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  • Question 1 - A 25-year-old woman presents to the emergency department with severe and persistent nausea...

    Incorrect

    • A 25-year-old woman presents to the emergency department with severe and persistent nausea and vomiting. She is currently 8 weeks pregnant. She is struggling to keep anything down and has experienced some weight loss over the past couple of weeks. Her vital signs are as follows: heart rate 103 bpm, respiratory rate 14, blood pressure 113/70 mmHg. Upon examination, her abdomen is soft and nontender, and a urine dipstick reveals 3+ ketones.

      What is the MOST appropriate initial anti-emetic medication to be used in this case?

      Your Answer: Metoclopramide

      Correct Answer: Promethazine

      Explanation:

      Vomiting is a common occurrence during the early stages of pregnancy, typically happening between 7 and 12 weeks. However, there is a more severe condition called hyperemesis gravidarum, which involves uncontrollable and intense nausea and vomiting. This condition can lead to imbalances in fluids and electrolytes, significant ketonuria, malnutrition, and weight loss. It is relatively rare, affecting less than 1% of pregnancies.

      For mild cases of nausea and vomiting in early pregnancy, dietary adjustments and non-pharmacological methods like consuming ginger or using P6 wrist acupressure can often provide relief.

      In severe cases where heavy ketonuria and severe dehydration are present, hospital admission is usually necessary for intravenous fluid rehydration. The NICE Clinical Knowledge Summary (CKS) on nausea and vomiting in pregnancy recommends using oral promethazine, oral cyclizine, or oral prochlorperazine as the first-line treatment if an anti-emetic is needed. After 24 hours, the situation should be reassessed to determine if the initial treatment is effective. If not, a second-line drug like metoclopramide or ondansetron should be considered.

      It’s important to exercise caution when using metoclopramide in patients under the age of 20 due to the increased risk of extrapyramidal side effects. Additionally, proton pump inhibitors (e.g., omeprazole) and histamine H2-receptor antagonists (e.g., ranitidine) can be beneficial for women experiencing significant dyspepsia alongside their nausea and vomiting.

      For more information, refer to the NICE CKS on nausea and vomiting in pregnancy.

    • This question is part of the following fields:

      • Obstetrics & Gynaecology
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  • Question 2 - A 32-year-old woman with a previous history of salpingitis presents with excessive vaginal...

    Correct

    • A 32-year-old woman with a previous history of salpingitis presents with excessive vaginal bleeding. Her pregnancy test is positive, and a preliminary diagnosis of an ectopic pregnancy is made.

      What is the most frequent anatomical site for an ectopic pregnancy to occur?

      Your Answer: Ampulla of Fallopian tube

      Explanation:

      An ectopic pregnancy happens when the fertilized egg attaches itself outside of the uterus. In over 95% of cases, ectopic pregnancies occur in the Fallopian tubes. Although rare, they can also occur in other locations such as the abdomen, cervix, and ovary.

      The most common location for an ectopic pregnancy in the Fallopian tube is the ampulla, accounting for approximately 70% of cases. The isthmus and infundibulum each account for 10-15% of cases, while the uterine part only accounts for 2-5%.

    • This question is part of the following fields:

      • Obstetrics & Gynaecology
      45.9
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  • Question 3 - A 25-year-old woman comes to the emergency department with severe and continuous nausea...

    Correct

    • A 25-year-old woman comes to the emergency department with severe and continuous nausea and vomiting. She is currently 8 weeks pregnant. She is struggling to retain any food and has experienced slight weight loss over the past two weeks. Her vital signs are as follows: heart rate 103 beats per minute, respiratory rate 14 breaths per minute, blood pressure 113/70 mmHg. Her abdomen is soft and not tender, and a urine dipstick test shows 3+ ketones.
      What is the MOST likely diagnosis?

      Your Answer: Hyperemesis gravidarum

      Explanation:

      Vomiting is a common occurrence during the early stages of pregnancy, typically happening between 7 and 12 weeks. However, there is a more severe condition called hyperemesis gravidarum, which involves uncontrollable and intense nausea and vomiting. This condition can lead to imbalances in fluids and electrolytes, significant ketonuria, malnutrition, and weight loss. It is relatively rare, affecting less than 1% of pregnancies.

