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Question 1
Correct
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A 32-year-old pregnant woman at 14 weeks gestation presents with a three-week history of severe nausea and vomiting. During examination, her pulse is 110 beats/min and blood pressure is 110/80 mmHg. The patient is also experiencing ataxia and diplopia. Urinalysis shows an increased specific gravity and 3+ ketones. The diagnosis of hyperemesis gravidarum is made, and the patient responds well to fluid resuscitation with 0.9% saline. What other treatment options should be considered for this patient?
Your Answer: Intravenous vitamins B and C (Pabrinex)
Explanation:Hyperemesis gravidarum is a pregnancy complication that can lead to severe dehydration, metabolic imbalances, and deficiencies in essential vitamins and minerals. If left untreated, it can also cause Wernicke’s encephalopathy, as evidenced by the patient’s diplopia and ataxia. To address this, it is recommended to supplement with thiamine (Vitamin B1) and a complex of vitamins B and C, such as Pabrinex.
Hyperemesis gravidarum is an extreme form of nausea and vomiting of pregnancy that occurs in around 1% of pregnancies and is most common between 8 and 12 weeks. It is associated with raised beta hCG levels and can be caused by multiple pregnancies, trophoblastic disease, hyperthyroidism, nulliparity, and obesity. Referral criteria for nausea and vomiting in pregnancy include continued symptoms with ketonuria and/or weight loss, a confirmed or suspected comorbidity, and inability to keep down liquids or oral antiemetics. The diagnosis of hyperemesis gravidarum requires the presence of 5% pre-pregnancy weight loss, dehydration, and electrolyte imbalance. Management includes first-line use of antihistamines and oral cyclizine or promethazine, with second-line options of ondansetron and metoclopramide. Admission may be needed for IV hydration. Complications can include Wernicke’s encephalopathy, Mallory-Weiss tear, central pontine myelinolysis, acute tubular necrosis, and fetal growth issues.
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This question is part of the following fields:
- Obstetrics
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Question 2
Incorrect
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A 29-year-old female attends the antenatal clinic for a booking appointment. What should be recognized as a risk factor for pre-eclampsia?
Your Answer: Body mass index of 29 kg/m^2
Correct Answer: Pre-existing renal disease
Explanation:Identify the following as potential risk factors:
– Being 40 years old or older
– Never having given birth
– Having a pregnancy interval of over 10 years
– Having a family history of pre-eclampsia
– Having previously experienced pre-eclampsia
– Having a body mass index (BMI) of 30 kg/m^2 or higher
– Having pre-existing vascular disease, such as hypertension.Pre-eclampsia is a condition that occurs during pregnancy and is characterized by high blood pressure, proteinuria, and edema. It can lead to complications such as eclampsia, neurological issues, fetal growth problems, liver involvement, and cardiac failure. Severe pre-eclampsia is marked by hypertension, proteinuria, headache, visual disturbances, and other symptoms. Risk factors for pre-eclampsia include hypertension in a previous pregnancy, chronic kidney disease, autoimmune disease, diabetes, chronic hypertension, first pregnancy, and age over 40. Aspirin may be recommended for women with high or moderate risk factors. Treatment involves emergency assessment, admission for observation, and medication such as labetalol, nifedipine, or hydralazine. Delivery of the baby is the most important step in management, with timing depending on the individual case.
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This question is part of the following fields:
- Obstetrics
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Question 3
Correct
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A 24-year-old primigravida is brought to the Emergency Department by her husband at 33 weeks of gestation after experiencing a generalised tonic–clonic seizure. Examination reveals blood pressure of 160/90 mmHg, temperature of 37 °C and 2+ pitting oedema in the lower extremities. She appears lethargic but responds to simple commands. What is the definitive treatment for this patient's condition?
Your Answer: Immediate delivery
Explanation:Eclampsia: Symptoms and Treatment
Eclampsia is a serious medical condition that can occur during pregnancy, characterized by pre-eclampsia and seizure activity. Symptoms may include hypertension, proteinuria, mental status changes, and blurred vision. Immediate delivery is the only definitive treatment for eclampsia, but magnesium can be given to reduce the risk of seizures in women with severe pre-eclampsia who are delivering within 24 hours. Eclampsia is more common in younger women with their first pregnancy and those with underlying vascular disorders. Hydralazine can be used to manage hypertension in pregnant women, but it is not the definitive treatment for eclampsia. Conservative management, such as salt and water restriction, bed rest, and close monitoring of blood pressure, is not appropriate for patients with eclampsia and associated seizure and mental state changes. ACE inhibitors are contraindicated during pregnancy, and labetalol is the first-line antihypertensive in pregnancy. Diazepam and magnesium sulfate can reduce seizures in eclampsia, but they are not the definitive treatment.
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This question is part of the following fields:
- Obstetrics
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Question 4
Correct
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A 9-year-old girl presents with her daughter, who is two weeks old and was diagnosed a few days following birth with an anterior tongue tie. She is still struggling to establish enough feeding due to poor latch and a poor seal, even though she is alternating between breastfeeding and bottle feeding of expressed milk. She has been reviewed by the health visitor twice who is satisfied with her breastfeeding technique. The baby was over the 50th centile at birth and now has dropped to the 25th centile.
Given the above, what is the next most appropriate step in the management of this child?Your Answer: Refer for frenotomy under no anaesthesia
Explanation:Management of Tongue Tie in Infants: Referral for Frenotomy under No Anaesthesia
Tongue tie is a congenital condition that affects a baby’s ability to move their tongue due to a thickened frenulum. This can cause problems with breastfeeding and bottle feeding, leading to poor weight gain and irritability. In severe cases, a referral for frenotomy is necessary. In infants under three months of age, the procedure can be performed without anaesthesia, though local anaesthesia may be used. Conservative management and support with breastfeeding should be attempted first, but if unsuccessful, a frenotomy should be performed as early as possible to give the baby and mother the best chance at successful feeding. Frenotomy under general anaesthesia is only necessary for infants over three months of age. Converting to bottle feeding is not a solution in severe cases of tongue tie.
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This question is part of the following fields:
- Obstetrics
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Question 5
Correct
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A 29-year-old woman who is 36 weeks pregnant arrives at the Emergency Department with a complaint of her 'waters breaking'. She reports experiencing a sudden release of clear fluid from her vagina, which has now reduced to a trickle, and she feels some pressure in her pelvis. What is the most suitable test to conduct next?
Your Answer: Speculum examination
Explanation:The initial investigation for preterm prelabour rupture of the membranes is a thorough speculum examination to check for the accumulation of amniotic fluid in the posterior vaginal vault. It is recommended to avoid bimanual examination to minimize the risk of infection. While cardiotocography can be used to assess foetal wellbeing, it is not the preferred first-line investigation. Foetal blood sampling is not the recommended initial investigation due to the potential risks of infection and miscarriage.
