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  • Question 1 - A 28-year-old woman who is 30 weeks pregnant is experiencing breathlessness and is...

    Correct

    • A 28-year-old woman who is 30 weeks pregnant is experiencing breathlessness and is undergoing investigation. A blood gas test is being conducted to aid in her management.
      What type of acid-base imbalance would you anticipate as a result of pregnancy?

      Your Answer: Respiratory alkalosis

      Explanation:

      Respiratory alkalosis can be caused by hyperventilation, such as during periods of anxiety. It can also be a result of conditions like pulmonary embolism, CNS disorders (such as stroke or encephalitis), altitude, pregnancy, or the early stages of aspirin overdose.

      Respiratory acidosis is often associated with chronic obstructive pulmonary disease (COPD) or life-threatening asthma. Other causes include pulmonary edema, sedative drug overdose (such as opiates or benzodiazepines), neuromuscular disease, obesity, or certain medications.

      Metabolic alkalosis can occur due to vomiting, potassium depletion (often caused by diuretic usage), Cushing’s syndrome, or Conn’s syndrome.

      Metabolic acidosis with a raised anion gap can be caused by conditions like lactic acidosis (which can result from hypoxemia, shock, sepsis, or infarction) or ketoacidosis (commonly seen in diabetes, starvation, or alcohol excess). Other causes include renal failure or poisoning (such as late stages of aspirin overdose, methanol, or ethylene glycol).

      Metabolic acidosis with a normal anion gap can be attributed to conditions like renal tubular acidosis, diarrhea, ammonium chloride ingestion, or adrenal insufficiency.

    • This question is part of the following fields:

      • Obstetrics & Gynaecology
      15.2
      Seconds
  • Question 2 - A 32-year-old woman arrives at the Emergency Department. She is 14 weeks pregnant...

    Correct

    • A 32-year-old woman arrives at the Emergency Department. She is 14 weeks pregnant and has experienced a significant amount of vaginal bleeding accompanied by the passage of blood clots. She reports feeling lightheaded. Her prenatal blood tests indicate that she is Rh-negative. Her vital signs are as follows: heart rate of 46, blood pressure of 82/43, respiratory rate of 22, and oxygen saturation of 94% on room air. The resuscitation nurse has successfully inserted an intravenous line, and a comprehensive set of blood samples, including a cross-match, has been sent to the laboratory.

      What is the MOST LIKELY diagnosis in this case?

      Your Answer: Cervical shock syndrome

      Explanation:

      This patient is experiencing vaginal bleeding along with bradycardia and hypotension. These symptoms can be attributed to a condition known as cervical shock syndrome. It is likely that the products of conception (POC) are located within the os. In cervical shock syndrome, the cervix becomes dilated due to the presence of POC, leading to an increase in bleeding and triggering a vasovagal reaction.

      To address this situation, it is crucial to conduct an urgent speculum examination. During this examination, the POC should be carefully removed using sterile sponge forceps.

    • This question is part of the following fields:

      • Obstetrics & Gynaecology
      26
      Seconds
  • Question 3 - A 32-year-old woman came in ten days ago with a fever, tenderness in...

    Incorrect

    • A 32-year-old woman came in ten days ago with a fever, tenderness in the suprapubic area, and discharge from the vagina. The doctor diagnosed her with pelvic inflammatory disease and started her on antibiotics. She initially got better but now she is back with intense pain in her lower abdomen and a temperature of 39.5°C.

      What is the MOST suitable first test to perform?

      Your Answer: Endocervical swab

      Correct Answer: Ultrasound scan

      Explanation:

      This patient is highly likely to have developed a tubo-ovarian abscess (TOA), which is a complication of pelvic inflammatory disease. TOA occurs when a pocket of pus forms in the fallopian tube and/or ovary. If the abscess ruptures, it can lead to sepsis and become life-threatening.

      The initial imaging modality of choice is transabdominal and endovaginal ultrasound. This imaging technique often reveals multilocular complex retro-uterine/adnexal masses with debris, septations, and irregular thick walls. These masses can be present on both sides.

      Urgent hospital admission is necessary, and the usual management involves draining the abscess and administering intravenous antibiotics. The abscess drainage can be guided by ultrasound or CT scanning.

      In some cases, laparotomy or laparoscopy may be required to drain the abscess.

