontaneously with falling beta-HCG levels. However, patients must be counselled on signs and symptoms of ovarian torsion and ruptured ovarian cysts.
A single uterine evacuation has no significant effect on future fertility, and pregnancy outcomes in subsequent pregnancies are comparable to that of the general population, despite a slight increased risk of developing molar pregnancy again.
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This question is part of the following fields:
- Obstetrics
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Question 11
Incorrect
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Among the statements given below which one is correct regarding shoulder dystocia?
Your Answer: Most cases can be resolved by hyper-extension of the mother thighs
Correct Answer: Erb palsy is common fetal injury
Explanation:Shoulder dystocia occurs when the bisacromial diameter, which is the breadth of the shoulders, exceed the diameter of pelvic inlet. This typically results in a bony impaction of the anterior shoulder against the maternal symphysis pubis, instead of an arrest at the pelvic inlet. Brachial plexus palsies including Erb’s palsy is the most common foetal injury associated with shoulder dystocia.
It is not hyper-extension but the hyper-flexion of maternal legs tightly on her abdomen, called as McRoberts manoeuvre, which facilitates delivery during shoulder dystocia. This technique is effective as it increases the mobility of sacroiliac joint during pregnancy, which allows the rotation of pelvis and thereby facilitating the release of fetal shoulder.
If this manoeuvre does not succeed, another technique called suprapubic pressure is done where an assistant applies pressure on the lower abdomen and gently pulls the delivered head. This technique is useful in about 42% of cases with shoulder dystocia.Maternal diabetes mellitus and foetal macrosomia both are a risk factor for shoulder dystocia.
Administration of epidural anaesthesia during labour increases the possibility of shoulder dystocia.
Risk of shoulder dystocia may increase with Oxytocin augmentation also.
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This question is part of the following fields:
- Obstetrics
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Question 12
Incorrect
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A 23-year-old woman at 36 weeks of gestation in her first pregnancy presents for headache and right upper quadrant abdominal pain for three days. The pregnancy has been normal and unremarkable until now. Her blood pressure is 145/90 mmHg and urinalysis shows protein ++. On physical exam, her ankles are slightly swollen. There is slight tenderness to palpation under the right costal margin. Which one of the following is the most likely diagnosis?
Your Answer: Acute fatty liver of pregnancy.
Correct Answer: Pre-eclampsia.
Explanation:There are a few differential diagnoses to think of in a patient that presents such as this one. Pre-eclampsia, cholecystitis, and fatty liver could all cause pain and tenderness, but cholecystitis would not normally cause the hypertension and proteinuria seen in this patient and neither would acute fatty liver of pregnancy. The more likely explanation is pre-eclampsia which must always be considered in the presence of these symptoms and signs. This process is particularly severe in the presence of pain and tenderness under the right costal margin due to liver capsule distension.
Chronic renal disease could cause the hypertension and mild proteinuria seen, but it would not usually produce the pain and tenderness that this patient has unless it was complicated by severe pre-eclampsia.
Biliary cholestasis does not usually produce pain.
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This question is part of the following fields:
- Obstetrics
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Question 13
Incorrect
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Warfarin is contraindicated during pregnancy. Which of the following complications are possible to develop if warfarin is used in second trimester of pregnancy?
Your Answer: Maternal cerebral bleeding
Correct Answer: Fetal optic atrophy
Explanation:Administration of warfarin should be avoided throughout pregnancy and especially during the first and third trimesters as it have the ability to cross placenta. Intake of warfarin during 6-12 weeks of gestation can results in fetal warfarin syndrome which is characterized by the following features:
– A characteristic nasal hypoplasia
– Short fingers with hypoplastic nails
– Calcified epiphyses, namely chondrodysplasia punctata, which is evident on X-ray as stippling of the epiphyses.
– Intellectual disability
– Low birth weightAs these effects are usually dose dependent, recent estimates shows that the risk of fetal warfarin syndrome is around 5% in babies of women who requires warfarin throughout pregnancy.