Preterm prelabour rupture of the membranes (PPROM) is a condition that occurs in approximately 2% of pregnancies, but it is responsible for around 40% of preterm deliveries. This condition can lead to various complications, including prematurity, infection, and pulmonary hypoplasia in the fetus, as well as chorioamnionitis in the mother. To confirm PPROM, a sterile speculum examination should be performed to check for pooling of amniotic fluid in the posterior vaginal vault. However, digital examination should be avoided due to the risk of infection. If pooling of fluid is not observed, testing the fluid for placental alpha microglobulin-1 protein (PAMG-1) or insulin-like growth factor binding protein-1 is recommended. Ultrasound may also be useful to show oligohydramnios.
The management of PPROM involves admission and regular observations to ensure that chorioamnionitis is not developing. Oral erythromycin should be given for ten days, and antenatal corticosteroids should be administered to reduce the risk of respiratory distress syndrome. Delivery should be considered at 34 weeks of gestation, but there is a trade-off between an increased risk of maternal chorioamnionitis and a decreased risk of respiratory distress syndrome as the pregnancy progresses. PPROM is a serious condition that requires prompt diagnosis and management to minimize the risk of complications for both the mother and the fetus.
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This question is part of the following fields:
- Obstetrics
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Question 6
Incorrect
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A 27-year-old woman gives birth vaginally to a healthy baby girl after a normal pregnancy. What is a third-degree tear of the perineum?
Your Answer: Injury to the perineal muscles but not the anal sphincter
Correct Answer: Injury to the perineum involving the anal sphincter complex
Explanation:Perineal tears are a common occurrence during childbirth, and the Royal College of Obstetricians and Gynaecologists (RCOG) has developed guidelines to classify them based on their severity. First-degree tears are superficial and do not require any repair, while second-degree tears involve the perineal muscle and require suturing by a midwife or clinician. Third-degree tears involve the anal sphincter complex and require repair in theatre by a trained clinician, with subcategories based on the extent of the tear. Fourth-degree tears involve the anal sphincter complex and rectal mucosa and also require repair in theatre by a trained clinician.
There are several risk factors for perineal tears, including being a first-time mother, having a large baby, experiencing a precipitate labour, and having a shoulder dystocia or forceps delivery. It is important for healthcare providers to be aware of these risk factors and to provide appropriate care and management during childbirth to minimize the risk of perineal tears. By following the RCOG guidelines and providing timely and effective treatment, healthcare providers can help ensure the best possible outcomes for both mother and baby.
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This question is part of the following fields:
- Obstetrics
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Question 7
Correct
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A 25-year-old primigravida woman at 36 weeks gestation comes in with mild irregular labor pains in the lower abdomen. Upon examination, her cervix is firm, posterior, and closed, and fetal heart tones are present. However, the pain subsides during the consultation. What would be the most suitable course of action?
Your Answer: Reassure and discharge
Explanation:False labor typically happens during the final month of pregnancy. It is characterized by contractions felt in the lower abdomen that are irregular and spaced out every 20 minutes. However, there are no progressive changes in the cervix.
Labour is divided into three stages, with the first stage beginning from the onset of true labour until the cervix is fully dilated. This stage is further divided into two phases: the latent phase and the active phase. The latent phase involves dilation of the cervix from 0-3 cm and typically lasts around 6 hours. The active phase involves dilation from 3-10 cm and progresses at a rate of approximately 1 cm per hour. In primigravidas, this stage can last between 10-16 hours.
During this stage, the baby’s presentation is important to note. Approximately 90% of babies present in the vertex position, with the head entering the pelvis in an occipito-lateral position. The head typically delivers in an occipito-anterior position.
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This question is part of the following fields:
- Obstetrics
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Question 8
Correct
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A 25-year-old primiparous patient is seen at home by the community midwife for a routine antenatal visit. She is 34 weeks pregnant and has had an uneventful pregnancy to date. On examination, she is well and has a symphysis fundal height of 33 cm. Her blood pressure is 155/92 mmHg and she has 2++ protein in the urine.
What is the most likely diagnosis?Your Answer: Pre-eclampsia
Explanation:Understanding Hypertension in Pregnancy
Hypertension in pregnancy can be a serious condition that requires urgent assessment and management. Pre-eclampsia, characterized by both hypertension and proteinuria, is a common diagnosis. Early detection and management can prevent complications.
Normal blood pressure during pregnancy typically drops slightly in the first and second trimesters and rises back to pre-pregnancy levels in the third trimester. However, some patients may have chronic hypertension that was previously undiagnosed.
White-coat hypertension, where blood pressure is elevated in a clinical setting but normal at home, should be ruled out before a diagnosis of pregnancy-induced hypertension is made. This type of hypertension occurs after week 20 of pregnancy but without proteinuria. Regular screening for proteinuria is necessary in these cases.
In cases of mild to moderate hypertension, patients may be admitted to the hospital and monitored or started on oral labetalol. Severe hypertension requires immediate hospitalization and treatment. Overall, understanding hypertension in pregnancy is crucial for the health and well-being of both the mother and baby.
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This question is part of the following fields:
- Obstetrics
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Question 9
Incorrect
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A 28-year-old patient presents to the Emergency Department with fresh red vaginal bleeding and lower abdominal pain.
The patient is at 36 weeks gestation and gravida 3, para 2. She is rhesus positive and a current smoker. Access to her current maternity notes is unavailable. She tells you she has pre-eclampsia for which she takes labetalol.
Maternal observations are normal and there are no concerns with foetal movements. A cardiotocograph (CTG) demonstrates that the foetal heart rate is 140 beats/min, variability is 15 beats/min, accelerations are present and there are no decelerations noted.
On examination, the uterus is hard and tender to palpation. The doctor suspects that the foetus may be in a transverse lie. The patient's pad is partially soaked but there is no active bleeding noted on a quick inspection.
What would the most appropriate first course of action be in this scenario?Your Answer: Administer anti-D antibodies and perform a Kleihauer test
Correct Answer: Administer corticosteroids and arrange admission to the ward
Explanation:When a pregnant patient presents with painful bleeding and a hard, tender uterus, it may indicate placental abruption. In this case, the patient has risk factors such as being a smoker, having pre-eclampsia, and a transverse lie. The management of placental abruption depends on the gestation, maternal condition, and fetal condition. In this scenario, the patient is stable, at 34 weeks gestation, and the fetus is not showing signs of distress. Therefore, the appropriate plan is to admit the patient and administer steroids for observation.