    • This question is part of the following fields:

      • Obstetrics & Gynaecology
      19.9
      Seconds
  • Question 4 - A 28-year-old woman comes in with lower abdominal pain, dyspareunia, and purulent vaginal...

    Correct

    • A 28-year-old woman comes in with lower abdominal pain, dyspareunia, and purulent vaginal discharge. A pregnancy test done today is negative and her last period was four weeks ago. Her temperature today is 38.6°C.

      What is the MOST LIKELY diagnosis?

      Your Answer: Pelvic inflammatory disease

      Explanation:

      Pelvic inflammatory disease (PID) is an infection that affects the upper female reproductive tract, including the uterus, fallopian tubes, and ovaries. It is typically caused by an ascending infection from the cervix. The most common culprits are sexually transmitted diseases like chlamydia and gonorrhea, with chlamydia being the most prevalent infection seen in UK genitourinary medicine clinics.

      PID can often be asymptomatic, but when symptoms do occur, they may include lower abdominal pain and tenderness, fever, painful urination, painful intercourse, purulent vaginal discharge, abnormal vaginal bleeding, and tenderness in the cervix and adnexa. It’s important to note that symptoms of ectopic pregnancy can be mistaken for PID, so a pregnancy test should always be conducted in patients with suspicious symptoms.

      To investigate a potential case of PID, endocervical swabs are taken to test for chlamydia and gonorrhea using nucleic acid amplification tests. It is recommended to start empirical antibiotic treatment as soon as a presumptive diagnosis of PID is made, without waiting for swab results.

      Mild to moderate cases of PID can usually be managed in primary care or outpatient settings. However, patients with severe disease should be admitted to the hospital for intravenous antibiotics. Signs of severe disease include a fever above 38°C, signs of a tubo-ovarian abscess, signs of pelvic peritonitis, or concurrent pregnancy.

      The current recommended treatment for outpatient cases of PID is a single intramuscular dose of ceftriaxone 500 mg, followed by oral doxycycline 100 mg twice daily and oral metronidazole 400 mg twice daily for 14 days. An alternative regimen is oral ofloxacin 400 mg twice daily and oral metronidazole 400 mg twice daily for 14 days.

      For severely ill patients in the inpatient setting, initial treatment consists of intravenous doxycycline, a single-dose of intravenous ceftriaxone, and intravenous metronidazole. Afterward, the treatment is switched to oral doxycycline and metronidazole to complete a 14-day course.

      If a patient fails to respond to treatment, laparoscopy is necessary to confirm the diagnosis or consider alternative diagnoses.

    • This question is part of the following fields:

      • Obstetrics & Gynaecology
      14.7
      Seconds
  • Question 5 - A 28-year-old woman comes in with lower abdominal pain, painful urination, pain during...

    Correct

    • A 28-year-old woman comes in with lower abdominal pain, painful urination, pain during intercourse, and thick, yellowish vaginal discharge. Based on the clinical findings, you diagnose her with pelvic inflammatory disease (PID).
      When would hospitalization be necessary in this case?

      Your Answer: Concurrent pregnancy

      Explanation:

      Pelvic inflammatory disease (PID) is a pelvic infection that affects the upper female reproductive tract, including the uterus, fallopian tubes, and ovaries. It is typically caused by an ascending infection from the cervix and is commonly associated with sexually transmitted diseases like chlamydia and gonorrhea. In the UK, genital Chlamydia trachomatis infection is the most common cause of PID seen in genitourinary medicine clinics.

      PID can often be asymptomatic, but when symptoms are present, they may include lower abdominal pain and tenderness, fever, painful urination, painful intercourse, purulent vaginal discharge, abnormal vaginal bleeding, and tenderness in the cervix and adnexa. It is important to note that symptoms of ectopic pregnancy can be similar to those of PID, so a pregnancy test should be conducted for all patients with suspicious symptoms.

      To investigate a possible case of PID, endocervical swabs should be taken to test for C. trachomatis and N. gonorrhoeae using nucleic acid amplification tests if available. Mild to moderate cases of PID can usually be managed in primary care or outpatient settings, while patients with severe disease should be admitted to the hospital for intravenous antibiotics. Signs of severe disease include a fever above 38°C, signs of a tubo-ovarian abscess, signs of pelvic peritonitis, or concurrent pregnancy.