      For mild cases of nausea and vomiting in early pregnancy, dietary adjustments and non-pharmacological measures like consuming ginger or using P6 wrist acupressure can often provide relief.

      In severe cases where heavy ketonuria and severe dehydration are present, hospital admission is usually necessary for intravenous fluid rehydration. The NICE Clinical Knowledge Summary (CKS) on nausea and vomiting in pregnancy recommends using oral promethazine, oral cyclizine, or oral prochlorperazine as the first-line treatment if an antiemetic is needed. After 24 hours, the situation should be reassessed to determine if the initial treatment is effective. If not, a second-line drug like metoclopramide or ondansetron should be considered.

      It’s important to note that metoclopramide should not be used in patients under the age of 20 due to the increased risk of extrapyramidal side effects. Additionally, proton pump inhibitors (e.g., omeprazole) and histamine H2-receptor antagonists (e.g., ranitidine) can be beneficial for women experiencing significant dyspepsia alongside their nausea and vomiting.

      For more information, you can refer to the NICE CKS on nausea and vomiting in pregnancy.

    • This question is part of the following fields:

      • Obstetrics & Gynaecology
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  • Question 4 - 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
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  • Question 5 - A 30-year-old woman who is 10-weeks pregnant comes in with abdominal pain and...

    Correct

    • A 30-year-old woman who is 10-weeks pregnant comes in with abdominal pain and vaginal bleeding. During the examination, her cervix is found to be open. A local early pregnancy assessment unit (EPAU) performs an ultrasound scan. The scan is unable to detect a fetal heartbeat but does show the presence of retained products of conception.

      What is the SINGLE most probable diagnosis?

      Your Answer: Incomplete miscarriage

      Explanation:

      An incomplete miscarriage occurs when a miscarriage occurs, but the products of conception have not been fully expelled from the uterus. This commonly happens between weeks 8 and 14 of pregnancy.

      Symptoms of an incomplete miscarriage include pain and bleeding, and the cervix is usually open. A diagnosis can be confirmed through an ultrasound scan, which will show the absence of a fetal heartbeat and retained products.

      Treatment for an incomplete miscarriage can be done medically, such as using misoprostol, or surgically, like undergoing an ERPC procedure.

      There are potential complications that can arise from an incomplete miscarriage, including endometritis, myometritis, septic shock, and disseminated intravascular coagulation (DIC).

    • This question is part of the following fields:

      • Obstetrics & Gynaecology
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  • Question 6 - You evaluate a 58-year-old woman who presents with postmenopausal bleeding. She has been...

    Incorrect

    • 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: Arrange an urgent ultrasound scan and review with results

      Correct 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
      40.3
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  • Question 7 - You evaluate a 32-year-old woman who is 14-weeks pregnant. During the examination, you...

    Correct

    • You evaluate a 32-year-old woman who is 14-weeks pregnant. During the examination, you observe a soft early systolic murmur that is most audible at the left sternal edge. Apart from this finding, the patient appears to be in good health, and the rest of the examination was unremarkable.
      What is the SINGLE most probable diagnosis?

      Your Answer: Functional murmur

      Explanation:

      Functional murmurs, also referred to as physiological or flow murmurs, are frequently observed during pregnancy and other conditions associated with increased blood flow. These murmurs arise as a result of the heightened resting cardiac output and do not necessitate any additional examination.

    • This question is part of the following fields:

      • Obstetrics & Gynaecology
      30.6
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  • Question 8 - A 32-year-old woman arrives at the Emergency Department. She is 14 weeks pregnant...

    Incorrect

    • 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: Rhesus haemolytic disease

      Correct 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
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  • Question 9 - 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: IV cefuroxime 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
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  • Question 10 - A 52-year-old woman comes in with postmenopausal bleeding. Her medical records indicate that...

    Incorrect

    • 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: Cervical smear

      Correct 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
      28
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  • Question 11 - A 28-year-old primigravida woman comes in with a slight vaginal bleeding. She describes...

