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Question 1
Correct
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A 28-year-old G2P1 woman arrives at the emergency department in the second stage of labour with the foetal head visible at the vaginal introitus. She has a history of a previous elective lower-segment Caesarean section, but no other significant medical history. Antenatal imaging revealed chorionic villi invasion into the myometrium, but not the perimetrium. Following delivery of the foetus, the patient experiences post-partum haemorrhage. What is the most probable cause of her post-partum haemorrhage?
Your Answer: Placenta increta
Explanation:Placenta increta is a condition where the chorionic villi, which are normally found in the endometrium, invade the myometrium. This can lead to significant bleeding during vaginal delivery. Placenta increta is more serious than placenta accreta, where the chorionic villi attach to the myometrium but do not invade it, but less severe than placenta percreta, where the chorionic villi invade the perimetrium.
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 2
Correct
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A 28-year-old woman is in labor with her first baby. In the second stage, fetal distress is detected, and instrumental delivery is being considered. What would be a contraindication to this procedure?
Your Answer: Head palpable abdominally
Explanation:Instrumental delivery is a method used to expedite delivery during the second stage of labor in order to prevent fetal and maternal morbidity. It involves the use of traction and is indicated in cases of prolonged active second stage, maternal exhaustion, fetal distress, breech presentation, and prophylactic use in medical conditions such as cardiovascular disease and hypertension. It can also be used to rotate a malpositioned fetal head.
To be eligible for instrumental delivery, the following requirements must be met, which can be remembered using the acronym FORCEPS:
– Fully dilated cervix, indicating that the second stage of labor has been reached
– Occiput anterior (OA) position, preferably with the head in the occiput posterior (OP) position, as delivery is possible with Kielland’s forceps and ventouse. The position of the head must be known to avoid maternal or fetal trauma and failure.
– Ruptured membranes
– Cephalic presentation
– Engaged presenting part, meaning that the head is at or below the ischial spines and cannot be palpated abdominally
– Pain relief
– Sphincter (bladder) empty, which usually requires catheterizationIt is important to note that there must be a clear indication for instrumental delivery.
When is a Forceps Delivery Necessary?
A forceps delivery may be necessary in certain situations during childbirth. These situations include fetal distress, maternal distress, failure to progress, and the need to control the head in a breech delivery. Fetal distress occurs when the baby is not receiving enough oxygen and can be detected through changes in the baby’s heart rate. Maternal distress can occur when the mother is exhausted or experiencing complications such as high blood pressure. Failure to progress refers to a situation where the mother has been pushing for an extended period of time without making progress. In a breech delivery, the baby’s head may need to be controlled to prevent injury. In these situations, a forceps delivery may be recommended by the healthcare provider to safely deliver the baby.
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This question is part of the following fields:
- Obstetrics
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Question 3
Incorrect
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A 33-year-old woman who is 28 weeks pregnant arrives at the emergency department with painless vaginal bleeding. She had her second baby three years ago, which was delivered via a c-section, but otherwise was a normal pregnancy. Upon obstetric examination, her uterus was non-tender, however, her baby was in breech presentation. The foetal heart rate was also normal, and she denied experiencing any contractions during the bleeding episode. What is the recommended next investigation for the most probable diagnosis?
Your Answer: MRI placenta
Correct Answer: Transvaginal ultrasound
Explanation:Understanding Placenta Praevia
Placenta praevia is a condition where the placenta is located wholly or partially in the lower uterine segment. It is a relatively rare condition, with only 5% of women having a low-lying placenta when scanned at 16-20 weeks gestation. However, the incidence at delivery is only 0.5%, as most placentas tend to rise away from the cervix.
There are several factors associated with placenta praevia, including multiparity, multiple pregnancy, and embryos implanting on a lower segment scar from a previous caesarean section. Clinical features of placenta praevia include shock in proportion to visible loss, no pain, a non-tender uterus, abnormal lie and presentation, and a usually normal fetal heart. Coagulation problems are rare, and small bleeds may occur before larger ones.
Diagnosis of placenta praevia should not involve digital vaginal examination before an ultrasound, as this may provoke severe haemorrhage. The condition is often picked up on routine 20-week abdominal ultrasounds, but the Royal College of Obstetricians and Gynaecologists recommends the use of transvaginal ultrasound for improved accuracy and safety. Placenta praevia is classified into four grades, with grade IV being the most severe, where the placenta completely covers the internal os.
In summary, placenta praevia is a rare condition that can have serious consequences if not diagnosed and managed appropriately. It is important for healthcare professionals to be aware of the associated factors and clinical features, and to use appropriate diagnostic methods for accurate grading and management.
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This question is part of the following fields:
- Obstetrics
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Question 4
Correct
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A 29-year-old woman on day one postpartum who is breastfeeding is concerned about the safety of her pain medication. When you arrive, you find that the patient was prescribed acetaminophen for pain relief, but when she was offered this, she told the midwife it cannot be used as it can have detrimental effects for her baby. She wants to know if there are any other options. You explain that acetaminophen is safe to use while breastfeeding. Which of the following analgesics is another safe first line treatment to use in women who are breastfeeding?
