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Question 1
Correct
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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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This question is part of the following fields:
- Obstetrics
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Question 2
Incorrect
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A 28-year-old woman attends her regular antenatal check at 16 weeks gestation. It is her second pregnancy and she has had no complications.
The nurse is discussing the results of previous tests, checking her urine and measuring her blood pressure. The patient has no protein in her urine and her blood pressure is 102/70 mmHg.
Which of the following describes a normal physiological change in this patient?Your Answer: Blood pressure drops throughout pregnancy
Correct Answer: An increase in heart rate and stroke volume lead to an increase in cardiac output
Explanation:Physiological Changes in Pregnancy
Pregnancy is a time of significant physiological changes in a woman’s body. These changes are mainly driven by progesterone rather than oestrogen. One of the changes is vasodilation, which leads to a drop in blood pressure initially, but it normalizes by term. However, an increase in heart rate and stroke volume leads to an increase in cardiac output.
Another change is a decrease in lower oesophageal sphincter tone and vascular resistance, which causes a drop in blood pressure. This decrease occurs over the first trimester but starts to increase to normal by term. Oestrogen is responsible for this change, and it also causes symptoms of reflux.
Pregnancy also causes a mild anaemia due to a drop in red cell volume. However, this is a dilutional anaemia caused by an increase in plasma volume. Additionally, there is an increase in clotting factors II, VII, IX, and X, which makes pregnancy a hypercoagulable state.
The functional residual capacity (FRC) increases in pregnancy, leading to more rapid breathing and smaller tidal volumes. This decrease in FRC means that oxygen reserve is less in pregnant women. Minute ventilation increases due to increased oxygen consumption and increased CO2 production. This is by increased tidal volume rather than respiratory rate.
Finally, the glomerular filtration rate (GFR) decreases secondary to progesterone, facilitating an increase in fluid retention and an increase in plasma volume. However, there is also an increase in aldosterone, which acts on the kidneys producing water and sodium retention, therefore causing an increase in plasma volume.
In conclusion, pregnancy causes significant physiological changes in a woman’s body, which are mainly driven by progesterone. These changes affect various systems, including the cardiovascular, respiratory, and renal systems.
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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 30-year-old nulliparous woman with Factor V Leiden presents for her initial antenatal visit. She has a history of unprovoked VTE, and the physician discusses thromboprophylaxis with her. What treatment pathway should be followed based on her risk?
Your Answer: Low molecular weight heparin (LMWH) antenatally + 6 weeks postpartum
Explanation:Factor V Leiden is a genetic condition that causes resistance to the breakdown of Factor V by activated Protein C, leading to an increased risk of blood clots. The RCOG has issued guidelines (Green-top Guideline No.37a) for preventing blood clots in pregnant women with this condition. As this patient has a history of VTE, she is at high risk during and after pregnancy and requires both antenatal and postnatal thromboprophylaxis. It is important to note that postnatal prophylaxis must be given for six weeks following antenatal prophylaxis.
Venous Thromboembolism in Pregnancy: Risk Assessment and Prophylactic Measures
Pregnancy increases the risk of developing venous thromboembolism (VTE), a condition that can be life-threatening for both the mother and the fetus. To prevent VTE, it is important to assess a woman’s individual risk during pregnancy and initiate appropriate prophylactic measures. This risk assessment should be done at the first antenatal booking and on any subsequent hospital admission.
Women with a previous history of VTE are automatically considered high risk and require low molecular weight heparin throughout the antenatal period, as well as input from experts. Women at intermediate risk due to hospitalization, surgery, co-morbidities, or thrombophilia should also be considered for antenatal prophylactic low molecular weight heparin.
The risk assessment at booking should include factors that increase the likelihood of developing VTE, such as age over 35, body mass index over 30, parity over 3, smoking, gross varicose veins, current pre-eclampsia, immobility, family history of unprovoked VTE, low-risk thrombophilia, multiple pregnancy, and IVF pregnancy.
If a woman has four or more risk factors, immediate treatment with low molecular weight heparin should be initiated and continued until six weeks postnatal. If a woman has three risk factors, low molecular weight heparin should be initiated from 28 weeks and continued until six weeks postnatal.
If a diagnosis of deep vein thrombosis (DVT) is made shortly before delivery, anticoagulation treatment should be continued for at least three months, as in other patients with provoked DVTs. Low molecular weight heparin is the treatment of choice for VTE prophylaxis in pregnancy, while direct oral anticoagulants (DOACs) and warfarin should be avoided.
In summary, a thorough risk assessment and appropriate prophylactic measures can help prevent VTE in pregnancy, which is crucial for the health and safety of both the mother and the fetus.
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This question is part of the following fields:
- Obstetrics
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Question 4
Incorrect
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A 16-year-old primiparous woman, who is 37 weeks pregnant, presents to the emergency department with a sudden onset of painful vaginal bleeding. She had been feeling unwell for a few days, experiencing lightheadedness upon standing. Despite being pregnant, she has not sought antenatal care, except for her initial booking visit.
Upon examination, her heart rate is 130 beats per minute, respiratory rate is 21 breaths per minute, and blood pressure is 96/65 mmHg. Her abdomen is tense, with a firm and fixed uterus.
What is the most likely risk factor for this complication in this 16-year-old pregnant woman?Your Answer: Age
Correct Answer: Polyhydramnios
Explanation:Placental Abruption: Causes, Symptoms, and Risk Factors
Placental abruption is a condition that occurs when the placenta separates from the uterine wall, leading to maternal bleeding into the space between them. Although the exact cause of this condition is unknown, certain factors have been associated with it, including proteinuric hypertension, cocaine use, multiparity, maternal trauma, and increasing maternal age. Placental abruption is not a common occurrence, affecting approximately 1 in 200 pregnancies.
The clinical features of placental abruption include shock that is disproportionate to the visible blood loss, constant pain, a tender and tense uterus, and a normal lie and presentation of the fetus. The fetal heart may be absent or distressed, and there may be coagulation problems. It is important to be aware of other conditions that may present with similar symptoms, such as pre-eclampsia, disseminated intravascular coagulation (DIC), and anuria.