    Incorrect

    • A 28-year-old primigravida woman comes in with a slight vaginal bleeding. She describes the bleeding as lighter than her typical menstrual period. She is currently 9 weeks pregnant and her pregnancy test is positive. During the examination, her abdomen is soft and nontender, and the cervical os is closed.

      What is the SINGLE most probable diagnosis?

      Your Answer: Inevitable miscarriage

      Correct Answer: Threatened miscarriage

      Explanation:

      A threatened miscarriage is characterized by bleeding in the first trimester of pregnancy, but without the passing of any products of conception and with a closed cervical os. The main features of a threatened miscarriage include vaginal bleeding, often in the form of brown discharge or spotting, minimal abdominal pain, and a positive pregnancy test. It is important for stable patients who are more than 6 weeks pregnant and experiencing bleeding in early pregnancy, without any signs of an ectopic pregnancy, to seek follow-up care at an early pregnancy assessment unit (EPAU).

    • This question is part of the following fields:

      • Obstetrics & Gynaecology
      24.3
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  • Question 12 - A 28-year-old woman comes in with lower abdominal pain, painful sex, and a...

    Incorrect

    • A 28-year-old woman comes in with lower abdominal pain, painful sex, and a thick, yellowish 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 suitable initial test to perform?

      Your Answer: Diagnostic laparoscopy

      Correct Answer: Endocervical swab

      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
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  • Question 13 - A 45-year-old woman that is 42-weeks pregnant becomes suddenly very breathless shortly after...

    Incorrect

    • A 45-year-old woman that is 42-weeks pregnant becomes suddenly very breathless shortly after going into labor. An ambulance is called, and she is ‘blue lighted’ into the resus area of your Emergency Department. She appears cyanosed and states that her heart feels like it is ‘beating very quickly’. Shortly after arriving in the Emergency Department, she becomes unresponsive. You notice a change in rhythm to ventricular fibrillation on the cardiac monitor and are unable to detect a pulse or any signs of life. She receives three stacked shocks and is managed according to the ALS algorithm, but initial attempts at resuscitation are unsuccessful.
      Which of the following management options is most likely to improve his likelihood of successful resuscitation?

      Your Answer: Displacing the uterus to the right

      Correct Answer: Peri-mortem Caesarean section

      Explanation:

      Based on her presentation, the most probable cause of the cardiac arrest in this case is either a pulmonary embolism or amniotic fluid embolism.

      When dealing with a cardiac arrest during pregnancy, there are several adjustments that need to be made compared to a regular cardiac arrest situation. These adjustments include:

      – Ensuring the presence of an obstetrician
      – Having a paediatrician or neonatologist available
      – Manually displacing the uterus to the left in order to relieve caval compression
      – Tilting the table to the left side, ideally at a 15-30 degree angle
      – Performing early tracheal intubation to reduce the risk of aspiration (it is recommended to seek expert anaesthetic assistance for this)
      – Initiating preparations for an emergency Caesarean section

      In the event of a cardiac arrest, a perimortem Caesarean section should be performed within 5 minutes of the onset. This procedure is crucial as it relieves caval compression, improves the chances of successful resuscitation by increasing venous return during CPR, and maximizes the likelihood of the infant’s survival. The best survival rate for the infant occurs when delivery is achieved within 5 minutes of the mother’s cardiac arrest.

    • This question is part of the following fields:

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

    Incorrect

    • A 25-year-old woman is brought in by ambulance following a car accident where she was a passenger in a car hit by a truck at high speed. She is 32 weeks pregnant. Her vital signs are as follows: heart rate 120, blood pressure 98/62, oxygen saturation 97% on high-flow oxygen, respiratory rate 24, temperature 36.8°C. Her cervical spine is immobilized. The airway is clear, and her chest examination is normal. She has experienced a small amount of vaginal bleeding and is experiencing abdominal pain and tenderness. Two large IV needles have been inserted in her arm, and a complete set of blood tests have been sent to the laboratory, including a request for a blood type and cross-match. She has also had a small amount of vaginal bleeding and is complaining of abdominal pain. It is noted from her initial blood tests that she is rhesus D negative.
      Which of the following adjustments should be made during the initial assessment?