Later exposure as after 12 weeks, is associated with symptoms like central nervous system anomalies, including microcephaly, hydrocephalus, agenesis of corpus callosum, Dandy-Walker malformation which is presented with complete absence cerebellar vermis and enlarged fourth ventricle, and mental retardation, as well as eye anomalies such as optic atrophy, microphthalmia and Peter anomaly (anterior segment dysgenesis).
Those newborns exposed to warfarin in all three trimesters there will be blindness and other complication of exposed to warfarin in neonates include perinatal intracranial and other major bleeding episodes. -
This question is part of the following fields:
- Obstetrics
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Question 14
Incorrect
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In her first pregnancy, a 27-year-old lady suffered a fever and malaise around 10 weeks of pregnancy. She had come into touch with a youngster who had been diagnosed with rubella two weeks prior. Which of the following would be the best next step in your management career?
Your Answer: Termination of the pregnancy.
Correct Answer: Serial blood samples for rubella antibody assessment.
Explanation:If the patient already has immunity (IgG positive) and if maternal rubella infection is the cause of the current symptoms (initial lgG and IgM negative, but IgM positive on a second sample 2-3 weeks later), amniocentesis may be required to confirm fetal infection.
Ultrasound may reveal growth limitation in late pregnancy, but a fetal congenital defect is rare when the infection begins at 10 weeks of pregnancy, and ultrasound testing at 12 weeks of pregnancy is unlikely to detect abnormalities, while it may discover one from 18-20 weeks. Given the well-known deleterious fetal effects of rubella infection in early pregnancy, gamma-globulin is unlikely to be beneficial at this point in the infective process, and pregnancy termination would certainly be considered by some individuals.
On the basis of prenatal rubella infection, this would not be recommended unless the infection was shown to have occurred. -
This question is part of the following fields:
- Obstetrics
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Question 15
Correct
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During pregnancy, which among these is NOT counted as physiological change?
Your Answer: Tidal volume 500ml.
Explanation:There is a significant increase in oxygen demand during pregnancy due to a 15% increase in the metabolic rate and a 20% increased consumption of oxygen. There is a 40–50% increase in minute ventilation, mostly due to an increase in tidal volume, rather than in the respiratory rate. In a healthy, young human adult, tidal volume is approximately 500 mL per inspiration
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This question is part of the following fields:
- Obstetrics
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Question 16
Incorrect
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A young couple visited your clinic for taking your opinion. The woman has a history of rheumatoid arthritis, and is on methotrexate and sulfasalazine; and they are planning to have a baby in next three months. What will be the most appropriate management in this patient during her pregnancy?
Your Answer: Stop sulfasalazine and continue methotrexate
Correct Answer: Stop methotrexate and continue sulfasalazine
Explanation:Rheumatoid arthritis and its prognosis during pregnancy are highly unpredictable, as the disease can improve in 75% of the cases and gets worse in 25%. During conception and pregnancy, it is advisable to avoid those rheumatoid arthritis medications which possess high risk in causing congenital disabilities. Most common such contraindicated remedies include methotrexate and leflunomide.
Drugs like Prednisone, Non-steroidal anti-inflammatory drugs and TNF inhibitors are also not considered safe during pregnancy, so if required these should be used under specialist supervision.Sulfasalazine and Antimalarials such as hydroxychloroquine are safe and can be used without much complications during pregnancy. In this given case, the patient should be advised to stop methotrexate and to continue sulfasalazine during pregnancy.
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This question is part of the following fields:
- Obstetrics
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Question 17
Correct
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A 33-year-old woman presented to the medical clinic with a history of type 2 diabetes mellitus. She plans to conceive in the next few months and asks for advice. Her fasting blood sugar is 10.5 mmol/L and her HbA1c is 9%. Which of the following is considered the best advice to give to the patient?