      Empirical antibiotic treatment should be initiated as soon as a presumptive diagnosis of PID is made clinically, without waiting for swab results. The current recommended outpatient treatment for PID is a single intramuscular dose of ceftriaxone 500 mg, followed by oral doxycycline 100 mg twice daily and oral metronidazole 400 mg twice daily for 14 days. An alternative regimen is oral ofloxacin 400 mg twice daily and oral metronidazole 400 mg twice daily for 14 days.

      For severely ill patients in the inpatient setting, initial treatment includes intravenous doxycycline, a single-dose of intravenous ceftriaxone, and intravenous metronidazole. This is then followed by a switch to oral doxycycline and metronidazole to complete a 14-day treatment course. If a patient fails to respond to treatment, laparoscopy is necessary to confirm the diagnosis or consider alternative diagnoses.

    • This question is part of the following fields:

      • Obstetrics & Gynaecology
      15.8
      Seconds
  • Question 6 - A 32-year-old woman who is 38 weeks pregnant is brought to the Emergency...

    Correct

    • A 32-year-old woman who is 38 weeks pregnant is brought to the Emergency Department after experiencing sudden difficulty breathing. Shortly after her arrival, she loses consciousness. The cardiac monitor displays ventricular fibrillation, confirming cardiac arrest.
      Which of the following statements about cardiac arrest during pregnancy is NOT true?

      Your Answer: The uterus should be manually displaced to the right

      Explanation:

      Cardiac arrest during pregnancy is a rare occurrence, happening in approximately 16 out of every 100,000 live births. It is crucial to consider both the mother and the fetus when dealing with cardiac arrest in pregnancy, as the best way to ensure a positive outcome for the fetus is by effectively resuscitating the mother.

      The main causes of cardiac arrest during pregnancy include pre-existing cardiac disease, pulmonary embolism, hemorrhage, ectopic pregnancy, hypertensive disorders of pregnancy, amniotic fluid embolism, and suicide. Many cardiovascular problems associated with pregnancy are caused by compression of the inferior vena cava.

      To prevent decompensation or potential cardiac arrest during pregnancy, it is important to follow these steps when dealing with a distressed or compromised pregnant patient:

      – Place the patient in the left lateral position or manually displace the uterus to the left.
      – Administer high-flow oxygen, guided by pulse oximetry.
      – Give a fluid bolus if there is low blood pressure or signs of hypovolemia.
      – Re-evaluate the need for any medications currently being administered.
      – Seek expert help and involve obstetric and neonatal specialists early.
      – Identify and treat the underlying cause.

      In the event of cardiac arrest during pregnancy, in addition to following the standard guidelines for basic and advanced life support, the following modifications should be made:

      – Immediately call for expert help, including an obstetrician, anesthetist, and neonatologist.
      – Start CPR according to the standard ALS guidelines, but adjust the hand position slightly higher on the sternum.
      – Ideally establish IV or IO access above the diaphragm to account for potential compression of the inferior vena cava.
      – Manually displace the uterus to the left to relieve caval compression.
      – Tilt the table to the left side (around 15-30 degrees of tilt).
      – Perform early tracheal intubation to reduce the risk of aspiration (seek assistance from an expert anesthetist).
      – Begin preparations for an emergency Caesarean section.

      A perimortem Caesarean section should be performed within 5 minutes of the onset of cardiac arrest. This delivery will alleviate caval compression and increase the chances of successful resuscitation by improving venous return during CPR. It will also maximize the chances of the infant’s survival, as the best survival rate occurs when delivery is achieved within 5 minutes of the mother’s cardiac arrest.

    • This question is part of the following fields:

      • Obstetrics & Gynaecology
      15.3
      Seconds
  • Question 7 - You evaluate a 45-year-old woman who presents with lower abdominal and pelvic pain....

    Correct

    • You evaluate a 45-year-old woman who presents with lower abdominal and pelvic pain. During a bimanual vaginal examination, you detect a significant pelvic mass. She has no significant medical history or gynecological issues, such as uterine fibroids.
      What would be the MOST suitable next step in managing this patient?

      Your Answer: Urgent referral to gynaecology service (for an appointment within 2 weeks)

      Explanation:

      Women who are 18 years or older and have a pelvic mass that is not clearly uterine fibroids should be promptly referred for assessment. In this case, an abdominal X-ray would not provide much useful information, and it is not advisable to take no action at this point. For more information, please refer to the NICE referral guidelines for suspected cancer.