      Your Answer: Anti-D immunoglobulin should be administered

      Correct Answer: The mother should be log rolled to her left side at a 15-30-degree angle

      Explanation:

      During pregnancy, the vena cava can be compressed by the uterus, leading to a decrease in venous return to the heart. This can worsen the shock state in cases of trauma by reducing cardiac output. To alleviate pressure on the inferior vena cava, the ATLS guidelines recommend manually displacing the uterus to the left side during the primary survey.

      If spinal immobilization is necessary, the mother should be log rolled to her left side at a 15-30-degree angle, raising the right side by 10-15 cm. To maintain spinal motion restriction while decompressing the vena cava, a bolstering device like a Cardiff wedge should be used to support the mother.

      Pregnancy causes an increase in intravascular volume, which means that pregnant patients can lose a significant amount of blood before showing signs of hypovolemia such as tachycardia and hypotension. Despite stable vital signs, the placenta may not receive adequate perfusion, putting the fetus at risk. Therefore, it is crucial to initiate fluid resuscitation, starting with crystalloid fluids and then using type-specific blood if necessary. Vasopressors should only be used as a last resort to restore maternal blood pressure, as they can further reduce uterine blood flow and lead to fetal hypoxia.

      If the mother is rhesus D negative, anti-D immunoglobulin should be administered within 72 hours. However, this is not a priority during the primary survey.

    • This question is part of the following fields:

      • Obstetrics & Gynaecology
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  • Question 15 - A 35-year-old woman came in ten days ago with a fever, tenderness in...

    Incorrect

    • A 35-year-old woman came in ten days ago with a fever, tenderness in the suprapubic area, and discharge from the vagina. The doctors 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 SINGLE most probable diagnosis?

      Your Answer: Uterine perforation

      Correct Answer: Tubo-ovarian abscess

      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
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  • Question 16 - A 25-year-old woman is brought in by ambulance following a car accident where...

    Correct

    • A 25-year-old woman is brought in by ambulance following a car accident where she was a passenger in a car hit by a truck at high speed. She is 32 weeks pregnant. Her vital signs are as follows: HR 98, BP 120/80, SaO2 99% on high-flow oxygen, RR 20, temperature 36.8°C. Her cervical spine is triply immobilized. The airway is clear, and her chest examination is unremarkable. She has experienced a small amount of vaginal bleeding and is experiencing abdominal pain. On examination, the uterus is tender and there are frequent uterine contractions.
      What is the SINGLE most likely diagnosis?

      Your Answer: Abruptio placentae

      Explanation:

      The primary cause of fetal death in trauma during pregnancy is maternal shock and maternal death. The second most common cause of fetal death is placental abruption. Abruptio placentae can be identified by the following signs: vaginal bleeding (present in 70% of cases), uterine tenderness, frequent uterine contractions, uterine tetany, and uterine irritability. While uterine ultrasonography can be helpful in diagnosing abruptio placentae, it is not definitive. A CT scan may also show signs of abruptio placenta. It is important to note that abruption can occur even after minor injuries later in pregnancy.

      Uterine rupture is a much rarer occurrence but is a catastrophic event that leads to rapid maternal and fetal death without immediate surgical intervention. Signs that suggest uterine rupture include vaginal hemorrhage, abdominal tenderness, abdominal guarding and rigidity, rebound tenderness, profound shock, abnormal fetal lie (such as oblique or transverse lie), easy palpation of fetal parts due to their location outside the uterus, and difficulty in palpating the uterine fundus when there is a rupture.

      It is crucial to be aware of these signs and symptoms in order to promptly identify and address any potential complications during pregnancy.

    • This question is part of the following fields:

      • Obstetrics & Gynaecology
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  • Question 17 - A 28-year-old primigravida woman comes in with a moderate amount of vaginal bleeding...

    Incorrect

    • A 28-year-old primigravida woman comes in with a moderate amount of vaginal bleeding and lower abdominal discomfort. She reports the bleeding to be heavier than her normal period. She is currently 9 weeks pregnant. During the examination, she experiences mild tenderness in her lower abdomen. A speculum examination is conducted, revealing an open cervical os.