Your Answer: Paracetamol
Explanation:Safe Pain Relief Options for Breastfeeding Mothers: A Guide to Medications
Breastfeeding mothers often experience pain and discomfort, and it is important to know which pain relief options are safe to use while nursing. Paracetamol and ibuprofen are considered safe and can be used as first-line medication for analgesia. Codeine and other opiates can be used sparingly as third-line medication, but caution must be taken as some women may be slow metabolizers and it can cause drowsiness and respiratory depression in the infant. Aspirin is contraindicated due to the risk of Reye’s disease and other side-effects. Naproxen is generally safe, but paracetamol and ibuprofen should be the mainstay of analgesia. Tramadol can be used with caution and should be prescribed by a specialist. It is important to advise the woman on the safe use of medication and to monitor for any signs of toxicity in the infant.
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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 woman with type 1 diabetes mellitus, well controlled on insulin, attends the Fetal Medicine Clinic for a growth scan at 36 weeks. The scan has been unremarkable, and the consultant will discuss the mode and timing of delivery today. The baby is cephalic, and the placenta is posterior and high.
Which of the following statements regarding the mode and timing of delivery in patients with diabetes is correct?Your Answer: Delivery is indicated by induction between 37+0 and 39+6 weeks’ gestation
Correct Answer: Women with gestational diabetes should give birth no later than 40+6 weeks’ gestation
Explanation:Managing Delivery in Women with Diabetes during Pregnancy
Women with diabetes during pregnancy require special attention during delivery to ensure the safety of both the mother and the baby. Here are some important considerations:
Delivery should not be delayed beyond 40+6 weeks’ gestation to avoid the risk of stillbirth.
Delivery before 37 weeks is not recommended unless there are metabolic or other maternal or fetal complications.
Vaginal delivery is not recommended in the presence of a macrosomic fetus, but the woman should be informed of the risks and make an informed decision.
Induction or elective Caesarean section should be considered between 37+0 and 38+6 weeks’ gestation to minimize the risk of stillbirth and fetal macrosomia.
Women with a previous Caesarean section can opt for vaginal birth after Caesarean section (VBAC) if the indication for the previous Caesarean section is not recurring.
During delivery, intrapartum glucose levels should be monitored closely, and appropriate interventions should be taken to maintain glucose levels between 4 and 7 mmol/l.
By following these guidelines, healthcare providers can ensure a safe delivery for women with diabetes during pregnancy.
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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 34-year-old multiparous patient has an uncomplicated delivery at 39 weeks gestation. One hour following delivery, the patient experiences severe postpartum hemorrhage that is immediately managed in the labor ward. After seven weeks, the patient reports difficulty breastfeeding due to insufficient milk production. What is the most probable explanation for this medical history?
Your Answer: Sheehan's syndrome
Explanation:Based on the clinical history provided, it appears that the patient may be suffering from Sheehan’s syndrome. This condition is typically caused by severe postpartum hemorrhage, which can lead to ischemic necrosis of the pituitary gland and subsequent hypopituitarism. Common symptoms of Sheehan’s syndrome include a lack of milk production and amenorrhea following childbirth. Diagnosis is typically made through inadequate prolactin and gonadotropin stimulation tests in patients with a history of severe postpartum hemorrhage. It is important to note that hyperprolactinemia, D2 receptor antagonist medication, and pituitary adenoma are not typically associated with a lack of milk production, but rather with galactorrhea.
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 7
Incorrect
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A 30-year-old woman 25 weeks into her first pregnancy comes in with vaginal bleeding. What distinguishing characteristic would suggest a diagnosis of placenta praevia instead of placenta abruption?
Your Answer: Tender, tense uterus
Correct Answer: No pain
Explanation:Differentiating Placental Abruption from Placenta Praevia in Antepartum Haemorrhage
Antepartum haemorrhage refers to bleeding from the genital tract after 24 weeks of pregnancy but before delivery of the fetus. It is important to determine the cause of the bleeding to provide appropriate management. Two common causes of antepartum haemorrhage are placental abruption and placenta praevia.
Placental abruption is characterized by shock that is not proportional to the visible loss, constant pain, a tender and tense uterus, a normal lie and presentation, and an absent or distressed fetal heart. Coagulation problems may also be present, and healthcare providers should be cautious of pre-eclampsia, disseminated intravascular coagulation (DIC), and anuria.
On the other hand, placenta praevia is characterized by shock that is proportional to the visible loss, no pain, a uterus that is not tender, an abnormal lie and presentation, and a usually normal fetal heart. Coagulation problems are rare, and small bleeds may occur before a large one. It is important to note that vaginal examination should not be performed in primary care for suspected antepartum haemorrhage, as women with placenta praevia may experience bleeding.
In summary, distinguishing between placental abruption and placenta praevia is crucial in managing antepartum haemorrhage. Healthcare providers should carefully assess the patient’s symptoms and perform appropriate diagnostic tests to determine the cause of the bleeding.
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This question is part of the following fields:
- Obstetrics
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Question 8
Incorrect
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An obstetrician is getting ready to perform an emergency lower segmental caesarian section for a 26-year-old woman who is experiencing complications of pre-eclampsia. Once the incision is made through the skin and superficial and deep fascia, what layers will the obstetrician need to traverse/cut through to access the fetus?
Your Answer: Rectus abdominis muscle - linea alba - transversalis fascia - extraperitoneal connective tissue - peritoneum - uterus
Correct Answer: Anterior rectus sheath - rectus abdominis muscle - transversalis fascia - extraperitoneal connective tissue - peritoneum - uterus
Explanation:In obstetric operating theatres or surgical vivas, a frequently asked question pertains to the structures that lie between the skin and the fetus during a lower segment Caesarian section. A confident and clear response indicates a sound understanding of local anatomy and the necessary incisions to reach the fetus. The layers between the skin and the fetus include the superficial fascia, deep fascia, anterior rectus sheath, rectus abdominis muscle (which is not cut but rather pushed laterally after incising the linea alba), transversalis fascia, extraperitoneal connective tissue, peritoneum, and uterus.