    • This question is part of the following fields:

      • Obstetrics & Gynaecology
      16.4
      Seconds
  • Question 8 - A 35-year-old woman comes in with amenorrhoea for the past six months following...

    Correct

    • A 35-year-old woman comes in with amenorrhoea for the past six months following childbirth. The delivery was complicated by a post-partum haemorrhage that necessitated a blood transfusion. She has been unable to produce breast milk or breastfeed. She has also mentioned a loss of hair in her underarm and pubic regions and a decreased sex drive.
      What is the SINGLE most probable diagnosis?

      Your Answer: Sheehan’s syndrome

      Explanation:

      Sheehan’s syndrome is a condition where the pituitary gland becomes damaged due to insufficient blood flow and shock during and after childbirth, leading to hypopituitarism. The risk of developing this syndrome is higher in pregnancies with conditions that increase the chances of bleeding, such as placenta praevia and multiple pregnancies. Sheehan’s syndrome is quite rare, affecting only 1 in 10,000 pregnancies.

      During pregnancy, the anterior pituitary gland undergoes hypertrophy, making it more vulnerable to ischaemia in the later stages. While the posterior pituitary gland is usually unaffected due to its direct arterial supply, there have been rare cases where it is also involved.

      The clinical features of Sheehan’s syndrome include the absence or infrequency of menstrual periods, the inability to produce milk and breastfeed (galactorrhoea), decreased libido, fatigue and tiredness, and loss of pubic and axillary hair. Additionally, secondary hypothyroidism and adrenal insufficiency may also occur.

      Serum prolactin levels are typically low, measuring less than 5ng/ml. An MRI can be helpful in ruling out other pituitary issues, such as a pituitary tumor.

      The management of Sheehan’s syndrome involves hormone replacement therapy. With appropriate treatment, the prognosis for this condition is excellent.

    • This question is part of the following fields:

      • Obstetrics & Gynaecology
      10.1
      Seconds
  • Question 9 - A 32-year-old woman who is 37-weeks pregnant is brought to the Emergency Department...

    Correct

    • A 32-year-old woman who is 37-weeks pregnant is brought to the Emergency Department due to severe headaches, visual disturbance, and abdominal pain. Shortly after arrival, she collapses and experiences a seizure. Her husband mentions that she has been receiving treatment for hypertension during the pregnancy.

      What is the most probable diagnosis in this case?

      Your Answer: Eclampsia

      Explanation:

      Eclampsia is the most likely diagnosis in this case. It is characterized by the occurrence of one or more convulsions on top of pre-eclampsia. To control seizures in eclampsia, the recommended treatment is magnesium sulphate. The Collaborative Eclampsia Trial regimen should be followed for administering magnesium sulphate. Initially, a loading dose of 4 g should be given intravenously over 5 to 15 minutes. This should be followed by a continuous infusion of 1 g per hour for 24 hours. If the woman experiences another eclamptic seizure, the infusion should be continued for an additional 24 hours after the last seizure. In case of recurrent seizures, a further dose of 2-4 g should be administered intravenously over 5 to 15 minutes. It is important to note that the only cure for eclampsia is the delivery of the fetus and placenta. Once the patient is stabilized, she should be prepared for an emergency caesarean section.

    • This question is part of the following fields:

      • Obstetrics & Gynaecology
      12.4
      Seconds
  • Question 10 - A 28-year-old woman comes in with lower abdominal pain, painful urination, painful intercourse,...

    Incorrect

    • A 28-year-old woman comes in with lower abdominal pain, painful urination, painful intercourse, and thick, yellowish vaginal discharge. A pregnancy test done today is negative. She has a temperature of 39.1°C, and there is tenderness in her abdomen during the examination.

      What is the MOST suitable treatment plan?

      Your Answer: IM ceftriaxone plus oral doxycycline and metronidazole

      Correct Answer: IV ceftriaxone and metronidazole plus oral doxycycline

      Explanation:

      Pelvic inflammatory disease (PID) is a pelvic infection that affects the upper female reproductive tract, including the uterus, fallopian tubes, and ovaries. It is typically caused by an ascending infection from the cervix and is commonly associated with sexually transmitted diseases like chlamydia and gonorrhea. In the UK, genital Chlamydia trachomatis infection is the most common cause of PID seen in genitourinary medicine clinics.