In summary, placental abruption is a serious condition that can have significant consequences for both the mother and the fetus. Understanding the risk factors and symptoms of this condition is important for early detection and appropriate management.
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This question is part of the following fields:
- Obstetrics
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Question 5
Incorrect
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A 28-year-old primigravida woman is rushed for an emergency caesarean section due to fetal distress and hypoxia detected on cardiotocography. She is currently at 31 weeks gestation.
After delivery, the baby is admitted to the neonatal intensive care unit (NICU) and given oxygen to aid breathing difficulties.
Several weeks later, during an ophthalmological examination, the baby is found to have bilateral absent red reflex and retinal neovascularisation.
What is the probable diagnosis?Your Answer: Retinoblastoma
Correct Answer: Retinopathy of prematurity
Explanation:Risks Associated with Prematurity
Prematurity is a condition that poses several risks to the health of newborns. The risk of mortality increases with decreasing gestational age. Premature babies are at risk of developing respiratory distress syndrome, intraventricular haemorrhage, necrotizing enterocolitis, chronic lung disease, hypothermia, feeding problems, infection, jaundice, and retinopathy of prematurity. Retinopathy of prematurity is a significant cause of visual impairment in babies born before 32 weeks of gestation. The cause of this condition is not fully understood, but it is believed that over oxygenation during ventilation can lead to the proliferation of retinal blood vessels, resulting in neovascularization. Screening for retinopathy of prematurity is done in at-risk groups. Premature babies are also at risk of hearing problems.
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This question is part of the following fields:
- Obstetrics
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Question 6
Correct
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A 25-year-old patient with a history of well-controlled epilepsy visits the general practice with her partner. They have been attempting to conceive through regular sexual intercourse for the past 10 months. The patient is currently taking omeprazole, levetiracetam, folic acid 400 micrograms, and paracetamol as needed. What medication adjustments would be most suitable?
Your Answer: Folic acid 5 milligrams
Explanation:Women on antiepileptics trying to conceive should receive 5mg folic acid. Letrozole and clomiphene are not appropriate for this patient. Adequate control of epilepsy is important and medication changes should be made by a specialist. This patient should be started on a high dose of folic acid due to the risk of neural tube defects.
Folic Acid: Importance, Deficiency, and Prevention
Folic acid is a vital nutrient that is converted to tetrahydrofolate (THF) in the body. It is found in green, leafy vegetables and plays a crucial role in the transfer of 1-carbon units to essential substrates involved in the synthesis of DNA and RNA. However, certain factors such as phenytoin, methotrexate, pregnancy, and alcohol excess can cause a deficiency in folic acid. This deficiency can lead to macrocytic, megaloblastic anemia and neural tube defects.
To prevent neural tube defects during pregnancy, it is recommended that all women take 400mcg of folic acid until the 12th week of pregnancy. Women at higher risk of conceiving a child with a neural tube defect should take 5mg of folic acid from before conception until the 12th week of pregnancy. Women are considered higher risk if they or their partner has a neural tube defect, they have had a previous pregnancy affected by a neural tube defect, or they have a family history of a neural tube defect. Additionally, women with certain medical conditions such as coeliac disease, diabetes, or thalassaemia trait, or those taking antiepileptic drugs, or who are obese (BMI of 30 kg/m2 or more) are also considered higher risk.
In summary, folic acid is an essential nutrient that plays a crucial role in DNA and RNA synthesis. Deficiency in folic acid can lead to serious health consequences, including neural tube defects. However, taking folic acid supplements during pregnancy can prevent these defects and ensure a healthy pregnancy.
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This question is part of the following fields:
- Obstetrics
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Question 7
Correct
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A 35-year-old woman who is 32 weeks pregnant presents with a two-week history of pruritus on her hands and feet without any visible rash. The symptoms are more severe at night and she has elevated liver function tests, with a bile acid level of 106 mmol/l. The obstetrician discusses with the patient about the possibility of induction of labour (IOL) after which week of gestation?
Your Answer: 37 weeks
Explanation:Obstetric cholestasis, which is indicated by the symptoms and blood results in a pregnant woman in the third trimester, increases the risk of stillbirth. Therefore, it is generally recommended to induce labour at 37-38 weeks gestation to minimize this risk. However, induction of labour should only be considered if there are significantly abnormal liver function tests or bile acid levels. It is not recommended before 37 weeks gestation. Women should be informed that the need for intervention may be stronger in those with more severe biochemical abnormalities.
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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This question is part of the following fields:
- Obstetrics
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Question 8
Incorrect
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A 34-year-old woman is at eight weeks’ gestation in her first pregnancy, with a body mass index (BMI) of 36.5 kg/m2. She has type 2 diabetes mellitus, and her sister had pre-eclampsia in both her pregnancies. She had deep vein thrombosis (DVT), following a long-haul flight to Australia last year.
Which of the following risk factors presenting in this patient’s history is considered a high-risk factor for the development of pre-eclampsia?Your Answer: Family history of a first-degree relative with pre-eclampsia
Correct Answer: Type 2 diabetes mellitus
Explanation:Pre-eclampsia Risk Factors in Pregnancy
During the first prenatal visit, women are screened for their risk of developing pre-eclampsia during pregnancy. High-risk factors include a personal history of pre-eclampsia, essential hypertension, type 1 or 2 diabetes mellitus, chronic kidney disease, or autoimmune conditions. Moderate risk factors include a BMI of 35-39.9 kg/m2, family history of pre-eclampsia, age of ≥ 40, first pregnancy, multiple pregnancy, and an interpregnancy interval of > 10 years. If any high or moderate risk factor is present, it is recommended that the woman take 75 mg of aspirin daily from the 12th week of gestation until delivery. A personal history of DVT is not a risk factor for pre-eclampsia, but it is associated with an increased risk of thrombi during pregnancy and the puerperium.