Caesarean Section: Types, Indications, and Risks
Caesarean section, also known as C-section, is a surgical procedure that involves delivering a baby through an incision in the mother’s abdomen and uterus. In recent years, the rate of C-section has increased significantly due to an increased fear of litigation. There are two main types of C-section: lower segment C-section, which comprises 99% of cases, and classic C-section, which involves a longitudinal incision in the upper segment of the uterus.
C-section may be indicated for various reasons, including absolute cephalopelvic disproportion, placenta praevia grades 3/4, pre-eclampsia, post-maturity, IUGR, fetal distress in labor/prolapsed cord, failure of labor to progress, malpresentations, placental abruption, vaginal infection, and cervical cancer. The urgency of C-section may be categorized into four categories, with Category 1 being the most urgent and Category 4 being elective.
It is important for clinicians to inform women of the serious and frequent risks associated with C-section, including emergency hysterectomy, need for further surgery, admission to intensive care unit, thromboembolic disease, bladder injury, ureteric injury, and death. C-section may also increase the risk of uterine rupture, antepartum stillbirth, placenta praevia, and placenta accreta in subsequent pregnancies. Other complications may include persistent wound and abdominal discomfort, increased risk of repeat C-section, readmission to hospital, haemorrhage, infection, and fetal lacerations.
Vaginal birth after C-section (VBAC) may be an appropriate method of delivery for pregnant women with a single previous C-section delivery, except for those with previous uterine rupture or classical C-section scar. The success rate of VBAC is around 70-75%.
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This question is part of the following fields:
- Obstetrics
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Question 9
Correct
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A patient 16/40 gestation contacts your clinic via phone. This is her first pregnancy and she is worried about not experiencing any foetal movements yet. You provide reassurance that foetal movements can be felt between 16-20 weeks gestation in first pregnancies. When should further investigation be considered if no foetal movements are felt by this time?
Your Answer: 24 weeks
Explanation:According to RCOG guidelines, women typically feel fetal movements by 20 weeks of gestation. However, if no movements are felt by 24 weeks, it is recommended to refer the woman to a maternal fetal medicine unit to assess for potential neuromuscular conditions.
Understanding Reduced Fetal Movements
Introduction:
Reduced fetal movements can indicate fetal distress and are a response to chronic hypoxia in utero. This can lead to stillbirth and fetal growth restriction. It is believed that placental insufficiency may also be linked to reduced fetal movements.Physiology:
Quickening is the first onset of fetal movements, which usually occurs between 18-20 weeks gestation and increases until 32 weeks gestation. Multiparous women may experience fetal movements sooner. Fetal movements should not reduce towards the end of pregnancy. There is no established definition for what constitutes reduced fetal movements, but less than 10 movements within 2 hours (in pregnancies past 28 weeks gestation) is an indication for further assessment.Epidemiology:
Reduced fetal movements affect up to 15% of pregnancies, with 3-5% of pregnant women having recurrent presentations with RFM. Fetal movements should be established by 24 weeks gestation.Risk factors for reduced fetal movements:
Posture, distraction, placental position, medication, fetal position, body habitus, amniotic fluid volume, and fetal size can all affect fetal movement awareness.Investigations:
Fetal movements are usually based on maternal perception, but can also be objectively assessed using handheld Doppler or ultrasonography. Investigations are dependent on gestation at onset of RFM. If concern remains, despite normal CTG, urgent (within 24 hours) ultrasound can be used.Prognosis:
Reduced fetal movements can represent fetal distress, but in 70% of pregnancies with a single episode of reduced fetal movement, there is no onward complication. However, between 40-55% of women who suffer from stillbirth experience reduced fetal movements prior to diagnosis. Recurrent RFM requires further investigations to consider structural or genetic fetal abnormalities. -
This question is part of the following fields:
- Obstetrics
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Question 10
Incorrect
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A 42-year-old woman has visited her doctor to discuss her plans of getting pregnant. She is seeking guidance on basic lifestyle modifications and medications she should be taking. The doctor advises her to take a high dose (5 mg) of folic acid. What is the rationale behind taking high dose folic acid?
Your Answer: Age >30
Correct Answer: BMI >30
Explanation:High dose 5mg folic acid should be prescribed to pregnant women with obesity (BMI >30 kg/m2) to reduce the risk of neural tube defects (NTD). Other factors that may require high dose folic acid include a history of NTD in a previous pregnancy or family history of NTD, as well as conditions such as antiepileptic drug use, coeliac disease, diabetes, and thalassaemia trait.
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 11
Incorrect
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A 29-year-old woman who is 36 weeks pregnant arrives at the Emergency Department with a complaint of her 'waters breaking'. She reports experiencing a sudden release of clear fluid from her vagina, which has now reduced to a trickle, and she feels some pressure in her pelvis. What is the most suitable test to conduct next?
Your Answer: Cardiotocography
Correct Answer: Speculum examination
Explanation:The initial investigation for preterm prelabour rupture of the membranes is a thorough speculum examination to check for the accumulation of amniotic fluid in the posterior vaginal vault. It is recommended to avoid bimanual examination to minimize the risk of infection. While cardiotocography can be used to assess foetal wellbeing, it is not the preferred first-line investigation. Foetal blood sampling is not the recommended initial investigation due to the potential risks of infection and miscarriage.