      PID can often be asymptomatic, but when symptoms are present, they may include lower abdominal pain and tenderness, fever, painful urination, painful intercourse, purulent vaginal discharge, abnormal vaginal bleeding, and tenderness in the cervix and adnexa. It is important to note that symptoms of ectopic pregnancy can be similar to those of PID, so a pregnancy test should be conducted for all patients with suspicious symptoms.

      To investigate a possible case of PID, endocervical swabs should be taken to test for C. trachomatis and N. gonorrhoeae using nucleic acid amplification tests if available. Mild to moderate cases of PID can usually be managed in primary care or outpatient settings, while patients with severe disease should be admitted to the hospital for intravenous antibiotics. Signs of severe disease include a fever above 38°C, signs of a tubo-ovarian abscess, signs of pelvic peritonitis, or concurrent pregnancy.

      Empirical antibiotic treatment should be initiated as soon as a presumptive diagnosis of PID is made clinically, without waiting for swab results. The current recommended outpatient treatment for PID is a single intramuscular dose of ceftriaxone 500 mg, followed by oral doxycycline 100 mg twice daily and oral metronidazole 400 mg twice daily for 14 days. An alternative regimen is oral ofloxacin 400 mg twice daily and oral metronidazole 400 mg twice daily for 14 days.

      For severely ill patients in the inpatient setting, initial treatment includes intravenous doxycycline, a single-dose of intravenous ceftriaxone, and intravenous metronidazole. This is then followed by a switch to oral doxycycline and metronidazole to complete a 14-day treatment course. If a patient fails to respond to treatment, laparoscopy is necessary to confirm the diagnosis or consider alternative diagnoses.

    • This question is part of the following fields:

      • Obstetrics & Gynaecology
      16.4
      Seconds
  • Question 11 - You assess a 27-year-old patient who is 10-weeks pregnant. She is concerned as...

    Correct

    • You assess a 27-year-old patient who is 10-weeks pregnant. She is concerned as she had contact with someone with chickenpox two days ago. She is unsure if she had chickenpox in her childhood.
      What is the MOST suitable initial course of action?

      Your Answer: She should have a blood test to check for varicella zoster immunity

      Explanation:

      Varicella can have serious consequences for pregnant women. If a woman contracts varicella during the first 28 weeks of pregnancy, there is a 1% chance that the fetus will be affected and develop foetal varicella syndrome (FVS). FVS is characterized by eye defects, limb underdevelopment, skin scarring, and neurological abnormalities.

      Pregnant women who have not had chickenpox or who test negative for VZV IgG should be advised to minimize contact with individuals who have chickenpox or shingles. If they are exposed, they should seek immediate medical help.

      If a pregnant woman is exposed to varicella, the first step is to perform a blood test to check for VZV immunity. If she is not immune and the exposure is significant, she should be given VZV immunoglobulin as soon as possible. This treatment is effective within 10 days of exposure.

      If a pregnant woman develops chickenpox, she should urgently seek medical assistance. There is an increased risk of pneumonia, encephalitis, and hepatitis for the mother, as well as a 1% risk of the fetus developing FVS.

      Acyclovir should be used cautiously before 20 weeks of gestation but is recommended after 20 weeks if the woman seeks medical help within 24 hours of the rash appearing.

      If a woman develops any complications of varicella, she must be referred to a hospital. Additionally, she should be referred to a specialized center five weeks after the infection for a detailed ultrasound scan to determine if FVS has occurred.

      For more information, refer to the Royal College of Obstetricians and Gynaecologists green-top guidelines for the management of VZV exposure and infection in pregnancy.

    • This question is part of the following fields:

      • Obstetrics & Gynaecology
      19.7
      Seconds
  • Question 12 - A 32-year-old woman who is 38 weeks pregnant is brought to the Emergency...

    Correct

    • A 32-year-old woman who is 38 weeks pregnant is brought to the Emergency Department after experiencing sudden difficulty breathing. Shortly after her arrival, she loses consciousness. The cardiac monitor displays ventricular fibrillation, confirming cardiac arrest.
      Which of the following statements about cardiac arrest during pregnancy is correct?

      Your Answer: Early tracheal intubation should be performed

      Explanation:

      Cardiac arrest during pregnancy is a rare occurrence, happening in approximately 16 out of every 100,000 live births. It is crucial to consider both the mother and the fetus when dealing with cardiac arrest in pregnancy, as the best way to ensure a positive outcome for the fetus is by effectively resuscitating the mother.