      What is the SINGLE most probable diagnosis?

      Your Answer: Missed miscarriage

      Correct Answer: Inevitable miscarriage

      Explanation:

      A threatened miscarriage happens when there is bleeding during the first trimester of pregnancy, but no fetal tissue has been expelled, and the opening of the cervix is closed.

      If cervical dilatation occurs, a threatened miscarriage can progress to become an inevitable miscarriage. In this case, the pain and bleeding are usually more intense, and upon examination, the cervix will be found to be open.

    • This question is part of the following fields:

      • Obstetrics & Gynaecology
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  • Question 18 - You assess a patient who has experienced a minor antepartum bleeding. You have...

    Incorrect

    • You assess a patient who has experienced a minor antepartum bleeding. You have a conversation with the obstetric team about the necessity of rhesus-D prophylaxis.
      Which ONE statement about anti-D is accurate?

      Your Answer: Anti-D is only given to RhD positive women

      Correct Answer: Routine antenatal prophylaxis is recommended for RhD negative women at 28 and 34 weeks

      Explanation:

      Anti-D is an antibody of the IgG class that targets the Rhesus D (RhD) antigen. It is specifically administered to women who are RhD negative, meaning they do not have the RhD antigen on their red blood cells. When a RhD negative woman is exposed to the blood of a RhD positive fetus, she may develop antibodies against RhD that can cross the placenta and attack the red blood cells of the fetus, leading to a condition called hemolytic disease of the newborn. Anti-D is given to bind to the fetal red blood cells in the mother’s circulation and neutralize them before an immune response is triggered.

      RhD should be administered in the event of a sensitizing event, which can include childbirth, antepartum hemorrhage, miscarriage, ectopic pregnancy, intrauterine death, amniocentesis, chorionic villus sampling, or abdominal trauma. It is important to administer Anti-D as soon as possible after a sensitizing event, but it can still provide some benefit even if given outside of the recommended 72-hour window, according to the British National Formulary (BNF).

      For RhD negative women, routine antenatal prophylaxis with Anti-D is recommended at 28 and 34 weeks of pregnancy, regardless of whether they have already received Anti-D earlier in the same pregnancy due to a sensitizing event.

      In cases of uncomplicated miscarriage before 12 weeks of gestation, confirmed by ultrasound, or mild and painless vaginal bleeding, prophylactic Anti-D is not necessary because the risk of feto-maternal hemorrhage is extremely low. However, in cases of therapeutic termination of pregnancy, whether through surgical or medical methods, confirmed RhD negative women who are not known to be sensitized to RhD should receive 250 IU of prophylactic Anti-D immunoglobulin.

    • This question is part of the following fields:

      • Obstetrics & Gynaecology
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  • Question 19 - A 72-year-old woman comes in with a dark reddish-brown vaginal discharge that has...

    Correct

    • A 72-year-old woman comes in with a dark reddish-brown vaginal discharge that has been ongoing for a couple of weeks. She has been on hormone replacement therapy (HRT) for the past ten years but does not take any other regular medications and is currently in good health.
      What is the MOST suitable initial investigation for this patient?

      Your Answer: Transvaginal ultrasound

      Explanation:

      Brown or reddish-brown discharge, which is commonly known as spotting, typically indicates the presence of blood in the fluid. It is important to approach any postmenopausal bleeding as a potential malignancy until proven otherwise.

      When investigating cases of postmenopausal bleeding, the first-line examination is a 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 significantly thinner compared to premenopausal women. The likelihood of endometrial cancer increases as the endometrium becomes thicker. In current practice in the UK, an endometrial thickness of 5 mm is considered the threshold.

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

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

    • This question is part of the following fields:

      • Obstetrics & Gynaecology
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  • Question 20 - 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
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  • Question 21 - A 25-year-old woman comes in with a slight vaginal bleeding and lower abdominal...