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This question is part of the following fields:
- Obstetrics
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Question 9
Correct
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A 20-year-old woman presents for her first antenatal appointment following a positive pregnancy test. She has no significant medical or family history and reports no smoking or alcohol consumption. Her BMI is 30.9kg/m², blood pressure is within normal limits, and a urine dipstick is unremarkable. What tests should be offered to her?
Your Answer: Oral glucose tolerance test (OGTT) at 24-28 weeks
Explanation:Gestational diabetes is a common medical disorder affecting around 4% of pregnancies. Risk factors include a high BMI, previous gestational diabetes, and family history of diabetes. Screening is done through an oral glucose tolerance test, and diagnostic thresholds have recently been updated. Management includes self-monitoring of blood glucose, diet and exercise advice, and medication if necessary. For pre-existing diabetes, weight loss and insulin are recommended, and tight glycemic control is important. Targets for self-monitoring include fasting glucose of 5.3 mmol/l and 1-2 hour post-meal glucose levels.
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This question is part of the following fields:
- Obstetrics
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Question 10
Incorrect
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A 35-year-old primigravida, who is 12 weeks pregnant, comes to your Antenatal clinic for counselling about Down syndrome screening, as her sister has the genetic condition. After discussing the various tests with her, she decides to opt for the earliest possible diagnostic test that will tell her whether her baby has Down syndrome.
What is the test that you are most likely to advise her to have?Your Answer: Amniocentesis
Correct Answer: Chorionic villus sampling (CVS)
Explanation:Prenatal Testing Options for Expecting Mothers
Expecting mothers have several options for prenatal testing to ensure the health of their developing baby. Chorionic villus sampling (CVS) is a diagnostic procedure that can be done from 11 weeks to detect chromosomal abnormalities. The risk of miscarriage is low, at 0.7% within 14 days and 1.3% within 30 days. Amniocentesis is another diagnostic option that can be done from 15 weeks, with a slightly lower risk of miscarriage at 0.6%.
Anomaly scans are typically done at 18-21 weeks to check for any physical abnormalities in the baby, such as spina bifida or anencephaly. The nuchal translucency test, combined with blood tests, is a screening test that can determine the individual’s risk for certain chromosomal abnormalities. The quadruple blood test is another screening option that measures various hormones and proteins to assess the risk of certain conditions.
Overall, expecting mothers have several options for prenatal testing to ensure the health of their baby. It is important to discuss these options with a healthcare provider to determine the best course of action for each individual pregnancy.
Understanding Prenatal Testing Options for Expecting Mothers
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This question is part of the following fields:
- Obstetrics
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Question 11
Correct
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A 34-year-old G3P2 woman comes to the antenatal clinic seeking advice on Down syndrome screening. She is currently 12+6 weeks pregnant and has had 2 previous caesarean deliveries. Although her previous children did not have Down's syndrome, she is worried about the effect of her advancing age on the likelihood of her baby being born with the condition. What tests would you suggest for this patient to assess her risk?
Your Answer: Nuchal translucency, β-hCG and PAPP-A
Explanation:A woman at 12 weeks gestation is seeking Down syndrome screening. Although her age increases the likelihood of her fetus having Down’s syndrome, it will not affect the initial screening process. The standard screening method involves an ultrasound to evaluate nuchal translucency and serum testing to measure levels of β-human chorionic gonadotropin (β-hCG) and pregnancy-associated plasma protein A (PAPP-A). This combined screening can also detect Edward’s (trisomy 18) and Patau (trisomy 13) syndromes. The triple test, which includes α-fetoprotein, unconjugated oestriol, and β-hCG, is conducted between 15-20 weeks gestation to assess for Down’s syndrome. The quadruple test is also an option for women who have missed the window for combined antenatal screening. A biophysical profile, which evaluates fetal wellbeing through ultrasound detection of heart rate, breathing, movement, tone, and amniotic fluid volume, is used to determine the need for rapid induction of labor.
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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This question is part of the following fields:
- Obstetrics
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Question 12
Correct
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A 28-year-old primigravida 1+0 arrives at 35 weeks gestation with a blood pressure reading of 165/120 mmHg and 3+ proteinuria on dipstick testing. She had a stable blood pressure of approximately 115/75mmHg before becoming pregnant, and her only medical history is well-managed asthma. Which of the following statements is correct regarding her treatment?
Your Answer: In induced labour, epidural anaesthesia should help reduce blood pressure
Explanation:1. The only effective treatment for pre-eclampsia is delivery, while IV magnesium sulphate is administered to prevent seizures in eclampsia.
2. Delivery on the same day is a viable option after 34 weeks.
3. Nifedipine is considered safe for breastfeeding mothers. (However, labetalol is the preferred antihypertensive medication, as beta-blockers should be avoided in patients with a history of asthma.)
4. Epidural anaesthesia can help lower blood pressure.
5. It is important to continue hypertension treatment during labour to manage blood pressure levels. Please refer to the NICE guideline on the diagnosis and management of hypertension in pregnancy for further information.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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This question is part of the following fields:
- Obstetrics
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Question 13
Correct
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A 25-year-old woman who is 28 weeks pregnant attends the joint antenatal and diabetes clinic for a review of her gestational diabetes. She was diagnosed with gestational diabetes at 24 weeks gestation after glucose was found on a routine urine dipstick. Despite a 2-week trial of lifestyle modifications, there was no improvement. She was then started on metformin for the past 2 weeks, which has also not improved her daily glucose measurements. During examination, her symphysio-fundal height measures 28 cm and foetal heart rate is present. What is the next appropriate step in her management?
Your Answer: Prescribe short-acting insulin only
Explanation:The recommended treatment for gestational diabetes is short-acting insulin, not longer-acting subcutaneous insulin. If lifestyle modifications and metformin do not improve the condition, the next step is to provide education on how to dose insulin in accordance with meals and offer short-acting insulin. Glibenclamide and gliclazide are not recommended for use in pregnancy due to the risk of adverse birth outcomes and neonatal hypoglycemia. Prescribing both drugs together or long-acting insulin is also not recommended. Short-acting insulin alone provides better postprandial glucose control and is more flexible in responding to the varying diets of pregnant women.