      The main causes of cardiac arrest during pregnancy include pre-existing cardiac disease, pulmonary embolism, hemorrhage, ectopic pregnancy, hypertensive disorders of pregnancy, amniotic fluid embolism, and suicide. Many cardiovascular problems associated with pregnancy are caused by compression of the inferior vena cava.

      To prevent decompensation or potential cardiac arrest during pregnancy, it is important to follow these steps when dealing with a distressed or compromised pregnant patient:

      – Place the patient in the left lateral position or manually displace the uterus to the left.
      – Administer high-flow oxygen, guided by pulse oximetry.
      – Give a fluid bolus if there is low blood pressure or signs of hypovolemia.
      – Re-evaluate the need for any medications currently being administered.
      – Seek expert help and involve obstetric and neonatal specialists early.
      – Identify and treat the underlying cause.

      In the event of cardiac arrest during pregnancy, in addition to following the standard guidelines for basic and advanced life support, the following modifications should be made:

      – Immediately call for expert help, including an obstetrician, anesthetist, and neonatologist.
      – Start CPR according to the standard ALS guidelines, but adjust the hand position slightly higher on the sternum.
      – Ideally establish IV or IO access above the diaphragm to account for potential compression of the inferior vena cava.
      – Manually displace the uterus to the left to relieve caval compression.
      – Tilt the table to the left side (around 15-30 degrees of tilt).
      – Perform early tracheal intubation to reduce the risk of aspiration (seek assistance from an expert anesthetist).
      – Begin preparations for an emergency Caesarean section.

      A perimortem Caesarean section should be performed within 5 minutes of the onset of cardiac arrest. This delivery will alleviate caval compression and increase the chances of successful resuscitation by improving venous return during CPR. It will also maximize the chances of the infant’s survival, as the best survival rate occurs when delivery is achieved within 5 minutes of the mother’s cardiac arrest.

    • This question is part of the following fields:

      • Obstetrics & Gynaecology
      9.5
      Seconds
  • Question 13 - You evaluate a 58-year-old woman who presents with postmenopausal bleeding. She has been...

    Correct

    • You evaluate a 58-year-old woman who presents with postmenopausal bleeding. She has been experiencing these symptoms for approximately one month. The patient is currently on hormone replacement therapy (HRT) to alleviate vasomotor symptoms.

      What would be the MOST SUITABLE next course of action for managing this patient?

      Your Answer: Urgent referral to gynaecology service (for an appointment within 2 weeks)

      Explanation:

      If you are a woman under the age of 55 and experiencing postmenopausal bleeding, it is important to seek medical attention promptly. One possible cause of this symptom could be endometrial cancer. To ensure timely diagnosis and treatment, it is recommended to follow the suspected cancer pathway referral guidelines provided by NICE. These guidelines aim to facilitate recognition and referral of suspected cancer cases. By adhering to these guidelines, you can increase the likelihood of securing an appointment for further evaluation within two weeks. to the NICE referral guidelines on recognition and referral of suspected cancer.

    • This question is part of the following fields:

      • Obstetrics & Gynaecology
      22.7
      Seconds
  • Question 14 - A 25-year-old woman is brought in by ambulance following a car crash where...

    Correct

    • A 25-year-old woman is brought in by ambulance following a car crash where she was a passenger in a vehicle struck by a truck at a high velocity. She is 32 weeks pregnant.

      What is the primary cause of fetal demise in traumatic incidents during pregnancy?

      Your Answer: Maternal shock

      Explanation:

      The primary reason for foetal death in trauma during pregnancy is maternal shock and maternal mortality. The second most prevalent cause of foetal death is placental abruption.

    • This question is part of the following fields:

      • Obstetrics & Gynaecology
      13.5
      Seconds
  • Question 15 - A 28-year-old woman comes in with lower abdominal pain, painful urination, painful intercourse,...

    Correct

    • A 28-year-old woman comes in with lower abdominal pain, painful urination, painful intercourse, and thick vaginal discharge. A pregnancy test done today is negative. She has no fever and her vital signs are normal. During the exam, her abdomen feels soft, but she experiences cervical motion tenderness during a pelvic examination.

      What is the MOST suitable treatment plan?

      Your Answer: IM ceftriaxone plus oral doxycycline and metronidazole

      Explanation:

      Pelvic inflammatory disease (PID) is a pelvic infection that affects the upper female reproductive tract, including the uterus, fallopian tubes, and ovaries. It is typically caused by an ascending infection from the cervix and is commonly associated with sexually transmitted diseases like chlamydia and gonorrhea. In the UK, genital Chlamydia trachomatis infection is the most common cause of PID seen in genitourinary medicine clinics.