Administering anti-D and performing a Kleihauer test is unnecessary as the patient is already known to be rhesus positive. Induction of labor is not indicated as the fetus has not matured to term. Emergency caesarean section would only be necessary if fetal distress was present. Performing a sterile speculum examination is not appropriate as it could cause or worsen hemorrhage, especially if the patient has placenta previa. The best course of action is to admit the patient to the ward until access to notes becomes available or an ultrasound is performed.
Placental Abruption: Causes, Management, and Complications
Placental abruption is a condition where the placenta separates from the uterine wall, leading to maternal haemorrhage. The severity of the condition depends on the extent of the separation and the gestational age of the fetus. Management of placental abruption is crucial to prevent maternal and fetal complications.
If the fetus is alive and less than 36 weeks, immediate caesarean delivery is recommended if there is fetal distress. If there is no fetal distress, close observation, administration of steroids, and no tocolysis are recommended. The decision to deliver depends on the gestational age of the fetus. If the fetus is alive and more than 36 weeks, immediate caesarean delivery is recommended if there is fetal distress. If there is no fetal distress, vaginal delivery is recommended. If the fetus is dead, vaginal delivery should be induced.
Placental abruption can lead to various maternal complications, including shock, disseminated intravascular coagulation (DIC), renal failure, and postpartum haemorrhage (PPH). Fetal complications include intrauterine growth restriction (IUGR), hypoxia, and death. The condition is associated with a high perinatal mortality rate and is responsible for 15% of perinatal deaths.
In conclusion, placental abruption is a serious condition that requires prompt management to prevent maternal and fetal complications. Close monitoring and timely intervention can improve the prognosis for both the mother and the baby.
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This question is part of the following fields:
- Obstetrics
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Question 10
Incorrect
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A 32-year-old woman who is at 16 weeks gestation attends her antenatal appointment and is given the option to undergo the quadruple test for chromosomal disorders. After consenting, she has a blood test and is later informed that the results indicate a higher likelihood of Down's syndrome in the fetus. The patient is now invited to discuss the next course of action. What is the probable outcome of the quadruple test?
Your Answer: Increased AFP, increased oestriol, increased hCG, increased inhibin A
Correct Answer: Decreased AFP, decreased oestriol, increased hCG, increased inhibin A
Explanation:The correct result for the quadruple test in a patient with Down’s syndrome is a decrease in AFP and oestriol, and an increase in hCG and inhibin A. This test is recommended by NICE for pregnant patients between 15-20 weeks gestation. If the screening test shows an increased risk, further diagnostic tests such as NIPT, amniocentesis, or chorionic villous sampling may be offered to confirm the diagnosis. It is important to note that a pattern of decreased AFP, decreased oestriol, decreased hCG, and normal inhibin A is suggestive of an increased risk of Edward’s syndrome. Increased AFP, increased oestriol, decreased hCG, and decreased inhibin A or any other combination of abnormal results may not be indicative of Down’s syndrome.
NICE updated guidelines on antenatal care in 2021, recommending the combined test for screening for Down’s syndrome between 11-13+6 weeks. The test includes nuchal translucency measurement, serum B-HCG, and pregnancy-associated plasma protein A (PAPP-A). The quadruple test is offered between 15-20 weeks for women who book later in pregnancy. Results are interpreted as either a ‘lower chance’ or ‘higher chance’ of chromosomal abnormalities. If a woman receives a ‘higher chance’ result, she may be offered a non-invasive prenatal screening test (NIPT) or a diagnostic test. NIPT analyzes cell-free fetal DNA in the mother’s blood and has high sensitivity and specificity for detecting chromosomal abnormalities. Private companies offer NIPT screening from 10 weeks gestation.
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This question is part of the following fields:
- Obstetrics
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Question 11
Incorrect
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A 26-year-old woman presents to the Emergency Department with minimal vaginal bleeding. She reports her last menstrual period as having been 4 weeks ago. She denies pain but reports severe nausea and vomiting. She has no significant past medical history and her last check-up 6 months ago did not reveal any abnormalities. On examination, her blood pressure is 160/110 mmHg and her uterus measures 12 weeks’ size. A serum beta human chorionic gonadotropin (β-HCG) level is drawn and found to be in excess of 300 000 iu. An ultrasound does not identify any foetal parts. What is this patient at risk of developing?
Your Answer: Rupture of the fallopian tube
Correct Answer: Pulmonary metastasis and thyroid dysfunction
Explanation:Diagnosing Gestational Trophoblastic Disease: Differential Diagnosis
Gestational trophoblastic disease is a rare condition that can present with symptoms similar to other pregnancy-related complications. When evaluating a patient with suspected gestational trophoblastic disease, it is important to consider the differential diagnosis and rule out other potential causes.
One common misdiagnosis is occlusion of the coronary vessels, as there is no association between gestational trophoblastic disease and coronary artery disease. Rupture of the fallopian tube may be a possibility if the patient had an ectopic pregnancy, but the history and examination are not suggestive of this. Septic miscarriage is also a possibility, but the symptoms and examination findings in this scenario are more typical of gestational trophoblastic disease.
Twin or triplet pregnancy is unlikely due to the absence of foetal parts and the elevated blood pressure. Instead, gestational trophoblastic disease should be considered when a patient presents with bleeding in early pregnancy, severe hyperemesis, new-onset hypertension prior to 20 weeks’ gestation, and a uterus that is larger than expected. An extremely elevated β-HCG and a classical ultrasound appearance resembling a ‘snow storm’ are also indicative of gestational trophoblastic disease.
It is important to note that gestational trophoblastic disease is strongly associated with thyroid dysfunction and that the lungs are among the first sites of metastatic disease. By considering the differential diagnosis and conducting appropriate testing, healthcare providers can accurately diagnose and treat gestational trophoblastic disease.
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This question is part of the following fields:
- Obstetrics
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Question 12
Correct
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A 32-year-old woman who is at 10 weeks’ gestation in her second pregnancy sees her midwife to receive her Booking Clinic blood results. She feels a bit tired at present and appears pale. She denies any infective symptoms, and observations and examination are unremarkable.