Preterm prelabour rupture of the membranes (PPROM) is a condition that occurs in approximately 2% of pregnancies, but it is responsible for around 40% of preterm deliveries. This condition can lead to various complications, including prematurity, infection, and pulmonary hypoplasia in the fetus, as well as chorioamnionitis in the mother. To confirm PPROM, a sterile speculum examination should be performed to check for pooling of amniotic fluid in the posterior vaginal vault. However, digital examination should be avoided due to the risk of infection. If pooling of fluid is not observed, testing the fluid for placental alpha microglobulin-1 protein (PAMG-1) or insulin-like growth factor binding protein-1 is recommended. Ultrasound may also be useful to show oligohydramnios.
The management of PPROM involves admission and regular observations to ensure that chorioamnionitis is not developing. Oral erythromycin should be given for ten days, and antenatal corticosteroids should be administered to reduce the risk of respiratory distress syndrome. Delivery should be considered at 34 weeks of gestation, but there is a trade-off between an increased risk of maternal chorioamnionitis and a decreased risk of respiratory distress syndrome as the pregnancy progresses. PPROM is a serious condition that requires prompt diagnosis and management to minimize the risk of complications for both the mother and the fetus.
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This question is part of the following fields:
- Obstetrics
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Question 12
Incorrect
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Lila, a 30-year-old pregnant woman, (gravidity 1, parity 0) currently 27+5, visits her general practitioner (GP) complaining of reflux. The GP prescribes a new medication for her reflux. Upon reviewing Lila's medical records, the GP notes that she is scheduled for a cervical smear test in two weeks. Lila reports no new discharge, bleeding, or pain. What is the recommended timing for Lila's next cervical smear test?
Your Answer: At delivery
Correct Answer: 3 months post-partum
Explanation:Cervical screening is typically postponed during pregnancy until…
Cervical Cancer Screening in the UK
Cervical cancer screening is a well-established program in the UK that aims to detect pre-malignant changes in the cervix. This program is estimated to prevent 1,000-4,000 deaths per year. However, it should be noted that around 15% of cervical adenocarcinomas are frequently undetected by screening.
The screening program has evolved significantly in recent years. Initially, smears were examined for signs of dyskaryosis, which may indicate cervical intraepithelial neoplasia. However, the introduction of HPV testing allowed for further risk stratification, and the NHS has now moved to an HPV first system. This means that a sample is tested for high-risk strains of human papillomavirus (hrHPV) first, and cytological examination is only performed if this is positive.
All women between the ages of 25-64 years are offered a smear test. Women aged 25-49 years are screened every three years, while those aged 50-64 years are screened every five years. However, cervical screening cannot be offered to women over 64. In Scotland, screening is offered from 25-64 every five years.
In special situations, cervical screening in pregnancy is usually delayed until three months post-partum, unless there are missed screenings or previous abnormal smears. Women who have never been sexually active have a very low risk of developing cervical cancer and may wish to opt-out of screening.
It is recommended to take a cervical smear around mid-cycle, although there is limited evidence to support this advice. Overall, the UK’s cervical cancer screening program is an essential tool in preventing cervical cancer and promoting women’s health.
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This question is part of the following fields:
- Obstetrics
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Question 13
Correct
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You are assessing a pregnant woman who is currently 30 weeks along with her second child. Her first child, who is now 3 years old, had neonatal sepsis caused by Group B Streptococcus (GBS). The patient is inquiring about measures that can be taken to prevent a recurrence of this in her current pregnancy. What treatment will be necessary for the patient and/or baby?
Your Answer: Maternal intravenous (IV) antibiotics during labour
Explanation:To prevent bacterial sepsis in newborns, maternal intravenous antibiotic prophylaxis should be provided to women who have previously given birth to a baby with early- or late-onset GBS disease. GBS is a common cause of sepsis in newborns, particularly in preterm infants with a birth weight of less than 1500 g. GBS is a commensal of the female genital tract and can cause urinary tract infections, septic abortion, and postpartum endometritis in mothers. In newborns, GBS can cause early or late infection, and antibiotics should be administered if signs of sepsis are present at birth.
Group B Streptococcus (GBS) is a common cause of severe infection in newborns. It is estimated that 20-40% of mothers carry GBS in their bowel flora, which can be passed on to their infants during labor and lead to serious infections. Prematurity, prolonged rupture of membranes, previous sibling GBS infection, and maternal pyrexia are all risk factors for GBS infection. The Royal College of Obstetricians and Gynaecologists (RCOG) has published guidelines on GBS management, which include not offering universal screening for GBS to all women and not offering screening based on maternal request. Women who have had GBS detected in a previous pregnancy should be offered intrapartum antibiotic prophylaxis (IAP) or testing in late pregnancy and antibiotics if still positive. IAP should also be offered to women with a previous baby with GBS disease, women in preterm labor, and women with a fever during labor. Benzylpenicillin is the preferred antibiotic for GBS prophylaxis.
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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 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 15
Correct
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A 27-year-old woman at 12 weeks gestation of her first pregnancy visits her doctor complaining of tremors after starting a medication for hyperemesis gravidarum. During the examination, the patient displays a resting tremor in her right hand and heightened tone in her upper limbs. What medication is the patient likely taking?
Your Answer: Metoclopramide
Explanation:Metoclopramide is an option for nausea and vomiting in pregnancy, but should not be used for more than 5 days due to the risk of extrapyramidal effects. A resting tremor and increased upper limb tone in a pregnant woman after starting medication for hyperemesis gravidarum may indicate extrapyramidal effects from metoclopramide. Cyclizine, ondansetron, and prednisolone are not likely to cause extrapyramidal effects, but may have other side effects and are not first-line treatments for hyperemesis gravidarum.