      PID can often be asymptomatic, but when symptoms are present, they may include lower abdominal pain and tenderness, fever, painful urination, painful intercourse, purulent vaginal discharge, abnormal vaginal bleeding, and tenderness in the cervix and adnexa. It is important to note that symptoms of ectopic pregnancy can be similar to those of PID, so a pregnancy test should be conducted for all patients with suspicious symptoms.

      To investigate a possible case of PID, endocervical swabs should be taken to test for C. trachomatis and N. gonorrhoeae using nucleic acid amplification tests if available. Mild to moderate cases of PID can usually be managed in primary care or outpatient settings, while patients with severe disease should be admitted to the hospital for intravenous antibiotics. Signs of severe disease include a fever above 38°C, signs of a tubo-ovarian abscess, signs of pelvic peritonitis, or concurrent pregnancy.

      Empirical antibiotic treatment should be initiated as soon as a presumptive diagnosis of PID is made clinically, without waiting for swab results. The current recommended outpatient treatment for PID is a single intramuscular dose of ceftriaxone 500 mg, followed by oral doxycycline 100 mg twice daily and oral metronidazole 400 mg twice daily for 14 days. An alternative regimen is oral ofloxacin 400 mg twice daily and oral metronidazole 400 mg twice daily for 14 days.

      For severely ill patients in the inpatient setting, initial treatment includes intravenous doxycycline, a single-dose of intravenous ceftriaxone, and intravenous metronidazole. This is then followed by a switch to oral doxycycline and metronidazole to complete a 14-day treatment course. If a patient fails to respond to treatment, laparoscopy is necessary to confirm the diagnosis or consider alternative diagnoses.

    • This question is part of the following fields:

      • Obstetrics & Gynaecology
      36.9
      Seconds
  • Question 16 - A 25-year-old woman comes in with a slight vaginal bleeding and lower abdominal...

    Correct

    • A 25-year-old woman comes in with a slight vaginal bleeding and lower abdominal discomfort. Her pregnancy test shows positive results. During the examination, she experiences tenderness in the right iliac fossa and right-sided adnexa. Additionally, she exhibits cervical motion tenderness.

      What is the SINGLE most probable diagnosis?

      Your Answer: Ectopic pregnancy

      Explanation:

      Bleeding in a confirmed early pregnancy, along with adnexal tenderness and cervical motion tenderness, is indicative of an ectopic pregnancy until proven otherwise. The amount of bleeding caused by an ectopic pregnancy can range from no bleeding or slight spotting to a level similar to a normal menstrual period. It is important to note that 90% of patients with an ectopic pregnancy experience abdominal pain. Other clinical features that may be present include shoulder tip pain, which is caused by irritation of the diaphragm, as well as adnexal tenderness, cervical motion tenderness, rebound tenderness, guarding, and adnexal masses in some cases. Additionally, hypotension and shock may occur.

    • This question is part of the following fields:

      • Obstetrics & Gynaecology
      13.9
      Seconds
  • Question 17 - A 32-year-old patient comes in with a complaint of excessive menstrual bleeding. The...

    Correct

    • A 32-year-old patient comes in with a complaint of excessive menstrual bleeding. The periods are not excessively painful. A recent ultrasound scan showed the presence of small fibroids, all measuring less than 2-3 cm in diameter. During the examination, a slightly enlarged uterus is palpated. The patient expresses a strong desire to start a family soon.
      What would be the most appropriate initial treatment option to consider in this case?

      Your Answer: Tranexamic acid

      Explanation:

      Tranexamic acid is the best choice for this patient because her periods are heavy, but not very painful, and her fibroids are small. Additionally, she wants to start a family soon, so contraceptive options are not as suitable. For more information, you can refer to the NICE guidelines on the assessment and management of heavy menstrual bleeding.

    • This question is part of the following fields:

      • Obstetrics & Gynaecology
      27
      Seconds
  • Question 18 - A 38-year-old woman comes in with a complaint of excessively heavy menstrual periods....

    Incorrect

    • A 38-year-old woman comes in with a complaint of excessively heavy menstrual periods. Her GP recently ordered a complete blood count, which came back normal. During a vaginal examination, no apparent abnormalities were found. She is content with having finished having children.
      Based on the latest NICE guidelines, what would be the most appropriate treatment option for her? Select only ONE response.