    Incorrect

    • 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: Incomplete miscarriage

      Correct 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
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  • Question 22 - A 30-year-old pregnant woman who has been receiving treatment for pre-eclampsia deteriorates and...

    Incorrect

    • A 30-year-old pregnant woman who has been receiving treatment for pre-eclampsia deteriorates and arrives at the Emergency Department. Upon evaluating the patient, you decide to admit her due to the development of HELLP syndrome.
      Which of the following is NOT an acknowledged complication of HELLP syndrome? Select ONE option.

      Your Answer: Placental abruption

      Correct Answer: Polycythaemia

      Explanation:

      HELLP syndrome is a condition that occurs in approximately 0.5% of pregnancies. It is characterized by haemolysis, elevated liver enzymes, and a low platelet count. While it typically occurs in the late third trimester, it has also been reported in the late second trimester. Around 33% of patients with HELLP syndrome will present shortly after giving birth.

      The initial symptoms of HELLP syndrome can be vague and include nausea, headaches, malaise, and pain in the upper right quadrant of the abdomen. Upon examination, raised blood pressure, proteinuria, and edema may be observed. Further investigations may reveal haemolysis on a blood film, elevated liver enzymes, low platelets, raised LDH, and raised bilirubin.

      Delivery of the baby is the main treatment for HELLP syndrome. However, complications can arise, such as disseminated intravascular coagulation (DIC), renal failure, liver failure, and pulmonary edema. It is crucial to tightly control blood pressure, and magnesium sulfate is often used to reduce the risk of progression to eclampsia. If DIC occurs, treatment with fresh frozen plasma is necessary.

      Without prompt recognition, approximately 25% of individuals with HELLP syndrome may experience severe complications, including placental abruption, liver failure, retinal detachment, and renal failure. With treatment, the mortality rate for the mother is around 1%, while the mortality rate for the baby ranges from 5-10%, depending on the gestational age at the time of delivery.

    • This question is part of the following fields:

      • Obstetrics & Gynaecology
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  • Question 23 - A 28-year-old woman who is 8-weeks pregnant is brought to the hospital due...

    Incorrect

    • A 28-year-old woman who is 8-weeks pregnant is brought to the hospital due to hyperemesis gravidarum.
      Which of the following is the LEAST probable complication associated with this condition?

      Your Answer: Mallory-Weiss tear

      Correct Answer: Hyperkalaemia

      Explanation:

      Vomiting is a common occurrence during the early stages of pregnancy, typically happening between 7 and 12 weeks. However, there is a more severe form called hyperemesis gravidarum, which affects less than 1% of pregnancies. This condition is characterized by uncontrollable and intense nausea and vomiting, leading to imbalances in fluids and electrolytes, significant ketonuria, nutritional deficiencies, and weight loss.

      Hyperemesis gravidarum can result in electrolyte imbalances, particularly hyponatremia and hypokalemia. However, it does not cause hyperkalemia. This persistent vomiting can also lead to other complications such as dehydration, acidosis, deficiencies in vitamins B1, B12, and B6, Mallory-Weiss tears, retinal hemorrhages, pneumothorax, prematurity, and small-for-gestational age babies.

    • This question is part of the following fields:

      • Obstetrics & Gynaecology
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  • Question 24 - You review a 62-year-old woman who presents with vaginal discharge. She has been...

    Correct

    • You review a 62-year-old woman who presents with vaginal discharge. She has been experiencing these symptoms for the past six weeks and describes the discharge as having a slight odor. The patient is not sexually active and has never had a similar discharge before. Additionally, she reports a single episode of visible blood in her urine one week ago but has not experienced any further episodes or discomfort while urinating.

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

      Your Answer: Organise a direct access ultrasound scan

      Explanation:

      According to the latest NICE guidance, it is recommended that women aged 55 and over with unexplained symptoms of vaginal discharge should undergo a direct access ultrasound scan to assess for endometrial cancer. This recommendation applies to women who are experiencing these symptoms for the first time or who have thrombocytosis, haematuria (blood in the urine), visible haematuria, low haemoglobin levels, or high blood glucose levels. For more information, please refer to the NICE referral guidelines on the recognition and referral of suspected cancer.