Hyperemesis gravidarum is an extreme form of nausea and vomiting of pregnancy that occurs in around 1% of pregnancies and is most common between 8 and 12 weeks. It is associated with raised beta hCG levels and can be caused by multiple pregnancies, trophoblastic disease, hyperthyroidism, nulliparity, and obesity. Referral criteria for nausea and vomiting in pregnancy include continued symptoms with ketonuria and/or weight loss, a confirmed or suspected comorbidity, and inability to keep down liquids or oral antiemetics. The diagnosis of hyperemesis gravidarum requires the presence of 5% pre-pregnancy weight loss, dehydration, and electrolyte imbalance. Management includes first-line use of antihistamines and oral cyclizine or promethazine, with second-line options of ondansetron and metoclopramide. Admission may be needed for IV hydration. Complications can include Wernicke’s encephalopathy, Mallory-Weiss tear, central pontine myelinolysis, acute tubular necrosis, and fetal growth issues.
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This question is part of the following fields:
- Obstetrics
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Question 16
Incorrect
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A 9-year-old girl presents with her daughter, who is two weeks old and was diagnosed a few days following birth with an anterior tongue tie. She is still struggling to establish enough feeding due to poor latch and a poor seal, even though she is alternating between breastfeeding and bottle feeding of expressed milk. She has been reviewed by the health visitor twice who is satisfied with her breastfeeding technique. The baby was over the 50th centile at birth and now has dropped to the 25th centile.
Given the above, what is the next most appropriate step in the management of this child?Your Answer: Refer for frenotomy under general anaesthesia
Correct Answer: Refer for frenotomy under no anaesthesia
Explanation:Management of Tongue Tie in Infants: Referral for Frenotomy under No Anaesthesia
Tongue tie is a congenital condition that affects a baby’s ability to move their tongue due to a thickened frenulum. This can cause problems with breastfeeding and bottle feeding, leading to poor weight gain and irritability. In severe cases, a referral for frenotomy is necessary. In infants under three months of age, the procedure can be performed without anaesthesia, though local anaesthesia may be used. Conservative management and support with breastfeeding should be attempted first, but if unsuccessful, a frenotomy should be performed as early as possible to give the baby and mother the best chance at successful feeding. Frenotomy under general anaesthesia is only necessary for infants over three months of age. Converting to bottle feeding is not a solution in severe cases of tongue tie.
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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 who is 4 weeks postpartum and breastfeeding presents with a history of a painful, erythematosus breast for the past 24 hours.
Her blood pressure is 118/78 mmHg, her heart rate is 72 beats per minute and her temperature is 37.2 degrees celsius. On examination her left breast is tender and erythematosus and warm to touch. There is no palpable lump and no visible fissure. You take a sample of breast milk to send for culture.
What is the most appropriate first line management?Your Answer: Advise to continue breastfeeding and give a course of oral flucloxacillin
Correct Answer: Advise to continue breastfeeding and use simple analgesia and warm compresses
Explanation:When managing mastitis in breastfeeding women, it is recommended to continue breastfeeding while using simple analgesia and warm compresses. If breastfeeding is too painful, expressing milk by hand or using a pump is advised to prevent milk stasis, which is often the cause of lactational mastitis. According to NICE clinical knowledge summaries (CKS), oral antibiotics are only necessary if there is an infected nipple fissure, symptoms do not improve after 12-24 hours despite effective milk removal, or breast milk culture is positive. Flucloxacillin is the first-line antibiotic for 10-14 days, while erythromycin or clarithromycin can be used for penicillin-allergic patients. Referral to a surgical team in the hospital is only necessary if a breast abscess is suspected, which is unlikely if there is no palpable lump in the breast.
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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A 25-year-old woman at 37-week’s gestation presents to the labour ward with a history of 4 hours of labour and uterine contractions occurring every 2 minutes. Her 34-week scan revealed grade III placenta praevia. On examination, her cervix is found to be dilated to 8 cm and effaced by 90%. Foetal cartography measurements are normal, and there is no vaginal bleeding. What should be the next course of action for this patient?
Your Answer: Continue with normal vaginal delivery
Correct Answer: Emergency caesarean section
Explanation:If a woman with placenta praevia goes into labour, an emergency caesarean section should be performed regardless of whether there is bleeding or not. Placenta praevia is when the placenta is located partially or fully in the lower uterine segment, and it is more common in multiple and multiparous pregnancies. Sometimes it is detected incidentally during routine antenatal scanning, while in other cases, it may present with symptoms such as vaginal bleeding and haemodynamic shock. If placenta praevia is detected on routine imaging, an elective caesarean section should be considered at 37-38 weeks, especially for grade III and IV placenta praevia, due to the higher risk of postpartum haemorrhage. However, in this scenario, the patient has gone into labour spontaneously, and immediate action is necessary. Therefore, an emergency caesarean section is the correct course of action. Anti-D is recommended for pregnant women with negative rhesus status to prevent antibody production to foetal blood cells. Although the mother’s rhesus status is not given, anti-D is a sensible option when in doubt. Inducing labour with oxytocin is not recommended for patients with placenta praevia as it can stimulate vaginal delivery and increase the risk of postpartum haemorrhage. Discharging the patient to continue the pregnancy as normal is not advisable due to the serious risks involved. Tocolytics, such as nifedipine, are not routinely indicated for patients with placenta praevia in labour, and an emergency caesarean section should take priority.