      Your Answer: Combined oral contraceptive

      Correct Answer: Mirena IUS

      Explanation:

      The most recent guidelines from the National Institute for Health and Care Excellence (NICE) recommend using a LNG-IUS, such as Mirena IUS, as the initial treatment for heavy menstrual bleeding (HMB) in women who have no identified pathology, fibroids smaller than 3 cm without uterine cavity distortion, or suspected/diagnosed adenomyosis. If a woman declines or cannot use an LNG-IUS, alternative pharmacological treatments can be considered. These include non-hormonal options like Tranexamic acid or NSAIDs, as well as hormonal options like combined hormonal contraception or cyclical oral progestogens. to the NICE guidelines on the assessment and management of heavy menstrual bleeding.

    • This question is part of the following fields:

      • Obstetrics & Gynaecology
      18.5
      Seconds
  • Question 19 - A 52-year-old woman comes in with postmenopausal bleeding. Her medical records indicate that...

    Correct

    • A 52-year-old woman comes in with postmenopausal bleeding. Her medical records indicate that she recently underwent a transvaginal ultrasound, which revealed an endometrial thickness of 6.5 mm. What is the MOST suitable next step in investigating her condition?

      Your Answer: Endometrial biopsy

      Explanation:

      postmenopausal bleeding should always be treated as a potential malignancy until proven otherwise. The first-line investigation for this condition is transvaginal ultrasound (TVUS). This method effectively assesses the risk of endometrial cancer by measuring the thickness of the endometrium.

      In postmenopausal women, the average endometrial thickness is much thinner compared to premenopausal women. The likelihood of endometrial cancer increases as the endometrium becomes thicker. Currently, in the UK, an endometrial thickness of 5 mm is considered the threshold.

      If the endometrial thickness is greater than 5 mm, there is a 7.3% chance of endometrial cancer. However, if a woman with postmenopausal bleeding has a uniform endometrial thickness of less than 5 mm, the likelihood of endometrial cancer is less than 1%.

      In cases where there is a high clinical risk, hysteroscopy and endometrial biopsy should also be performed. The definitive diagnosis is made through histological examination. If the endometrial thickness is greater than 5 mm, an endometrial biopsy is recommended.

    • This question is part of the following fields:

      • Obstetrics & Gynaecology
      22.6
      Seconds
  • Question 20 - A 25-year-old woman who is 32-weeks pregnant in her first pregnancy is brought...

    Correct

    • A 25-year-old woman who is 32-weeks pregnant in her first pregnancy is brought in by ambulance after a car accident. She has noticeable bruising on her lower abdomen and is experiencing intense abdominal pain. During the examination, you are unable to feel the top of the uterus and can easily feel the baby's body parts. Blood samples have been sent to the lab and the patient has an IV line in place.

      What is the MOST LIKELY diagnosis?

      Your Answer: Primary uterine rupture

      Explanation:

      Uterine rupture can occur in two forms: primary, which happens without any previous uterine surgery or trauma, and secondary, which occurs when there is scar dehiscence. In secondary rupture, the rupture can range from the peritoneum to the endometrium, or the peritoneum may remain intact while the underlying uterine tissue ruptures.

      There are several risk factors associated with uterine rupture, including multiparity, a uterine scar from a previous Caesarean section, previous uterine surgery, dysfunctional labor, and augmented labor with medications like oxytocin or prostaglandins.

      The clinical features of uterine rupture include abdominal pain and tenderness, abdominal guarding and rigidity, inability to feel the uterine fundus (in cases of fundal rupture), cessation of uterine contractions, chest pain or shoulder tip pain, vaginal bleeding, abnormal fetal lie (such as oblique or transverse), easy palpation of fetal parts outside the uterus, absent fetal heart sounds, and abnormal CTG findings like late decelerations and reduced variability. Maternal shock can also occur and may be severe.

      Immediate resuscitation is crucial and should involve intravenous fluids and/or blood transfusion. This should be followed by a laparotomy. After the baby is delivered, the uterus should be repaired or a hysterectomy may be performed. The decision between these two management options depends on factors such as the site and extent of the rupture, as well as the mother’s condition, age, and parity.

    • This question is part of the following fields:

      • Obstetrics & Gynaecology
      15
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