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  • Question 1 - A 32 year old male presents to the emergency department complaining of sudden...

    Incorrect

    • A 32 year old male presents to the emergency department complaining of sudden shortness of breath. During the initial assessment, the patient mentions that he is currently 28 weeks into his partner's pregnancy. While the nurse is still conducting the assessment, the patient suddenly collapses and the nurse urgently calls for your assistance. The patient has no detectable pulse and is not making any effort to breathe. You decide to initiate cardiopulmonary resuscitation (CPR).

      What adjustments should be made to the management of cardiac arrest when performing CPR on a pregnant patient?

      Your Answer: Use chest compression: rescue breath ratio of 15:2

      Correct Answer: Hand position for chest compressions 2-3 cm higher

      Explanation:

      When administering CPR to a pregnant patient, it is important to make certain modifications. Firstly, the hand position for chest compressions should be adjusted to be 2-3 cm higher than usual. Additionally, the uterus should be manually displaced to the left in order to minimize compression on the inferior vena cava. If possible, a 15-30 degree left lateral tilt should be implemented. If resuscitation efforts do not result in the return of spontaneous circulation, it is advisable to seek urgent obstetric input for potential consideration of a C-section delivery. Lastly, when inserting an ET tube, it may be necessary to use a size that is 0.5-1.0mm smaller due to potential narrowing of the trachea caused by edema.

      Further Reading:

      Cardiopulmonary arrest is a serious event with low survival rates. In non-traumatic cardiac arrest, only about 20% of patients who arrest as an in-patient survive to hospital discharge, while the survival rate for out-of-hospital cardiac arrest is approximately 8%. The Resus Council BLS/AED Algorithm for 2015 recommends chest compressions at a rate of 100-120 per minute with a compression depth of 5-6 cm. The ratio of chest compressions to rescue breaths is 30:2.

      After a cardiac arrest, the goal of patient care is to minimize the impact of post cardiac arrest syndrome, which includes brain injury, myocardial dysfunction, the ischaemic/reperfusion response, and the underlying pathology that caused the arrest. The ABCDE approach is used for clinical assessment and general management. Intubation may be necessary if the airway cannot be maintained by simple measures or if it is immediately threatened. Controlled ventilation is aimed at maintaining oxygen saturation levels between 94-98% and normocarbia. Fluid status may be difficult to judge, but a target mean arterial pressure (MAP) between 65 and 100 mmHg is recommended. Inotropes may be administered to maintain blood pressure. Sedation should be adequate to gain control of ventilation, and short-acting sedating agents like propofol are preferred. Blood glucose levels should be maintained below 8 mmol/l. Pyrexia should be avoided, and there is some evidence for controlled mild hypothermia but no consensus on this.

      Post ROSC investigations may include a chest X-ray, ECG monitoring, serial potassium and lactate measurements, and other imaging modalities like ultrasonography, echocardiography, CTPA, and CT head, depending on availability and skills in the local department. Treatment should be directed towards the underlying cause, and PCI or thrombolysis may be considered for acute coronary syndrome or suspected pulmonary embolism, respectively.

      Patients who are comatose after ROSC without significant pre-arrest comorbidities should be transferred to the ICU for supportive care. Neurological outcome at 72 hours is the best prognostic indicator of outcome.

    • This question is part of the following fields:

      • Obstetrics & Gynaecology
      64.3
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  • Question 2 - 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
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  • Question 3 - 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
      16.3
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  • Question 4 - 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
      19.1
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  • Question 5 - A 25-year-old woman who is 32-weeks pregnant in her first pregnancy is brought...

    Incorrect

    • 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: Placenta praevia

      Correct 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
      19.5
      Seconds
  • Question 6 - A 32-year-old patient comes in with a complaint of excessive menstrual bleeding. The...

    Incorrect

    • 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: Myomectomy

      Correct 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
      22.9
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  • Question 7 - A 3 year old is brought to the emergency department due to concern...