Her full blood count is as follows:
Investigation Result Normal value
Haemoglobin 101 g/l 115–155 g/l
Mean corpuscular volume (MCV) 73 fl 76–98 fl
White cell count (WCC) 7 × 109/l 4–11 × 109/l
Platelets 323 × 109/l 150–400 × 109/l
Which of the following statements best describes the management of anaemia in pregnancy?Your Answer: A trial of iron supplementation, followed by a re-check of the full blood count at two weeks, is the standard method for treating anaemia in pregnancy
Explanation:The standard method for treating anaemia in pregnancy is to conduct a full blood count at the booking appointment and at 28 weeks, or when the patient is symptomatic, and to initiate treatment if a normocytic or microcytic anaemia is detected. Iron deficiency is the most common cause of anaemia in pregnancy, and oral iron supplementation is the first-line treatment. A repeat full blood count should be performed two weeks after starting iron supplementation, and if there is an upward trend in haemoglobin levels, iron supplementation should continue. If the trial fails to increase haemoglobin levels, further investigations should be conducted, and referral to a Combined Obstetric/Haematologic Clinic may be necessary. Serum ferritin is the most specific test for iron deficiency anaemia, and a value of < 30 μg/l in pregnancy should prompt iron supplementation. All pregnant women in the UK are not recommended to be offered iron supplementation, but only those with anaemia. Anaemia is defined as a haemoglobin level of < 110 g/dl in the first trimester and < 105 g/l in the second trimester. In an uncomplicated, low-risk pregnancy, the full blood count is assessed twice, at the booking visit and at 28 weeks of gestation. Postpartum anaemia is defined as a haemoglobin level of < 100 g/l, and oral iron supplementation for three months is recommended to replenish iron stores. Ferrous sulfate and ferrous fumarate are commonly used oral preparations of iron.
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This question is part of the following fields:
- Obstetrics
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Question 13
Correct
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A 35-year-old woman visits the GP clinic complaining of nausea and vomiting. She is currently 8 weeks pregnant and it is her first pregnancy. She desires an antiemetic to use during the first trimester so she can continue working. She is not experiencing dehydration, has no ketonuria, and can retain fluids. She has no previous medical conditions. What is the best course of action for her management?
Your Answer: Prescribe promethazine
Explanation:Promethazine is the appropriate medication to prescribe for nausea and vomiting in pregnancy, as it is a first-line antiemetic. Metoclopramide should be avoided due to the risk of extrapyramidal effects if used for more than 5 days. While alternative methods such as ginger and acupressure bands may be discussed, as the patient has requested medication, it is appropriate to prescribe promethazine. It is also important to support the patient’s decision to continue working if that is her preference.
Hyperemesis gravidarum is an extreme form of nausea and vomiting of pregnancy that occurs in around 1% of pregnancies and is most common between 8 and 12 weeks. It is associated with raised beta hCG levels and can be caused by multiple pregnancies, trophoblastic disease, hyperthyroidism, nulliparity, and obesity. Referral criteria for nausea and vomiting in pregnancy include continued symptoms with ketonuria and/or weight loss, a confirmed or suspected comorbidity, and inability to keep down liquids or oral antiemetics. The diagnosis of hyperemesis gravidarum requires the presence of 5% pre-pregnancy weight loss, dehydration, and electrolyte imbalance. Management includes first-line use of antihistamines and oral cyclizine or promethazine, with second-line options of ondansetron and metoclopramide. Admission may be needed for IV hydration. Complications can include Wernicke’s encephalopathy, Mallory-Weiss tear, central pontine myelinolysis, acute tubular necrosis, and fetal growth issues.
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This question is part of the following fields:
- Obstetrics
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Question 14
Incorrect
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A 25-year-old patient who is 20 weeks pregnant visits your GP clinic with worries about a high reading on a blood pressure machine at home. She has no medical history and is not experiencing any symptoms. During the clinic visit, her blood pressure is measured at 160/110 mmHg and there is no indication of proteinuria on urine dipstick testing. What is the best course of action for management?
Your Answer: Start labetalol and aspirin and assess again in 7 days time
Correct Answer: Arrange obstetric assessment immediately with likely admission to hospital
Explanation:All pregnant women who develop hypertension (systolic blood pressure over 140 mmHg or diastolic blood pressure over 90 mmHg) after 20 weeks of pregnancy should receive a secondary care assessment by a healthcare professional trained in managing hypertensive disorders of pregnancy. It is not recommended to delay this assessment by monitoring blood pressure over several days or providing lifestyle advice alone. The obstetric department may initiate antihypertensive medication and aspirin for the patient, but those with a blood pressure of 160/110 or higher are likely to be admitted for further monitoring and treatment.
Pre-eclampsia is a condition that occurs during pregnancy and is characterized by high blood pressure, proteinuria, and edema. It can lead to complications such as eclampsia, neurological issues, fetal growth problems, liver involvement, and cardiac failure. Severe pre-eclampsia is marked by hypertension, proteinuria, headache, visual disturbances, and other symptoms. Risk factors for pre-eclampsia include hypertension in a previous pregnancy, chronic kidney disease, autoimmune disease, diabetes, chronic hypertension, first pregnancy, and age over 40. Aspirin may be recommended for women with high or moderate risk factors. Treatment involves emergency assessment, admission for observation, and medication such as labetalol, nifedipine, or hydralazine. Delivery of the baby is the most important step in management, with timing depending on the individual case.
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This question is part of the following fields:
- Obstetrics
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Question 15
Correct
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A 35-year-old woman who is 32 weeks pregnant presents with a two-week history of pruritus on her hands and feet without any visible rash. The symptoms are more severe at night and she has elevated liver function tests, with a bile acid level of 106 mmol/l. The obstetrician discusses with the patient about the possibility of induction of labour (IOL) after which week of gestation?
Your Answer: 37 weeks
Explanation:Obstetric cholestasis, which is indicated by the symptoms and blood results in a pregnant woman in the third trimester, increases the risk of stillbirth. Therefore, it is generally recommended to induce labour at 37-38 weeks gestation to minimize this risk. However, induction of labour should only be considered if there are significantly abnormal liver function tests or bile acid levels. It is not recommended before 37 weeks gestation. Women should be informed that the need for intervention may be stronger in those with more severe biochemical abnormalities.
Intrahepatic Cholestasis of Pregnancy: Symptoms and Management
Intrahepatic cholestasis of pregnancy, also known as obstetric cholestasis, is a condition that affects approximately 1% of pregnancies in the UK. It is characterized by intense itching, particularly on the palms, soles, and abdomen, and may also result in clinically detectable jaundice in around 20% of patients. Raised bilirubin levels are seen in over 90% of cases.
The management of intrahepatic cholestasis of pregnancy typically involves induction of labor at 37-38 weeks, although this practice may not be evidence-based. Ursodeoxycholic acid is also widely used, although the evidence base for its effectiveness is not clear. Additionally, vitamin K supplementation may be recommended.
It is important to note that the recurrence rate of intrahepatic cholestasis of pregnancy in subsequent pregnancies is high, ranging from 45-90%. Therefore, close monitoring and management are necessary for women who have experienced this condition in the past.
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This question is part of the following fields:
- Obstetrics
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Question 16
Incorrect
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A 35-year-old woman who is 28 weeks pregnant is brought to the maternity ward due to excessive vaginal bleeding. She has a negative Rhesus factor. What is the best course of action for preventing Rhesus sensitization?