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 19
Incorrect
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A diabetic woman attends for an ultrasound scan during her third trimester of pregnancy. The physician reporting the scan calculates an amniotic index >95th centile and diagnoses polyhydramnios.
What volume of amniotic fluid is considered to be consistent with polyhydramnios?Your Answer: >3–4 l of amniotic fluid
Correct Answer: >2–3 l of amniotic fluid
Explanation:Understanding Polyhydramnios: Excess Amniotic Fluid in Pregnancy
Polyhydramnios is a condition in which there is an excess of amniotic fluid in the second and third trimesters of pregnancy. This excess fluid is produced by the fetal kidneys and is normally swallowed by the fetus. Diagnosis of polyhydramnios is made by ultrasound assessment of the amount of fluid. If the deepest vertical pool is greater than 8 cm or if the amniotic fluid index (AFI) is greater than the 95th percentile for the corresponding gestational age, polyhydramnios is diagnosed.
Polyhydramnios occurs in approximately 2% of all pregnancies and is associated with maternal diabetes and fetal anomalies resulting in gastrointestinal obstruction, such as esophageal atresia and poor fetal swallowing.
It is important to note that normal amniotic fluid varies and increases with gestational age, peaking at around 1 liter. An excess of 2 liters or more is considered consistent with polyhydramnios. Understanding this condition can help healthcare providers monitor and manage pregnancies for the best possible outcomes.
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This question is part of the following fields:
- Obstetrics
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Question 20
Incorrect
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A 28-year-old primigravida at 37 weeks presents to the antenatal unit with complaints of right-sided abdominal pain and vomiting. She denies any abnormal discharge and reports normal fetal movements. Her blood pressure is 148/97 mmHg and her blood results show Hb of 93 g/l, platelets of 89 * 109/l, WBC of 9.0 * 109/l, urate of 0.49 mmol/l, bilirubin of 32 µmol/l, ALP of 203 u/l, ALT of 190 u/l, and AST of 233 u/l. What is the most likely diagnosis?
Your Answer: Obstetric cholestasis
Correct Answer: HELLP syndrome
Explanation:The most probable diagnosis in this case is HELLP syndrome, which is a severe form of pre-eclampsia characterized by haemolysis, elevated liver enzymes, and low platelets. While hypertension, vomiting, and abdominal pain can support the diagnosis, they are not mandatory. The abdominal pain may indicate liver inflammation and stretching of the liver capsule.
Intense pruritus is the primary symptom of obstetric cholestasis, and a rise in serum bile acids is the most sensitive marker. Acute fatty liver is another severe condition associated with pre-eclampsia, which causes higher elevations in liver enzymes and deep jaundice. Hyperuricaemia can be a useful marker of pre-eclampsia and does not necessarily indicate gout. Urate levels increase due to reduced kidney function and clearance. Hyperemesis gravidarum is unlikely to present for the first time this late in pregnancy and should be a diagnosis of exclusion.
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 21
Correct
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A 28-year-old pregnant woman with type 1 diabetes inquires about the frequency of blood glucose level testing during her pregnancy.
Your Answer: Daily fasting, pre-meal, 1-hour post-meal and bedtime tests.
Explanation:It is important for pregnant individuals with type 1 diabetes to closely monitor their blood glucose levels by testing multiple times throughout the day. This is recommended by NICE NG3.
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 22
Incorrect
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A 35-year-old woman who is 28 weeks pregnant is brought to the maternity ward due to excessive vaginal bleeding. She has a negative Rhesus factor. What is the best course of action for preventing Rhesus sensitization?
Your Answer: Anti-D immunoglobulin infusion
Correct Answer: One dose of Anti-D immunoglobulin followed by a Kleihauer test
Explanation:What is the recommended prophylaxis for Rhesus sensitisation in a Rhesus negative mother with antepartum haemorrhage?
Antepartum haemorrhage increases the risk of Rhesus sensitisation and Rhesus disease of the newborn in subsequent pregnancies due to fetomaternal haemorrhage (FMH). The correct approach is to administer one dose of anti-D immunoglobulin immediately, followed by a Kleihauer test. This test detects fetal cells in the maternal circulation and estimates the volume of FMH, allowing for the calculation of additional anti-D immunoglobulin. While routine prophylaxis at 28 weeks should still be given, there is no such thing as an anti-D immunoglobulin infusion. These recommendations are based on the British Committee for Standards in Haematology guidelines for the prevention of haemolytic disease of the fetus and newborn.
Rhesus negative pregnancies can lead to the formation of anti-D IgG antibodies in the mother if she delivers a Rh +ve child, which can cause haemolysis in future pregnancies. Prevention involves testing for D antibodies and giving anti-D prophylaxis to non-sensitised Rh -ve mothers at 28 and 34 weeks. Anti-D immunoglobulin should be given within 72 hours in various situations. Tests should be done on all babies born to Rh -ve mothers, and affected fetuses may experience various complications and require treatment such as transfusions and UV phototherapy.
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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 36-year-old overweight gravida 3 para 2 presents with a tender and swollen left leg at 32 weeks of gestation. The clinician initiates appropriate treatment and decides to monitor it with a specific blood test. What is the name of this blood test?
Your Answer: Prothrombin time (PT)
Correct Answer: Anti-Xa activity
Explanation: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 24
Correct
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A 28-year-old woman has recently given birth to a healthy baby without any complications. She is curious about iron supplementation and has undergone blood tests which reveal a Hb level of 107 g/L. What is the appropriate Hb cut-off for initiating treatment in this patient?