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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This question is part of the following fields:
- Obstetrics
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Question 14
Correct
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A 25-year-old woman presents to the emergency department at 37 weeks of pregnancy with a chief complaint of feeling unwell and having a fever. Upon examination, she is found to have a temperature of 38ºC and a heart rate of 110 bpm. The fetus is also tachycardic. The patient reports experiencing urinary incontinence three weeks ago, followed by some discharge, but denies any other symptoms. What is the probable cause of her current condition?
Your Answer: Chorioamnionitis
Explanation:When dealing with preterm premature rupture of membranes (PPROM), it’s important to consider the possibility of chorioamnionitis in women who exhibit a combination of maternal pyrexia, maternal tachycardia, and fetal tachycardia. While other conditions like pelvic inflammatory disease and urinary tract infections may also be considered, chorioamnionitis is the most probable diagnosis. Immediate cesarean section and intravenous antibiotics will likely be necessary.
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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This question is part of the following fields:
- Obstetrics
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Question 15
Incorrect
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A 32-year-old pregnant woman is concerned about the risk of measles, mumps, and rubella (MMR) infection for her unborn baby. She has never been vaccinated for MMR and is currently 14 weeks pregnant. There are no sick contacts around her.
What is the appropriate course of action in this situation?Your Answer:
Correct Answer: Refrain from giving her any MMR vaccination now and at any stage of her pregnancy
Explanation:The MMR vaccine, which contains live attenuated virus, should not be given to women who are pregnant or trying to conceive. It is recommended that women avoid getting pregnant for at least 28 days after receiving the vaccine. If a pregnant woman is not immune to MMR, she should avoid contact with individuals who have the disease. In the event that a woman receives the MMR vaccine unintentionally during the periconception period or early pregnancy, termination of pregnancy is not necessary. This information is based on the guidelines provided by the American College of Obstetricians and Gynecologists.
Rubella and Pregnancy: Risks, Features, Diagnosis, and Management
Rubella, also known as German measles, is a viral infection caused by the togavirus. Thanks to the introduction of the MMR vaccine, it is now rare. However, if contracted during pregnancy, there is a risk of congenital rubella syndrome, which can cause serious harm to the fetus. It is important to note that the incubation period is 14-21 days, and individuals are infectious from 7 days before symptoms appear to 4 days after the onset of the rash.
The risk of damage to the fetus is highest in the first 8-10 weeks of pregnancy, with a risk as high as 90%. However, damage is rare after 16 weeks. Features of congenital rubella syndrome include sensorineural deafness, congenital cataracts, congenital heart disease (e.g. patent ductus arteriosus), growth retardation, hepatosplenomegaly, purpuric skin lesions, ‘salt and pepper’ chorioretinitis, microphthalmia, and cerebral palsy.
If a suspected case of rubella in pregnancy arises, it should be discussed immediately with the local Health Protection Unit (HPU) as type/timing of investigations may vary. IgM antibodies are raised in women recently exposed to the virus. It should be noted that it is very difficult to distinguish rubella from parvovirus B19 clinically. Therefore, it is important to also check parvovirus B19 serology as there is a 30% risk of transplacental infection, with a 5-10% risk of fetal loss.
If a woman is tested at any point and no immunity is demonstrated, they should be advised to keep away from people who might have rubella. Non-immune mothers should be offered the MMR vaccination in the post-natal period. However, MMR vaccines should not be administered to women known to be pregnant or attempting to become pregnant.
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This question is part of the following fields:
- Obstetrics
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Question 16
Incorrect
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A 36-year-old woman presents with increasing bloating and mild lower abdominal pain that started 3 hours ago. On examination, there is abdominal tenderness and ascites, but no guarding. She denies any vaginal bleeding. Her vital signs include a heart rate of 98/minute, a blood pressure of 90/55 mmHg, and a respiratory rate of 22/minute. The patient is currently undergoing IVF treatment and had her final hCG injection 5 days ago. She has been having regular, unprotected sex during treatment. A pregnancy test confirms she is pregnant. What is the most likely diagnosis?
Your Answer:
Correct Answer: Ovarian hyperstimulation syndrome
Explanation:The patient’s symptoms suggest a gynecological issue, possibly ovarian hyperstimulation syndrome, which can occur as a side-effect of ovulation induction. The presence of ascites, low blood pressure, and tachycardia indicate fluid loss into the abdomen, but the absence of peritonitis suggests it is not a catastrophic hemorrhage. The recent hCG injection increases the likelihood of ovarian hyperstimulation syndrome, which is more common with IVF and injectable treatments than with oral fertility agents like clomiphene. Ovarian cyst rupture, ovarian torsion, red degeneration, and ruptured ectopic pregnancy are unlikely explanations for the patient’s symptoms.
Ovulation induction is often required for couples who have difficulty conceiving naturally due to ovulation disorders. Normal ovulation requires a balance of hormones and feedback loops between the hypothalamus, pituitary gland, and ovaries. There are three main categories of anovulation: hypogonadotropic hypogonadal anovulation, normogonadotropic normoestrogenic anovulation, and hypergonadotropic hypoestrogenic anovulation. The goal of ovulation induction is to induce mono-follicular development and subsequent ovulation to lead to a singleton pregnancy. Forms of ovulation induction include exercise and weight loss, letrozole, clomiphene citrate, and gonadotropin therapy. Ovarian hyperstimulation syndrome is a potential side effect of ovulation induction and can be life-threatening if not managed promptly.
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This question is part of the following fields:
- Obstetrics
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Question 17
Incorrect
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A 32-year-old woman gives birth to her second child. The baby is born via normal vaginal delivery and weighs 3.8 kg. The baby has a normal Newborn and Infant Physical Examination (NIPE) after birth and the mother recovers well following the delivery. The mother wishes to breastfeed her baby and is supported to do so by the midwives on the ward.
They are visited at home by the health visitor two weeks later. The health visitor asks how they have been getting on and the mother explains that she has been experiencing problems with breastfeeding and that her baby often struggles to latch on to her breast. She explains that this has made her very anxious that she is doing something wrong and has made her feel like she is failing as a mother. When her baby does manage to latch on to feed he occasionally gets reflux and vomits afterward. The health visitor weighs the baby who is now 3.4kg.