Your Answer: Routine Anti-D immunoglobulin prophylaxis at 28 weeks
Correct Answer: One dose of Anti-D immunoglobulin followed by a Kleihauer test
Explanation:What is the recommended prophylaxis for Rhesus sensitisation in a Rhesus negative mother with antepartum haemorrhage?
Antepartum haemorrhage increases the risk of Rhesus sensitisation and Rhesus disease of the newborn in subsequent pregnancies due to fetomaternal haemorrhage (FMH). The correct approach is to administer one dose of anti-D immunoglobulin immediately, followed by a Kleihauer test. This test detects fetal cells in the maternal circulation and estimates the volume of FMH, allowing for the calculation of additional anti-D immunoglobulin. While routine prophylaxis at 28 weeks should still be given, there is no such thing as an anti-D immunoglobulin infusion. These recommendations are based on the British Committee for Standards in Haematology guidelines for the prevention of haemolytic disease of the fetus and newborn.
Rhesus negative pregnancies can lead to the formation of anti-D IgG antibodies in the mother if she delivers a Rh +ve child, which can cause haemolysis in future pregnancies. Prevention involves testing for D antibodies and giving anti-D prophylaxis to non-sensitised Rh -ve mothers at 28 and 34 weeks. Anti-D immunoglobulin should be given within 72 hours in various situations. Tests should be done on all babies born to Rh -ve mothers, and affected fetuses may experience various complications and require treatment such as transfusions and UV phototherapy.
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This question is part of the following fields:
- Obstetrics
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Question 17
Incorrect
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A 28-year-old woman with a history of back pain uses paracetamol and ibuprofen regularly for pain relief. She and her partner are planning to have a baby, and would like to know about the safety of analgesics during pregnancy.
What is the best statement regarding the safety of analgesics in pregnancy?Your Answer: Paracetamol can be used as it does not cross the placenta
Correct Answer: Codeine phosphate can be used at low doses if needed
Explanation:Safe and Unsafe Painkillers in Pregnancy
Pregnancy can be a challenging time for women, especially when it comes to managing pain. While some painkillers are safe to use during pregnancy, others can have harmful effects on the developing fetus. Here is a breakdown of some commonly used painkillers and their safety in pregnancy.
Codeine phosphate: Low doses of codeine phosphate are generally safe to use during pregnancy. However, if taken closer to delivery, the neonate should be observed for signs of respiratory depression, drowsiness, or opioid withdrawal.
Naproxen: Naproxen belongs to the family of NSAIDs and is contraindicated in pregnancy. However, it is safe to use in the postpartum period and by women who are breastfeeding.
Ibuprofen: Ibuprofen and other NSAIDs should be avoided during pregnancy as they are associated with teratogenic effects and other congenital problems.
Paracetamol: Paracetamol is the analgesic of choice in pregnancy and is safe to use within the recommended limits. However, patients should be cautioned against taking paracetamol and low-dose co-codamol concurrently.
Tramadol: Tramadol should be avoided in pregnancy as it has been shown to be embryotoxic in animal models.
In conclusion, it is important for pregnant women to consult with their healthcare provider before taking any painkillers to ensure the safety of both mother and fetus.
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This question is part of the following fields:
- Obstetrics
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Question 18
Correct
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A 26-year-old female student presents to the Emergency Department with severe abdominal pain that started suddenly while she was shopping 3 hours ago. She reports not having her periods for 8 weeks and being sexually active. She also has a history of pelvic inflammatory disease 4 years ago. On examination, there is generalised guarding and signs of peritonism. An urgent ultrasound scan reveals free fluid in the pouch of Douglas with an empty uterine cavity, and a positive urine βhCG. Basic bloods are sent. Suddenly, her condition deteriorates, and her vital signs are BP 85/50 mmHg, HR 122/min, RR 20/min, and O2 saturation 94%.
What is the most appropriate next step?Your Answer: Resuscitate and arrange for emergency laparotomy
Explanation:There is a strong indication of a ruptured ectopic pregnancy based on the clinical presentation. The patient’s condition has deteriorated significantly, with symptoms of shock and a systolic blood pressure below 90 mmHg. Due to her unstable cardiovascular state, urgent consideration must be given to performing an emergency laparotomy.
Understanding Ectopic Pregnancy
Ectopic pregnancy occurs when a fertilized egg implants outside the uterus. This condition is characterized by lower abdominal pain and vaginal bleeding, typically occurring 6-8 weeks after the start of the last period. The pain is usually constant and may be felt on one side of the abdomen due to tubal spasm. Vaginal bleeding is usually less than a normal period and may be dark brown in color. Other symptoms may include shoulder tip pain, pain on defecation/urination, dizziness, fainting, or syncope. Breast tenderness may also be reported.
During examination, abdominal tenderness and cervical excitation may be observed. However, it is not recommended to examine for an adnexal mass due to the risk of rupturing the pregnancy. Instead, a pelvic examination to check for cervical excitation is recommended. In cases of pregnancy of unknown location, serum bHCG levels >1,500 may indicate an ectopic pregnancy. It is important to seek medical attention immediately if ectopic pregnancy is suspected as it can be life-threatening.
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This question is part of the following fields:
- Obstetrics
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Question 19
Correct
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A 24-year-old woman presents to the labour suite after being admitted 45 minutes ago. She is unsure of her gestational age but believes she is around 8 months pregnant based on her positive pregnancy test. She has not received any antenatal care and is currently homeless due to a violent relationship. The patient has been experiencing contractions for the past 3 hours and her waters broke 5 hours ago. Upon examination, her cervix is soft, anterior, 90% effaced, and dilated to 7 cm. The foetus is in a breech position with the presenting part at station 0 and engaged. What is the most appropriate course of action?
Your Answer: Arrange caesarean section within 75 minutes
Explanation:A category 2 caesarean section is the best management for a woman with an undiagnosed breech birth in labour who is not fully dilated. The decision to perform the caesarean section should be made within 75 minutes and the procedure should be arranged accordingly. Adopting an all-fours position or attempting external cephalic version with enhanced monitoring are not appropriate in this case. McRoberts manoeuvre is also not the correct management for breech birth.
Caesarean Section: Types, Indications, and Risks
Caesarean section, also known as C-section, is a surgical procedure that involves delivering a baby through an incision in the mother’s abdomen and uterus. In recent years, the rate of C-section has increased significantly due to an increased fear of litigation. There are two main types of C-section: lower segment C-section, which comprises 99% of cases, and classic C-section, which involves a longitudinal incision in the upper segment of the uterus.