Your Answer: 100
Explanation:During pregnancy, women are checked for anaemia twice – once at the initial booking visit (usually around 8-10 weeks) and again at 28 weeks. The National Institute for Health and Care Excellence (NICE) has set specific cut-off levels to determine if a pregnant woman requires oral iron therapy. These levels are less than 110 g/L in the first trimester, less than 105 g/L in the second and third trimesters, and less than 100 g/L postpartum.
If a woman’s iron levels fall below these cut-offs, she will be prescribed oral ferrous sulfate or ferrous fumarate. It is important to continue this treatment for at least three months after the iron deficiency has been corrected to allow the body to replenish its iron stores. By following these guidelines, healthcare professionals can help ensure that pregnant women receive the appropriate care to prevent and manage anaemia during pregnancy.
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This question is part of the following fields:
- Obstetrics
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Question 25
Incorrect
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A 20-year-old woman presents with a positive pregnancy test and is diagnosed with an ectopic pregnancy after ruling out an intrauterine pregnancy. She is asymptomatic and her serum beta-human chorionic gonadotropin (B-hCG) level is 877 IU/L. A transvaginal ultrasound shows a 24mm adnexal mass without a heartbeat and no free fluid in the abdomen. Although expectant management is an option, she declines. What is the recommended initial treatment?
Your Answer: Misoprostol
Correct Answer: Methotrexate
Explanation:According to the National Institute for Health and Care Excellence (NICE), if a woman has an unruptured ectopic pregnancy measuring less than 35mm without visible heartbeat, a serum B-hCG level of less than 1500 IU/L, no intrauterine pregnancy, and no pain, the recommended first-line treatment is methotrexate, provided the patient is willing to attend follow-up appointments. However, if the woman declines expectant management, which is an option for a small number of women with low B-hCG, no symptoms, and a tubal ectopic pregnancy measuring less than 35mm without heartbeat, methotrexate is the preferred treatment option. Methotrexate is a chemotherapeutic drug that interferes with DNA synthesis and disrupts cell multiplication, preventing the pregnancy from developing. Laparoscopic salpingectomy (or salpingostomy if there is a risk of infertility) is the other treatment option, which should be offered if the ectopic pregnancy is larger than 35mm, causing severe pain, or if the B-hCG level is greater than 1500. However, there is a risk of infertility if a problem arises with the remaining Fallopian tube in the future. Misoprostol and mifepristone are not recommended for the management of ectopic pregnancy.
Understanding Ectopic Pregnancy
Ectopic pregnancy occurs when a fertilized egg implants outside the uterus. This condition is characterized by lower abdominal pain and vaginal bleeding, typically occurring 6-8 weeks after the start of the last period. The pain is usually constant and may be felt on one side of the abdomen due to tubal spasm. Vaginal bleeding is usually less than a normal period and may be dark brown in color. Other symptoms may include shoulder tip pain, pain on defecation/urination, dizziness, fainting, or syncope. Breast tenderness may also be reported.
During examination, abdominal tenderness and cervical excitation may be observed. However, it is not recommended to examine for an adnexal mass due to the risk of rupturing the pregnancy. Instead, a pelvic examination to check for cervical excitation is recommended. In cases of pregnancy of unknown location, serum bHCG levels >1,500 may indicate an ectopic pregnancy. It is important to seek medical attention immediately if ectopic pregnancy is suspected as it can be life-threatening.
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This question is part of the following fields:
- Obstetrics
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Question 26
Incorrect
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A 27-year-old G4P3 woman presents with a lump in the breast, having ceased breastfeeding her youngest child two weeks prior. Her past medical history is significant for previous episodes of mastitis when breastfeeding her older children. On examination the lump is in the right breast at the six o'clock position, 3 cm from the nipple. The lump is non-tender and the overlying skin seems unaffected. Her observations are as follows:
Heart rate: 90,
Respiratory rate: 14,
Blood pressure: 112/72 mmHg,
Oxygen saturation: 99%,
Temperature: 37.5 Cº.
What is the probable diagnosis, and what is the most appropriate next step in investigation?Your Answer:
Correct Answer: Galactocele, no further investigation necessary
Explanation:Galactocele and breast abscess can be distinguished based on clinical history and examination findings, without the need for further investigation.
Recent discontinuation of breastfeeding is a risk factor for both mastitis/abscess formation and galactocele formation. Galactoceles are distinguishable from breast abscesses because they are painless and non-tender upon examination, and there are no signs of infection locally or systemically.
Although the patient’s history of mastitis increases the likelihood of a breast abscess, the clinical presentation strongly suggests a galactocele (i.e. painless lump, no localized redness, and absence of fever).Understanding Galactocele
Galactocele is a condition that commonly affects women who have recently stopped breastfeeding. It occurs when a lactiferous duct becomes blocked, leading to the accumulation of milk and the formation of a cystic lesion in the breast. Unlike an abscess, galactocele is usually painless and does not cause any local or systemic signs of infection.
In simpler terms, galactocele is a type of breast cyst that develops when milk gets trapped in a duct. It is not a serious condition and can be easily diagnosed by a doctor. Women who experience galactocele may notice a lump in their breast, but it is usually painless and does not require any treatment. However, if the lump becomes painful or infected, medical attention may be necessary. Overall, galactocele is a common and harmless condition that can be managed with proper care and monitoring.