What is the next most appropriate step?Your Answer:
Correct Answer: Refer her to a midwife-led breastfeeding clinic
Explanation:If a baby loses more than 10% of its birth weight, it is necessary to refer the mother and baby to a midwife for assistance in increasing the baby’s weight.
Breastfeeding Problems and Their Management
Breastfeeding is a natural process, but it can come with its own set of challenges. Some of the minor problems that breastfeeding mothers may encounter include frequent feeding, nipple pain, blocked ducts, and nipple candidiasis. These issues can be managed by seeking advice on proper positioning, trying breast massage, and using appropriate medication.
Mastitis is a more serious problem that affects around 1 in 10 breastfeeding women. It is characterized by symptoms such as fever, nipple fissure, and persistent pain. Treatment involves the use of antibiotics, such as flucloxacillin, for 10-14 days. Breastfeeding or expressing milk should continue during treatment to prevent complications such as breast abscess.
Breast engorgement is another common problem that causes breast pain in breastfeeding women. It occurs in the first few days after birth and affects both breasts. Hand expression of milk can help relieve the discomfort of engorgement. Raynaud’s disease of the nipple is a less common problem that causes nipple pain and blanching. Treatment involves minimizing exposure to cold, using heat packs, and avoiding caffeine and smoking.
If a breastfed baby loses more than 10% of their birth weight in the first week of life, it may be a sign of poor weight gain. This should prompt consideration of the above breastfeeding problems and an expert review of feeding. Monitoring of weight should continue until weight gain is satisfactory.
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This question is part of the following fields:
- Obstetrics
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Question 18
Incorrect
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You are asked to assess a woman who has given birth to her third child 2 hours ago. The baby was born at term, weighed 4.2kg, and was in good health. She had a natural delivery that lasted for 7 hours, and opted for a physiological third stage. According to the nurse, she has lost around 750ml of blood, but her vital signs are stable and the bleeding seems to be decreasing. What is the leading reason for her blood loss?
Your Answer:
Correct Answer: Uterine atony
Explanation:PPH, which is the loss of 500ml or more from the genital tract within 24 hours of giving birth, is primarily caused by uterine atony. It can be classified as minor (500-1000ml) or major (>1000ml) and has a mortality rate of 6 deaths/million deliveries. The causes of PPH can be categorized into the ‘four T’s’: tone, tissue (retained placenta), trauma, and thrombin (coagulation abnormalities).
Understanding Postpartum Haemorrhage
Postpartum haemorrhage (PPH) is a condition where a woman experiences blood loss of more than 500 ml after giving birth vaginally. It can be classified as primary or secondary. Primary PPH occurs within 24 hours after delivery and is caused by the 4 Ts: tone, trauma, tissue, and thrombin. The most common cause is uterine atony. Risk factors for primary PPH include previous PPH, prolonged labour, pre-eclampsia, increased maternal age, emergency Caesarean section, and placenta praevia.
In managing PPH, it is important to involve senior staff immediately and follow the ABC approach. This includes two peripheral cannulae, lying the woman flat, blood tests, and commencing a warmed crystalloid infusion. Mechanical interventions such as rubbing up the fundus and catheterisation are also done. Medical interventions include IV oxytocin, ergometrine, carboprost, and misoprostol. Surgical options such as intrauterine balloon tamponade, B-Lynch suture, ligation of uterine arteries, and hysterectomy may be considered if medical options fail to control the bleeding.
Secondary PPH occurs between 24 hours to 6 weeks after delivery and is typically due to retained placental tissue or endometritis. It is important to understand the causes and risk factors of PPH to prevent and manage this life-threatening emergency effectively.
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This question is part of the following fields:
- Obstetrics
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Question 19
Incorrect
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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:
Correct 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.
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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 30-year-old woman, mother of three, presents on day eight postpartum with difficulties breastfeeding. She has exclusively breastfed her other two children. She tells you her baby has problems latching, is feeding for a long time and is always hungry. She has sore nipples as a result of the poor latch.
On examination, you notice that the baby cannot bring his tongue past the lower lip and there is restriction in movement. On lifting the tongue, it acquires a heart shape with a central notch, but you cannot visualise the frenulum.
Which of the following is the most likely diagnosis?Your Answer:
Correct Answer: Posterior tongue tie
Explanation:Common Oral Abnormalities in Infants: Tongue Tie, Upper Lip Tie, Cleft Lip, and Cleft Palate
Tongue tie, also known as ankyloglossia, is a condition that affects up to 10% of live births, more commonly in boys than girls. It is characterized by a short, thickened frenulum attaching the tongue to the floor of the mouth, limiting tongue movements and causing difficulties with breastfeeding. Mothers may report that their infant takes a long time to feed, is irritable, and experiences nipple injury. Examination findings include limited tongue movements, inability to lift the tongue high or move it past the lower lip, and a characteristic heart-shaped notch when attempting to lift the tongue. Tongue tie can be anterior or posterior, with the latter being deeper in the mouth and more difficult to see.
Upper lip tie is a similar condition, with a frenulum attaching the upper lip to the gum line. This can also cause difficulties with breastfeeding due to limited movement of the upper lip.
Cleft lip and cleft palate are congenital malformations that occur when the facial structures fail to fuse properly during development. Cleft lip presents as a gap in the upper lip, while cleft palate is a gap in the roof of the mouth. Both can cause difficulties with feeding and require surgical intervention.
It is important for healthcare providers to be aware of these common oral abnormalities in infants and provide appropriate management and referrals to ensure optimal feeding and development.
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This question is part of the following fields:
- Obstetrics
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Question 21
Incorrect
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A 34-year-old woman in her second pregnancy comes in at 11 weeks with a 1-day history of vaginal bleeding. Bleeding began as a light brown discharge while wiping and was accompanied by menstrual-like cramps. Symptoms have since subsided. During the examination, the abdomen is soft and painless, the cervical os is closed, and there is some dark brown discharge in the vaginal area.