C-section may be indicated for various reasons, including absolute cephalopelvic disproportion, placenta praevia grades 3/4, pre-eclampsia, post-maturity, IUGR, fetal distress in labor/prolapsed cord, failure of labor to progress, malpresentations, placental abruption, vaginal infection, and cervical cancer. The urgency of C-section may be categorized into four categories, with Category 1 being the most urgent and Category 4 being elective.
It is important for clinicians to inform women of the serious and frequent risks associated with C-section, including emergency hysterectomy, need for further surgery, admission to intensive care unit, thromboembolic disease, bladder injury, ureteric injury, and death. C-section may also increase the risk of uterine rupture, antepartum stillbirth, placenta praevia, and placenta accreta in subsequent pregnancies. Other complications may include persistent wound and abdominal discomfort, increased risk of repeat C-section, readmission to hospital, haemorrhage, infection, and fetal lacerations.
Vaginal birth after C-section (VBAC) may be an appropriate method of delivery for pregnant women with a single previous C-section delivery, except for those with previous uterine rupture or classical C-section scar. The success rate of VBAC is around 70-75%.
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This question is part of the following fields:
- Obstetrics
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Question 20
Incorrect
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You are observing an antenatal clinic and your next patient is a 26-year-old woman who is 16 weeks pregnant with her first child. Take a brief history of this patient.
The patient has a past medical history of coeliac disease and hypothyroidism. She takes no regular medications and has no known drug allergies. Her family history is relevant for her father has type 1 diabetes. She has never smoked and since pregnancy, has stopped drinking alcohol.
What additional tests, if any, should be arranged for this patient based on her medical history?Your Answer: Oral glucose tolerance test at 18-22 weeks
Correct Answer: Oral glucose tolerance test at 24-28 weeks
Explanation:Pregnant women with a first-degree relative with diabetes should be screened for gestational diabetes with an OGTT at 24-28 weeks. No further tests are required, but thyroid function tests should be done in each trimester for those with an existing diagnosis of hypothyroidism. OGTT should not be done at 18-22 weeks.
Gestational diabetes is a common medical disorder affecting around 4% of pregnancies. Risk factors include a high BMI, previous gestational diabetes, and family history of diabetes. Screening is done through an oral glucose tolerance test, and diagnostic thresholds have recently been updated. Management includes self-monitoring of blood glucose, diet and exercise advice, and medication if necessary. For pre-existing diabetes, weight loss and insulin are recommended, and tight glycemic control is important. Targets for self-monitoring include fasting glucose of 5.3 mmol/l and 1-2 hour post-meal glucose levels.
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This question is part of the following fields:
- Obstetrics
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Question 21
Incorrect
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A 29-year-old woman presents with hypertension at 12 weeks into her pregnancy. She has no history of hypertension. She complains of headache and tenderness in the right lower quadrant. An ultrasound of her pelvis reveals multiple cysts in both ovaries. There are no signs of hirsutism or virilism. What is the most probable diagnosis?
Your Answer: Luteoma of pregnancy
Correct Answer: Molar pregnancy
Explanation:Possible Causes of Hirsutism in Women: A Differential Diagnosis
Hirsutism, the excessive growth of hair in women in a male pattern, can be caused by various underlying conditions. Here are some possible causes and their distinguishing features:
Molar Pregnancy: This condition is characterized by hypertension in the first trimester of pregnancy. Excessive stimulation of ovarian follicles by high levels of gonadotrophins or human chorionic gonadotrophin (hCG) can lead to the formation of multiple theca lutein cysts bilaterally.
Congenital Adrenal Hyperplasia: This disease, which is mostly found in women, can present with gradual onset of hirsutism without virilization. It is caused by a deficiency of 21-hydroxylase and is characterized by an elevated serum concentration of 17-hydroxyprogesterone.
Luteoma of Pregnancy: This benign, solid ovarian tumor develops during pregnancy and disappears after delivery. It may be associated with excess androgen production, leading to hirsutism and virilization.
Adrenal Tumor: Androgen-secreting adrenal tumors can cause rapid onset of severe hirsutism, with or without virilization. Amenorrhea is found in almost half of the patients, and testosterone and dihydrotestosterone sulfate concentrations are elevated.
Polycystic Ovary Syndrome: Women with this condition are at higher risk of developing pre-eclampsia. However, the development of hypertension in the first trimester of pregnancy makes it more likely that there is a molar pregnancy present, with theca lutein cysts seen on ultrasound.
In summary, hirsutism in women can be caused by various conditions, and a differential diagnosis is necessary to determine the underlying cause and appropriate treatment.
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This question is part of the following fields:
- Obstetrics
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Question 22
Incorrect
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A 28-year-old G2P1 woman is admitted to the maternity ward after experiencing regular contractions. During a vaginal examination, the midwife confirms that the mother is currently in the first stage of labor. When does this stage of labor typically end?
Your Answer: 4 cm cervical dilation
Correct Answer: 10 cm cervical dilation
Explanation:The first stage of labour begins with the onset of true labour and ends when the cervix is fully dilated at 10cm. During this stage, regular contractions occur and the cervix gradually dilates. It is important to note that although 4 cm and 6cm cervical dilation occur during this stage, it does not end until the cervix is fully effaced at 10cm. The second stage of labour ends with the birth of the foetus, not the first.
Labour is divided into three stages, with the first stage beginning from the onset of true labour until the cervix is fully dilated. This stage is further divided into two phases: the latent phase and the active phase. The latent phase involves dilation of the cervix from 0-3 cm and typically lasts around 6 hours. The active phase involves dilation from 3-10 cm and progresses at a rate of approximately 1 cm per hour. In primigravidas, this stage can last between 10-16 hours.
During this stage, the baby’s presentation is important to note. Approximately 90% of babies present in the vertex position, with the head entering the pelvis in an occipito-lateral position. The head typically delivers in an occipito-anterior position.
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This question is part of the following fields:
- Obstetrics
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Question 23
Correct
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Samantha is a 28-year-old woman who has been diagnosed with epilepsy and is currently taking carbamazepine. She has just given birth to a baby boy and is uncertain about breastfeeding. Samantha is worried that her medication may harm her baby if she continues to breastfeed. What guidance would you offer Samantha regarding her antiepileptic medication and breastfeeding?
Your Answer: Continue carbamazepine, continue breastfeeding
Explanation:Mothers often have concerns about the use of antiepileptic medication during and after pregnancy, particularly when it comes to breastfeeding. However, according to a comprehensive document released by the Royal College of Obstetricians and Gynaecologists, nearly all antiepileptic drugs are safe to use while breastfeeding. This is because only negligible amounts of the medication are passed to the baby through breast milk, and studies have not shown any negative impact on the child’s cognitive development. Therefore, it is recommended that mothers continue their current antiepileptic regime and are encouraged to breastfeed. It is important to note that stopping the medication without consulting a neurologist can lead to further seizures.