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This question is part of the following fields:
- Obstetrics
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Question 27
Incorrect
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A 27-year-old woman presents at 18 weeks’ gestation, seeking advice. She was collecting her son from school the other day when the teacher alerted the parents that a few children had developed ‘slapped cheek syndrome’. One of those children was at her house with his parents for dinner over the weekend.
She is concerned she may have been infected and is worried about her baby. She had all her paediatric vaccinations, as per the National Health Service (NHS) schedule.
Which of the following should be the next step in the investigation of this patient?Your Answer:
Correct Answer: Parvovirus B19 immunoglobulin G (IgG) and immunoglobulin M (IgM) serology
Explanation:Serology Testing for Parvovirus B19 and Rubella During Pregnancy
During pregnancy, it is important to investigate exposure to certain viruses, such as parvovirus B19 and rubella, as they can have detrimental effects on the fetus. Serology testing for immunoglobulin G (IgG) and immunoglobulin M (IgM) antibodies is used to determine if a patient has had a previous infection or if there is a recent or acute infection.
Parvovirus B19 is a DNA virus that commonly affects children and can cause slapped cheek syndrome. If a patient has had significant exposure to parvovirus B19, IgG and IgM serology testing is performed. A positive IgG and negative IgM result indicates an old infection, while a negative IgG and IgM result requires repeat testing in one month. A positive IgM result indicates a recent infection, which requires further confirmation and referral to a specialist center for fetal monitoring.
Varicella IgG serology is performed if there was exposure to chickenpox during pregnancy. A positive result indicates immunity to the virus, and no further investigation is required.
Rubella IgG and IgM serology is used to investigate exposure to rubella during pregnancy. A positive IgG indicates previous exposure or immunity from vaccination, while a positive IgM indicates a recent or acute infection.
In conclusion, serology testing is an important tool in investigating viral exposure during pregnancy and can help guide appropriate management and monitoring.
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This question is part of the following fields:
- Obstetrics
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Question 28
Incorrect
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A 35-year-old woman who has given birth before is experiencing advanced labour at 37 weeks gestation. An ultrasound reveals that the baby is in a breech presentation. Despite pushing for one and a half hours, the buttocks are still not visible. What is the appropriate course of action in this scenario?
Your Answer:
Correct Answer: Caesarean section
Explanation:A vaginal delivery is expected to be challenging due to the foetal presentation and station. Singleton pregnancies are not recommended for breech extraction, which also demands expertise. Hence, it is advisable to opt for a Caesarean section.
Breech presentation occurs when the caudal end of the fetus is in the lower segment, and it is more common at 28 weeks than near term. Risk factors include uterine malformations, placenta praevia, and fetal abnormalities. Management options include spontaneous turning, external cephalic version (ECV), planned caesarean section, or vaginal delivery. The RCOG recommends informing women that planned caesarean section reduces perinatal mortality and early neonatal morbidity, but there is no evidence that the long-term health of babies is influenced by how they are born. ECV is contraindicated in certain cases, such as where caesarean delivery is required or there is an abnormal cardiotocography.
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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 29-year-old female attends the antenatal clinic for a booking appointment. What should be recognized as a risk factor for pre-eclampsia?
Your Answer:
Correct Answer: Pre-existing renal disease
Explanation:Identify the following as potential risk factors:
– Being 40 years old or older
– Never having given birth
– Having a pregnancy interval of over 10 years
– Having a family history of pre-eclampsia
– Having previously experienced pre-eclampsia
– Having a body mass index (BMI) of 30 kg/m^2 or higher
– Having pre-existing vascular disease, such as hypertension.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 30
Incorrect
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A 25-year-old female patient visits her GP complaining of abdominal pain and a positive pregnancy test, despite having an intrauterine system. She is urgently referred to the emergency department where an ultrasound scan confirms a tubal ectopic pregnancy with a visible heartbeat. The patient has never been pregnant before but desires to have a family in the future. There is no history of sexually transmitted infections. What is the best course of action for management?
Your Answer:
Correct Answer: Salpingectomy
Explanation:For women without other risk factors for infertility, salpingectomy is the preferred first-line treatment for ectopic pregnancy requiring surgical management, rather than salpingostomy. This is the case for a patient with visible foetal heartbeat and pain, as expectant management would be inappropriate and methotrexate is not suitable. Misoprostol is also not appropriate as it is used for incomplete miscarriages, which is not the case for this patient.
Ectopic pregnancy is a serious condition that requires prompt investigation and management. Women who are stable are typically investigated and managed in an early pregnancy assessment unit, while those who are unstable should be referred to the emergency department. The investigation of choice for ectopic pregnancy is a transvaginal ultrasound, which will confirm the presence of a positive pregnancy test.
There are three ways to manage ectopic pregnancies: expectant management, medical management, and surgical management. The choice of management will depend on various criteria, such as the size of the ectopic pregnancy, whether it is ruptured or not, and the patient’s symptoms and hCG levels. Expectant management involves closely monitoring the patient over 48 hours, while medical management involves giving the patient methotrexate and requires follow-up. Surgical management can involve salpingectomy or salpingostomy, depending on the patient’s risk factors for infertility.
Salpingectomy is the first-line treatment for women without other risk factors for infertility, while salpingostomy should be considered for women with contralateral tube damage. However, around 1 in 5 women who undergo a salpingostomy require further treatment, such as methotrexate and/or a salpingectomy. It is important to carefully consider the patient’s individual circumstances and make a decision that will provide the best possible outcome.
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This question is part of the following fields:
- Obstetrics
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