    • This question is part of the following fields:

      • Obstetrics & Gynaecology
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  • Question 25 - 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: Abdominal X-ray

      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
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  • Question 26 - A 32-year-old woman who is 38 weeks pregnant is brought to the Emergency...

    Incorrect

    • 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: The neonate’s survival should be prioritised over the mother’s

      Correct 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
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  • Question 27 - You evaluate a 45-year-old woman who presents with lower abdominal and pelvic pain....

    Incorrect

    • 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: Arrange an abdominal X-ray and review with results

      Correct 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
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  • Question 28 - You review a patient with Sheehan’s syndrome following a postpartum hemorrhage. She would...

    Incorrect

    • You review a patient with Sheehan’s syndrome following a postpartum hemorrhage. She would like to ask you some questions about her diagnosis.
      Which ONE statement about this condition is accurate?

      Your Answer: The risk is lower in multiple pregnancy

      Correct Answer: Diabetes insipidus may occur

      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. However, 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 not affected due to its own direct blood supply, there have been rare cases where it is involved. In these instances, central diabetes insipidus, a form of posterior pituitary dysfunction, can occur as a complication of Sheehan’s syndrome.

      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, loss of pubic and axillary hair, and the potential development of secondary hypothyroidism and adrenal insufficiency. Serum prolactin levels are typically low (less than 5ng/ml). An MRI can be helpful in ruling out other pituitary issues, such as a pituitary tumor.

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

    • This question is part of the following fields:

      • Obstetrics & Gynaecology
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  • Question 29 - A 32-year-old woman who is 39-weeks pregnant is brought to the Emergency Department...

    Incorrect

    • A 32-year-old woman who is 39-weeks pregnant is brought to the Emergency Department due to severe headaches, visual disturbances, and abdominal pain. Shortly after arrival, she experiences a seizure and collapses. Her husband mentions that she has been receiving treatment for hypertension during the pregnancy.

      What is the most suitable initial treatment in this case?

      Your Answer: IV phenobarbital

      Correct Answer: IV magnesium sulphate

      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
      53.7
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  • Question 30 - A 30-year-old pregnant woman who has been receiving treatment for pre-eclampsia deteriorates and...

    Incorrect

    • A 30-year-old pregnant woman who has been receiving treatment for pre-eclampsia deteriorates and arrives at the Emergency Department. Upon evaluating the patient, you decide to admit her due to the development of HELLP syndrome.
      Which of the following signs or symptoms would NOT raise suspicion of HELLP syndrome in a pregnant patient?

      Your Answer:

      Correct Answer: Symptoms occurring around 16 weeks gestation

      Explanation:

      HELLP syndrome is a condition that occurs in approximately 0.5% of pregnancies. It is characterized by haemolysis, elevated liver enzymes, and a low platelet count. While it typically occurs in the late third trimester, it has also been reported in the late second trimester. Around 33% of patients with HELLP syndrome will present shortly after giving birth.

      The initial symptoms of HELLP syndrome can be vague and include nausea, headaches, malaise, and pain in the upper right quadrant of the abdomen. Upon examination, raised blood pressure, proteinuria, and edema may be observed. Further investigations may reveal haemolysis on a blood film, elevated liver enzymes, low platelets, raised LDH, and raised bilirubin.

      Delivery of the baby is the main treatment for HELLP syndrome. However, complications can arise, such as disseminated intravascular coagulation (DIC), renal failure, liver failure, and pulmonary edema. It is crucial to tightly control blood pressure, and magnesium sulfate is often used to reduce the risk of progression to eclampsia. If DIC occurs, treatment with fresh frozen plasma is necessary.

      Without prompt recognition, approximately 25% of individuals with HELLP syndrome may experience severe complications, including placental abruption, liver failure, retinal detachment, and renal failure. With treatment, the mortality rate for the mother is around 1%, while the mortality rate for the baby ranges from 5-10%, depending on the gestational age at the time of delivery.

    • This question is part of the following fields:

      • Obstetrics & Gynaecology
      0
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Obstetrics & Gynaecology (11/29) 38%
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