What ultrasound results would confirm the diagnosis?Your Answer:
Correct Answer: Gestational sac seen within the uterus; fetal heart rate present
Explanation:Understanding Different Types of Miscarriage
Miscarriage is the loss of pregnancy before 20 weeks’ gestation and can occur due to various risk factors. There are different types of miscarriage, each with its own set of symptoms and ultrasound findings.
Threatened Miscarriage: This type presents with lower abdominal pain and light brown discharge. Ultrasound reveals an intrauterine gestational sac and fetal heart rate. Patients may experience further threatened miscarriage or proceed to a complete or full-term pregnancy.
Inevitable Miscarriage: Active bleeding within the uterine cavity is suggestive of an ongoing miscarriage. The cervical os is open, and products of conception may be seen within the vagina. This type will inevitably progress to a miscarriage.
Complete Miscarriage: An empty uterus is associated with a complete miscarriage. Examination reveals a closed cervical os and may or may not be associated with vaginal bleeding.
Missed Miscarriage: A gestational sac small for dates, associated with an absent fetal heart rate, is an incidental finding. Examination is unremarkable, with a closed cervical os and no evidence of vaginal bleeding.
Incomplete Miscarriage: Products of conception are seen within the uterus, with an absent fetal heart rate. Examination reveals an open or closed cervical os and bleeding. If this miscarriage does not proceed to a complete miscarriage, it will require surgical evacuation.
Understanding the different types of miscarriage can help patients and healthcare providers manage the condition effectively.
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This question is part of the following fields:
- Obstetrics
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Question 22
Incorrect
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A 35-year-old woman with G4P3 at 39 weeks gestation presents to the labour ward following a spontaneous rupture of membranes. She delivers a healthy baby vaginally but experiences excessive bleeding and hypotension. Despite attempts to control the bleeding, the senior doctor decides to perform a hysterectomy. Upon examination, the pathologist observes that the chorionic villi have deeply invaded the myometrium but not the perimetrium.
What is the diagnosis?Your Answer:
Correct Answer: Placenta increta
Explanation:The correct answer is placenta increta, where the chorionic villi invade the myometrium but not the perimetrium. The patient’s age and history of multiple pregnancies increase the risk of this abnormal placentation, which can be diagnosed through pathological studies. Placenta accreta, percreta, and previa are incorrect answers, as they involve different levels of placental attachment and can cause different symptoms.
Understanding Placenta Accreta
Placenta accreta is a condition where the placenta attaches to the myometrium instead of the decidua basalis, which can lead to postpartum hemorrhage. This condition is caused by a defective decidua basalis. There are three types of placenta accreta, which are categorized based on the degree of invasion. The first type is accreta, where the chorionic villi attach to the myometrium. The second type is increta, where the chorionic villi invade into the myometrium. The third type is percreta, where the chorionic villi invade through the perimetrium.
There are certain risk factors that increase the likelihood of developing placenta accreta, such as having a previous caesarean section or placenta previa. It is important for healthcare providers to be aware of these risk factors and monitor patients closely during pregnancy and delivery. Early detection and management of placenta accreta can help prevent complications and ensure the best possible outcome for both the mother and baby.
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This question is part of the following fields:
- Obstetrics
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Question 23
Incorrect
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A 33-week gestation woman presents for a follow-up ultrasound scan after her 20-week scan revealed a low-lying placenta. The repeat scan conducted in the department indicates that the placenta is partially covering the cervix's top. The obstetric consultant counsels her on the recommended mode of delivery. She has had four previous pregnancies, all of which she delivered vaginally, and has no medical or surgical history.
What is the appropriate recommendation that should be offered to her regarding the mode of delivery?Your Answer:
Correct Answer: Elective caesarean section at 37-38 weeks
Explanation:Women with grade III/IV placenta praevia should have an elective caesarean section at 37-38 weeks to prevent the risk of haemorrhage during vaginal delivery. Induction of labour and offering a caesarean section at 39-40 weeks are not recommended.
Management and Prognosis of Placenta Praevia
Placenta praevia is a condition where the placenta is located wholly or partially in the lower uterine segment. If a low-lying placenta is detected at the 20-week scan, a rescan is recommended at 32 weeks. There is no need to limit activity or intercourse unless there is bleeding. If the placenta is still present at 32 weeks and is grade I/II, then a scan every two weeks is recommended. A final ultrasound at 36-37 weeks is necessary to determine the method of delivery. For grades III/IV, an elective caesarean section is recommended between 37-38 weeks. However, if the placenta is grade I, a trial of vaginal delivery may be offered. If a woman with known placenta praevia goes into labour before the elective caesarean section, an emergency caesarean section should be performed due to the risk of post-partum haemorrhage.
In cases where placenta praevia is accompanied by bleeding, the woman should be admitted and an ABC approach should be taken to stabilise her. If stabilisation is not possible, an emergency caesarean section should be performed. If the woman is in labour or has reached term, an emergency caesarean section is also necessary.
The prognosis for placenta praevia has improved significantly, and death is now extremely rare. The major cause of death in women with placenta praevia is post-partum haemorrhage.
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This question is part of the following fields:
- Obstetrics
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Question 24
Incorrect
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A 25-year-old patient visits the antenatal clinic after her 20-week scan reveals a low-lying placenta. She is concerned about what this means and if any action needs to be taken. This is her first pregnancy, and she has not experienced any complications thus far. She has no known medical conditions and does not take any regular medications. The patient mentions that her mother had a placenta-related issue that resulted in significant bleeding, and she is worried that the same may happen to her. What steps would you take to assist this patient?
Your Answer:
Correct Answer: Rescan at 32 weeks
Explanation:In the event that a low-lying placenta is detected during the 20-week scan, it is recommended to undergo a follow-up scan at 32 weeks for further evaluation.