    Incorrect

    • A 3 year old is brought to the emergency department due to concern that the patient has developed a fever, symptoms of a cold, and a widespread rash with blisters. You diagnose the child with chickenpox and advise the mother on how to manage the condition. The mother informs you that she is 12 weeks pregnant and is worried about the potential consequences of contracting chickenpox during pregnancy.

      What is the most significant complication of chickenpox infection for the mother during pregnancy?

      Your Answer: Myocarditis

      Correct Answer: Pneumonitis

      Explanation:

      Pregnant women who contract chickenpox for the first time are more likely to develop pneumonitis, a condition characterized by inflammation of the lungs. Additionally, these women face a five-fold increased risk of pneumonitis compared to non-pregnant individuals. Furthermore, the fetus is at risk of developing fetal varicella syndrome, a condition associated with chickenpox infection during pregnancy.

      Further Reading:

      Chickenpox exposure during pregnancy poses risks to both the mother and the fetus. The mother has a 5 times greater risk of developing pneumonitis, a potentially serious complication. The fetus is at risk of developing fetal varicella syndrome (FVS) if the maternal exposure occurs before 20 weeks gestation. The risk of FVS is around 1% in these cases and includes features such as skin scarring, eye defects, limb hypoplasia, microcephaly, and learning disabilities. There have been very few cases of FVS reported between 20-28 weeks gestation and none following 28 weeks.

      Other risks to the fetus include the development of shingles in infancy, which has a 1-2% risk if the maternal exposure occurs in the second or third trimester. There is also a risk of severe neonatal varicella if the mother develops a rash between 5 days before and 2 days after birth. This condition can be fatal to the newborn child in around 20% of cases.

      In the management of chickenpox exposure during pregnancy, it is important to determine if the mother is immune to varicella. If there is any doubt, maternal blood should be urgently checked for varicella antibodies. If the pregnant woman is not immune, she should be given varicella zoster immunoglobulin (VZIG) as soon as possible. VZIG is considered effective up to 10 days post-exposure. Consensus guidelines also recommend the use of oral aciclovir if the pregnant woman presents with chickenpox within 24 hours of the rash onset.

    • This question is part of the following fields:

      • Obstetrics & Gynaecology
      36.3
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  • Question 8 - A 28-year-old woman comes in with lower abdominal pain, painful urination, pain during...

    Incorrect

    • 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: Abnormal vaginal bleeding

      Correct 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
      8.5
      Seconds
  • Question 9 - A 28-year-old woman gives birth to a baby with microcephaly at 36-weeks gestation....

    Incorrect

    • A 28-year-old woman gives birth to a baby with microcephaly at 36-weeks gestation. She remembers experiencing a flu-like illness and skin rash early in the pregnancy after being bitten by a mosquito while visiting relatives in Brazil.

      What is the SINGLE most probable organism responsible for causing this birth defect?

      Your Answer: Dengue virus

      Correct Answer: Zika virus

      Explanation:

      The Zika virus is a newly emerging virus that is transmitted by mosquitoes. It was first discovered in humans in Uganda in 1952. Recently, there has been a significant outbreak of the virus in South America.

      When a person contracts the Zika virus, about 1 in 5 individuals will experience clinical illness, while the rest will show no symptoms at all. The most common symptoms of the virus include fever, rash, joint pain, and conjunctivitis. These symptoms typically last for no more than a week.

      While not completely conclusive, the evidence from the recent outbreak strongly suggests a connection between Zika virus infection and microcephaly.

    • This question is part of the following fields:

      • Obstetrics & Gynaecology
      20.5
      Seconds
  • Question 10 - A 28-year-old woman who is 30 weeks pregnant is experiencing breathlessness and is...

    Incorrect

    • 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: Normal anion gap metabolic acidosis

      Correct 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
      43.9
      Seconds

SESSION STATS - PERFORMANCE PER SPECIALTY

Obstetrics & Gynaecology (3/10) 30%
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