Pregnancy and breastfeeding can be a concern for women with epilepsy. It is generally recommended that women continue taking their medication during pregnancy, as the risks of uncontrolled seizures outweigh the potential risks to the fetus. However, it is important for women to take folic acid before pregnancy to reduce the risk of neural tube defects. The use of antiepileptic medication during pregnancy can increase the risk of congenital defects, but this risk is still relatively low. It is recommended to aim for monotherapy and there is no need to monitor drug levels. Sodium valproate is associated with neural tube defects, while carbamazepine is considered the least teratogenic of the older antiepileptics. Phenytoin is associated with cleft palate, and lamotrigine may require a dose increase during pregnancy. Breastfeeding is generally safe for mothers taking antiepileptics, except for barbiturates. Pregnant women taking phenytoin should be given vitamin K in the last month of pregnancy to prevent clotting disorders in the newborn.
A warning has been issued about the use of sodium valproate during pregnancy and in women of childbearing age. New evidence suggests a significant risk of neurodevelopmental delay in children following maternal use of this medication. Therefore, it should only be used if clearly necessary and under specialist neurological or psychiatric advice. It is important for women with epilepsy to discuss their options with their healthcare provider and make informed decisions about their treatment during pregnancy and breastfeeding.
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This question is part of the following fields:
- Obstetrics
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Question 24
Correct
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A 36-year-old woman is admitted to the hospital for delivery. She has had two previous vaginal deliveries. After three hours, she gives birth to a healthy baby girl with APGAR scores of 9 at 1 minute and 10 at 5 and 10 minutes. However, the newborn appears to be macrosomic, and during delivery, the mother suffers a perineal tear. The midwife calls the doctor to suture the tear and upon examination, they discover an injury to the superficial and deep transverse perineal muscles, involving the external and internal anal sphincters, with mucosal sparing. What degree of injury does she have?
Your Answer: Third-degree
Explanation:The perineal tear in this patient involves the anal sphincter complex, including both the external and internal anal sphincters, which is classified as a third-degree injury. This type of tear is typically caused by the intense pressure and stretching that occurs during childbirth, particularly in first-time mothers or those delivering larger babies, often due to undiagnosed gestational diabetes.
Perineal tears are a common occurrence during childbirth, and the Royal College of Obstetricians and Gynaecologists (RCOG) has developed guidelines to classify them based on their severity. First-degree tears are superficial and do not require any repair, while second-degree tears involve the perineal muscle and require suturing by a midwife or clinician. Third-degree tears involve the anal sphincter complex and require repair in theatre by a trained clinician, with subcategories based on the extent of the tear. Fourth-degree tears involve the anal sphincter complex and rectal mucosa and also require repair in theatre by a trained clinician.
There are several risk factors for perineal tears, including being a first-time mother, having a large baby, experiencing a precipitant labour, and having a shoulder dystocia or forceps delivery. It is important for healthcare providers to be aware of these risk factors and to provide appropriate care and management during childbirth to minimize the risk of perineal tears. By following the RCOG guidelines and providing timely and effective treatment, healthcare providers can help ensure the best possible outcomes for both mother and baby.
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This question is part of the following fields:
- Obstetrics
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Question 25
Correct
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A 35-year-old woman has been diagnosed with gestational diabetes during her second pregnancy. Despite progressing well, she has been experiencing persistent nausea and vomiting throughout her pregnancy. In her previous pregnancy, she tried taking metformin but it worsened her symptoms and caused frequent loose stools. As a result, she refuses to take metformin again. She has made changes to her diet and lifestyle for the past two weeks, but her blood results show little improvement. Her fasting plasma glucose levels are 6.8 mmol/L, which is still above the normal range of <5.3mmol/L. What should be the next step in managing her gestational diabetes?
Your Answer: Commence insulin
Explanation:If blood glucose targets are not achieved through diet and metformin in gestational diabetes, insulin should be introduced as the next step. This is in accordance with current NICE guidelines, which recommend that pregnant women with any form of diabetes aim for plasma glucose levels below specific target values. Commencing anti-emetic medications or metformin would not be the most appropriate options in this scenario, as the former would not address the underlying issue of gestational diabetes and the latter is not acceptable to the patient. Additionally, offering a 2 week trial of diet and exercise changes would not be appropriate at this stage, as medication is now required. However, this may be an option for patients with a fasting plasma glucose of between 6.0 and 6.9 mmol/L without complications, who can be offered a trial of diet and exercise for 2 weeks before medication is considered if blood glucose targets are not met.
Gestational diabetes is a common medical disorder affecting around 4% of pregnancies. Risk factors include a high BMI, previous gestational diabetes, and family history of diabetes. Screening is done through an oral glucose tolerance test, and diagnostic thresholds have recently been updated. Management includes self-monitoring of blood glucose, diet and exercise advice, and medication if necessary. For pre-existing diabetes, weight loss and insulin are recommended, and tight glycemic control is important. Targets for self-monitoring include fasting glucose of 5.3 mmol/l and 1-2 hour post-meal glucose levels.
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This question is part of the following fields:
- Obstetrics
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Question 26
Correct
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A 28-year-old woman is in labor with her first baby. In the second stage, fetal distress is detected, and instrumental delivery is being considered. What would be a contraindication to this procedure?
Your Answer: Head palpable abdominally
Explanation:Instrumental delivery is a method used to expedite delivery during the second stage of labor in order to prevent fetal and maternal morbidity. It involves the use of traction and is indicated in cases of prolonged active second stage, maternal exhaustion, fetal distress, breech presentation, and prophylactic use in medical conditions such as cardiovascular disease and hypertension. It can also be used to rotate a malpositioned fetal head.
To be eligible for instrumental delivery, the following requirements must be met, which can be remembered using the acronym FORCEPS:
– Fully dilated cervix, indicating that the second stage of labor has been reached
– Occiput anterior (OA) position, preferably with the head in the occiput posterior (OP) position, as delivery is possible with Kielland’s forceps and ventouse. The position of the head must be known to avoid maternal or fetal trauma and failure.
– Ruptured membranes
– Cephalic presentation
– Engaged presenting part, meaning that the head is at or below the ischial spines and cannot be palpated abdominally
– Pain relief
– Sphincter (bladder) empty, which usually requires catheterizationIt is important to note that there must be a clear indication for instrumental delivery.
When is a Forceps Delivery Necessary?