Your Answer: Achieve HbA1c value less than 7% before she gets pregnant
Explanation:Women with diabetes have increased risk for adverse maternal and neonatal outcomes and similar risks are present for either type 1 or type 2 diabetes. Both forms of diabetes require similar intensity of diabetes care. Preconception planning is very important to avoid unintended pregnancies, and to minimize risk of congenital defects. Haemoglobin A1c goal at conception is <6.5% and during pregnancy is <6.0%.
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This question is part of the following fields:
- Obstetrics
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Question 18
Correct
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An otherwise healthy 21 year old primigravida comes to your office for a routine visit at 16 weeks gestation. She has had a normal pregnancy to date, and her only medication is a multivitamin with 0.4 mg folic acid. You order a maternal serum alpha-fetoprotein level. Adjusted for gestational age, maternal weight, and race, the results are significantly elevated. Which one of the following would you now recommend?
Your Answer: Fetal ultrasonography
Explanation:A 16-week visit is advised for all pregnant women to offer an alpha-fetoprotein (AFP) screening for neural tube defects and Down syndrome- An AFP level 2-5 times the median value for normal controls at the same gestational age is considered elevate- Approximately 5%-10% of patients who undergo AFP screening will have an elevated level, and most of these women will have normal foetuses. Fetal ultrasonography should be performed to detect multiple gestation, fetal demise, or fetal anomalies (neural tube defects, ventral abdominal wall defects, and urinary tract anomalies) as well as to confirm gestational age, as all of these factors are associated with elevated AFP levels. Amniocentesis is offered if the ultrasonography does not indicate the reason for the elevated AFP. Chorionic villus sampling is offered in the evaluation of suspected chromosomal anomalies as an adjunct to amniocentesis. Serum hCG would be indicated in the workup of suspected Down syndrome, where the AFP would be low, not elevate- The hCG level would be expected to be over 2-5 multiples of the mean (MoM) with Down syndrome.
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This question is part of the following fields:
- Obstetrics
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Question 19
Incorrect
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A diminishing blood volume within the first 4 hours post-partum may be seen when a warning sign occurs. Which of the following is considered the single most important warning sign for the said situation?
Your Answer: Decrease in blood pressure
Correct Answer: Tachycardia
Explanation:Postpartum haemorrhage (PPH) is a cumulative blood loss greater than 1000 mL with signs and symptoms of hypovolemia within 24 hours of the birth process, regardless of the route of delivery.
The first step in managing hemorrhagic shock is recognition. This should occur before the development of hypotension. Close attention should be paid to physiological responses to low blood volume. Tachycardia, tachypnoea, and narrowing pulse pressure may be the initial signs.
Tachycardia is typically the first abnormal vital sign of hemorrhagic shock. As the body attempts to preserve oxygen delivery to the brain and heart, blood is shunted away from extremities and nonvital organs. This causes cold and modelled extremities with delayed capillary refill. This shunting ultimately leads to worsening acidosis.
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This question is part of the following fields:
- Obstetrics
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Question 20
Incorrect
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A patient in the first trimester of pregnancy has just learned that her husband has acute hepatitis B. She feels well, and her screening test for hepatitis B surface antigen (HBsAg) was negative last month. She has not been immunized against hepatitis B. Which one of the following would be the most appropriate management of this patient?
Your Answer: Use of condoms for the remainder of the pregnancy, and administration of immunization after delivery
Correct Answer: Administration of both HBIG and hepatitis B vaccine now
Explanation:Hepatitis B immune globulin (HBIG) should be administered as soon as possible to patients with known exposure to hepatitis – Hepatitis B vaccine is a killed-virus vaccine and can be used safely in pregnancy, with no need to wait until after organogenesis. This patient has been exposed to sexual transmission for at least 6 weeks, given that the incubation period is at least that long, so it is too late to use condoms to prevent infection. The patient is unlikely to be previously immune to hepatitis B, given that she has no history of hepatitis B infection, immunization, or carriage- Because the patient’s HBsAg is negative, she is not the source of her husband’s infection. Full treatment for this patient has an efficacy of only 75%, so follow-up testing is still needed.
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This question is part of the following fields:
- Obstetrics
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