Management and Prognosis of Placenta Praevia
Placenta praevia is a condition where the placenta is located wholly or partially in the lower uterine segment. If a low-lying placenta is detected at the 20-week scan, a rescan is recommended at 32 weeks. There is no need to limit activity or intercourse unless there is bleeding. If the placenta is still present at 32 weeks and is grade I/II, then a scan every two weeks is recommended. A final ultrasound at 36-37 weeks is necessary to determine the method of delivery. For grades III/IV, an elective caesarean section is recommended between 37-38 weeks. However, if the placenta is grade I, a trial of vaginal delivery may be offered. If a woman with known placenta praevia goes into labour before the elective caesarean section, an emergency caesarean section should be performed due to the risk of post-partum haemorrhage.
In cases where placenta praevia is accompanied by bleeding, the woman should be admitted and an ABC approach should be taken to stabilise her. If stabilisation is not possible, an emergency caesarean section should be performed. If the woman is in labour or has reached term, an emergency caesarean section is also necessary.
The prognosis for placenta praevia has improved significantly, and death is now extremely rare. The major cause of death in women with placenta praevia is post-partum haemorrhage.
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This question is part of the following fields:
- Obstetrics
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Question 25
Incorrect
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A 28-year-old woman presents at 12 weeks’ gestation for her dating scan. The radiographer calls you in to speak to the patient, as the gestational sac is small for dates and she is unable to demonstrate a fetal heart rate. On further questioning, the patient reports an episode of bleeding while abroad at nine weeks’ gestation, which settled spontaneously.
Which of the following is the most likely diagnosis?Your Answer:
Correct Answer: Missed miscarriage
Explanation:Different Types of Miscarriage: Symptoms and Diagnosis
Miscarriage is the loss of pregnancy before 20 weeks’ gestation. There are several types of miscarriage, each with its own symptoms and diagnosis.
Missed miscarriage is an incidental finding where the patient presents without symptoms, but the ultrasound shows a small gestational sac and no fetal heart rate.
Complete miscarriage is when all products of conception have been passed, and the uterus is empty and contracted.
Incomplete miscarriage is when some, but not all, products of conception have been expelled, and the patient experiences vaginal bleeding with an open or closed os.
Inevitable miscarriage is when the pregnancy will inevitably be lost, and the patient presents with active bleeding, abdominal pain, and an open cervical os.
Threatened miscarriage is when there is an episode of bleeding, but the pregnancy is unaffected, and the patient experiences cyclical abdominal pain and dark red-brown bleeding. The cervical os is closed, and ultrasound confirms the presence of a gestational sac and fetal heart rate.
It is important to seek medical attention if any symptoms of miscarriage occur.
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This question is part of the following fields:
- Obstetrics
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Question 26
Incorrect
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A 35-year-old Gravida 3 Para 3 has given birth to a healthy baby girl. The baby's APGAR score was 9 at 1 minute and 10 at 5 and 10 minutes.
Regrettably, the mother experienced a perineal tear during delivery. The tear involves the superficial and deep transverse perineal muscles, but the anal sphincter remains intact.
What is the recommended course of action for management?Your Answer:
Correct Answer: Suturing on the ward
Explanation:A second-degree perineal tear can be repaired on the ward by a midwife or clinician with sufficient experience. This type of tear involves the perineal muscle but not the anal sphincter, and is commonly seen in first-time mothers. Repairing the tear on the ward is a safe option that does not pose any long-term risks. For first-degree tears, a conservative approach is usually taken as they only involve superficial damage. Packing and healing by secondary intention is not appropriate for perineal tears, as it is a treatment for abscesses. Referring the patient to a urogynaecology clinic is also not necessary, as perineal tears require immediate repair. Repair in theatre is reserved for third and fourth-degree tears, which involve the anal sphincter complex and rectal mucosa.
Perineal tears are a common occurrence during childbirth, and the Royal College of Obstetricians and Gynaecologists (RCOG) has developed guidelines to classify them based on their severity. First-degree tears are superficial and do not require any repair, while second-degree tears involve the perineal muscle and require suturing by a midwife or clinician. Third-degree tears involve the anal sphincter complex and require repair in theatre by a trained clinician, with subcategories based on the extent of the tear. Fourth-degree tears involve the anal sphincter complex and rectal mucosa and also require repair in theatre by a trained clinician.
There are several risk factors for perineal tears, including being a first-time mother, having a large baby, experiencing a precipitant labour, and having a shoulder dystocia or forceps delivery. It is important for healthcare providers to be aware of these risk factors and to provide appropriate care and management during childbirth to minimize the risk of perineal tears. By following the RCOG guidelines and providing timely and effective treatment, healthcare providers can help ensure the best possible outcomes for both mother and baby.
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This question is part of the following fields:
- Obstetrics
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Question 27
Incorrect
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A 32-year-old, G2P1, presents to the obstetrics assessment unit with vaginal bleeding and mild abdominal pain at 15 weeks gestation. What aspect of her medical history would raise concern for a possible miscarriage?
Your Answer:
Correct Answer: Large cervical cone biopsy
Explanation:There are several factors that can increase the risk of miscarriage, including age, previous miscarriages, chronic conditions, uterine or cervical problems (such as large cervical cone biopsies or Mullerian duct anomalies), smoking, alcohol and illicit drug use, and weight. Invasive prenatal tests like chorionic villus sampling and amniocentesis also carry a slight risk of miscarriage. It’s important to note that other options are not considered risk factors for 2nd-trimester miscarriage.
Miscarriage: Understanding the Epidemiology
Miscarriage, also known as abortion, refers to the expulsion of the products of conception before 24 weeks. To avoid any confusion, the term miscarriage is often used. According to epidemiological studies, approximately 15-20% of diagnosed pregnancies will end in miscarriage during early pregnancy. In fact, up to 50% of conceptions may not develop into a blastocyst within 14 days.
Recurrent spontaneous miscarriage, which is defined as the loss of three or more consecutive pregnancies, affects approximately 1% of women. Understanding the epidemiology of miscarriage is important for healthcare providers and patients alike. It can help to identify risk factors and provide appropriate counseling and support for those who have experienced a miscarriage. By raising awareness and promoting education, we can work towards reducing the incidence of miscarriage and improving the overall health and well-being of women and their families.
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This question is part of the following fields:
- Obstetrics
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Question 28
Incorrect
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A 35-year-old G1P0 woman is brought to the hospital at 39 weeks of gestation by her husband because she is experiencing strong uterine contractions. She delivers a healthy baby with an Apgar score of 8, 5 min after birth. However, she experiences significant bleeding with an estimated blood loss of six litres and is hypotensive with a BP of 60/24 mmHg despite aggressive resuscitation. The placenta appears to be adherent to the uterine wall and the surgeons are unable to separate it. It is noted that she was treated with ceftriaxone for a gonococcal infection 5 years ago, although she had lower abdominal pain for some time after.
What is the definitive treatment for this patient’s present condition?Your Answer:
Correct Answer: Hysterectomy
Explanation:The patient is suffering from placenta accreta, a pregnancy complication where the placenta attaches to the myometrium wall. This condition is often caused by past Caesarean sections, Asherman syndrome, or pelvic inflammatory disease, which the patient had due to a previous infection with Neisseria gonorrhoeae. To prevent co-transmission with Chlamydia trachomatis, doxycycline is given with a third-generation cephalosporin. The patient’s placenta accreta is likely due to scarring from pelvic inflammatory disease, and a total hysterectomy may be necessary if the patient’s condition worsens. While the patient may require a large blood transfusion, immediate transfusion is not the definitive treatment. Oxytocin may be used as a first-line treatment, but a hysterectomy is the definitive treatment if bleeding persists. Phenylephrine, a vasoconstrictor, may decrease bleeding but is not a definitive treatment for placenta accreta. Dinoprostone, a prostaglandin E2 analogue, is not indicated for placenta accreta.
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This question is part of the following fields:
- Obstetrics
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Question 29
Incorrect
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A 28-year-old primigravida patient presents to the emergency department with a 3-day history of light per-vaginal spotting. Based on her last menstrual period date, she is 8 weeks and 4 days gestation and has not yet undergone any scans. She reports no abdominal pain or flooding episodes and has no prior medical history. A transvaginal ultrasound scan reveals a closed cervical os with a single intrauterine gestational sac, a 2 mm yolk sac, and a crown-rump length measuring 7.8mm, without cardiac activity. What is the most probable diagnosis for this patient?
Your Answer:
Correct Answer: Missed miscarriage
Explanation:A diagnosis of miscarriage can be made when a transvaginal ultrasound shows a crown-rump length greater than 7mm without cardiac activity. In this case, the patient has experienced a missed miscarriage, as the ultrasound revealed an intrauterine foetus of a size consistent with around 6 weeks gestation, but without heartbeat. The closed cervical os and history of spotting further support this diagnosis. A complete miscarriage, inevitable miscarriage, and partial miscarriage are not applicable in this scenario.
Miscarriage is a common complication that can occur in up to 25% of all pregnancies. There are different types of miscarriage, each with its own set of symptoms and characteristics. Threatened miscarriage is painless vaginal bleeding that occurs before 24 weeks, typically at 6-9 weeks. The bleeding is usually less than menstruation, and the cervical os is closed. Missed or delayed miscarriage is when a gestational sac containing a dead fetus is present before 20 weeks, without the symptoms of expulsion. The mother may experience light vaginal bleeding or discharge, and the symptoms of pregnancy may disappear. Pain is not usually a feature, and the cervical os is closed. Inevitable miscarriage is characterized by heavy bleeding with clots and pain, and the cervical os is open. Incomplete miscarriage occurs when not all products of conception have been expelled, and there is pain and vaginal bleeding. The cervical os is open in this type of miscarriage.
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This question is part of the following fields:
- Obstetrics
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Question 30
Incorrect
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A 28-year-old woman presents one week following delivery with some concerns about breastfeeding. She is exclusively breastfeeding at present, but the baby has lost weight (400 g) and she finds breastfeeding difficult and painful. The baby weighed 3200 grams at the time of birth. There is pain in both nipples, worse at the beginning of the feed, and clicking noises are heard when the baby is feeding. She sometimes has to stop feeding because of the discomfort.
On examination, the breasts are engorged and there is no area of erythema or tenderness. The nipples appear normal, and there is no discharge or erythema.
Which of the following is the most appropriate next step in this patient’s management?Your Answer:
Correct Answer: Refer to a breastfeeding specialist for assessment
Explanation:Management of Breastfeeding Difficulties: Referral to a Specialist for Assessment
Breastfeeding is a crucial process for the health and well-being of both the mother and the infant. However, some mothers may experience difficulties, such as poor latch, which can lead to pain, discomfort, and inadequate feeding. In such cases, it is essential to seek professional help from a breastfeeding specialist who can assess the situation and offer advice and support.
One of the key indicators of poor latch is pain in both nipples, especially at the beginning of the feed, accompanied by clicking noises from the baby, indicating that they are chewing on the nipple. Additionally, if the baby has lost weight, it may be a sign that they are not feeding enough. On the other hand, a good latch is characterized by a wide-open mouth of the baby, with its chin touching the breast and the nose free, less areola seen under the chin than over the nipple, the lips rolled out, and the absence of pain. The mother should also listen for visible and audible swallowing sounds.
In cases where there is no evidence of skin conditions or nipple infection, the patient does not require any treatment at present. However, if there is suspicion of a fungal infection of the nipple, presenting with sharp pain and itching of the nipples, associated with erythema and worsening of the pain after the feeds, topical miconazole may be recommended. Similarly, if there is psoriasis of the nipple and areola, presenting as raised, red plaques with an overlying grey-silver scale, regular emollients may be advised.
It is important to note that flucloxacillin is not recommended in cases where there is no evidence of infection, such as ductal infection or mastitis. Moreover, nipple shields are not recommended as they often exacerbate the poor positioning and symptoms associated with poor latch.
In summary, seeking professional help from a breastfeeding specialist is crucial in managing breastfeeding difficulties, especially poor latch. The specialist can observe the mother breastfeeding, offer advice, and ensure that the method is improved to allow successful feeding.
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This question is part of the following fields:
- Obstetrics
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