A forceps delivery may be necessary in certain situations during childbirth. These situations include fetal distress, maternal distress, failure to progress, and the need to control the head in a breech delivery. Fetal distress occurs when the baby is not receiving enough oxygen and can be detected through changes in the baby’s heart rate. Maternal distress can occur when the mother is exhausted or experiencing complications such as high blood pressure. Failure to progress refers to a situation where the mother has been pushing for an extended period of time without making progress. In a breech delivery, the baby’s head may need to be controlled to prevent injury. In these situations, a forceps delivery may be recommended by the healthcare provider to safely deliver the baby.
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This question is part of the following fields:
- Obstetrics
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Question 27
Correct
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A 35-year-old woman is 39 weeks pregnant with twins (dichorionic diamniotic). During labor, the midwife observes the umbilical cord protruding from the vagina. The emergency button is pressed, and the woman is rushed for an emergency C-section. What is the most probable cause of umbilical cord prolapse?
Your Answer: Artificial amniotomy
Explanation:The most probable reason for umbilical cord prolapse is artificial rupture of membranes. Factors such as cephalic presentation, nulliparity, and prolonged pregnancy decrease the chances of cord prolapse. Prostaglandins do not significantly affect the risk of cord prolapse.
Understanding Umbilical Cord Prolapse
Umbilical cord prolapse is a rare but serious complication that can occur during delivery. It happens when the umbilical cord descends ahead of the presenting part of the fetus, which can lead to compression or spasm of the cord. This can cause fetal hypoxia and potentially irreversible damage or death. Certain factors increase the risk of cord prolapse, such as prematurity, multiparity, polyhydramnios, twin pregnancy, cephalopelvic disproportion, and abnormal presentations like breech or transverse lie.
Around half of all cord prolapses occur when the membranes are artificially ruptured. Diagnosis is usually made when the fetal heart rate becomes abnormal and the cord is palpable vaginally or visible beyond the introitus. Cord prolapse is an obstetric emergency that requires immediate management. The presenting part of the fetus may be pushed back into the uterus to avoid compression, and the cord should be kept warm and moist to prevent vasospasm. The patient may be asked to go on all fours or assume the left lateral position until preparations for an immediate caesarian section have been carried out. Tocolytics may be used to reduce uterine contractions, and retrofilling the bladder with saline can help elevate the presenting part. Although caesarian section is the usual first-line method of delivery, an instrumental vaginal delivery may be possible if the cervix is fully dilated and the head is low.
In conclusion, umbilical cord prolapse is a rare but serious complication that requires prompt recognition and management. Understanding the risk factors and appropriate interventions can help reduce the incidence of fetal mortality associated with this condition.
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This question is part of the following fields:
- Obstetrics
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Question 28
Incorrect
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A 36-year-old woman has given birth to her first child and was given a dose of intramuscular syntocinon before the placenta was delivered. During the wait for the placenta, she experiences a blood loss of 400ml. Even after the placenta is delivered, the bleeding continues and she loses an additional 500ml of blood. The medical team initiates the necessary resuscitation measures and the major haemorrhage protocol. The cause of the bleeding is identified as uterine atony, and the patient is given boluses of syntocinon, ergometrine, and carboprost. However, the bleeding persists. What is the most appropriate next step?
Your Answer: Hysterectomy
Correct Answer: Intra-uterine Bakri catheter
Explanation:The correct first-line surgical intervention for postpartum haemorrhage is an intra-uterine Bakri catheter. This device is used to tamponade the bleeding caused by uterine atony, which is a failure of the uterine myometrium cells to contract. Hysterectomy is not the first option as it is a last resort and will make the patient infertile. Lying the patient on her left lateral side is not relevant for a woman who has already delivered her baby. Ligation of the internal iliac artery may be used, but it is not the next most appropriate step as it may lead to ischaemic complications. Intra-uterine balloon tamponade is the first-line surgical intervention if other measures fail.
Understanding Postpartum Haemorrhage
Postpartum haemorrhage (PPH) is a condition where a woman experiences blood loss of more than 500 ml after giving birth vaginally. It can be classified as primary or secondary. Primary PPH occurs within 24 hours after delivery and is caused by the 4 Ts: tone, trauma, tissue, and thrombin. The most common cause is uterine atony. Risk factors for primary PPH include previous PPH, prolonged labour, pre-eclampsia, increased maternal age, emergency Caesarean section, and placenta praevia.
In managing PPH, it is important to involve senior staff immediately and follow the ABC approach. This includes two peripheral cannulae, lying the woman flat, blood tests, and commencing a warmed crystalloid infusion. Mechanical interventions such as rubbing up the fundus and catheterisation are also done. Medical interventions include IV oxytocin, ergometrine, carboprost, and misoprostol. Surgical options such as intrauterine balloon tamponade, B-Lynch suture, ligation of uterine arteries, and hysterectomy may be considered if medical options fail to control the bleeding.
Secondary PPH occurs between 24 hours to 6 weeks after delivery and is typically due to retained placental tissue or endometritis. It is important to understand the causes and risk factors of PPH to prevent and manage this life-threatening emergency effectively.
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This question is part of the following fields:
- Obstetrics
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Question 29
Correct
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A 32-year-old woman who is 28-weeks pregnant arrives at the emergency department with a swollen and tender left calf, which is confirmed as a DVT. Suddenly, she experiences acute shortness of breath and complains of pleuritic chest pain. What is the best initial management step for the most probable diagnosis?
Your Answer: She should be started immediately on low molecular weight heparin
Explanation:When a pregnant woman with a confirmed DVT is suspected of having a PE, the first step is to immediately administer LMWH to avoid any delay in treatment. PE during pregnancy can be life-threatening for both the mother and the foetus, causing hypoxia and even cardiac arrest. Thrombolysis is not recommended during pregnancy as it can lead to severe haemorrhage in the placenta and foetus. Apixaban is not approved for use during pregnancy and may have teratogenic effects. Similarly, warfarin is not safe during pregnancy and can cause congenital malformations and haemorrhage in the placenta. While a CTPA can be diagnostic, waiting for the scan can be risky for the mother and baby. Therefore, LMWH should be started without delay, and further investigations can be carried out to confirm or rule out a PE.
Investigation of DVT/PE during Pregnancy
Guidelines for investigating deep vein thrombosis (DVT) and pulmonary embolism (PE) during pregnancy were updated in 2015 by the Royal College of Obstetricians. For suspected DVT, compression duplex ultrasound should be performed if there is clinical suspicion. In cases of suspected PE, an ECG and chest x-ray should be performed in all patients. If a woman presents with symptoms and signs of DVT, compression duplex ultrasound should be performed. If DVT is confirmed, no further investigation is necessary, and treatment for venous thromboembolism (VTE) should continue. The decision to perform a ventilation/perfusion (V/Q) scan or computed tomography pulmonary angiography (CTPA) should be made at a local level after discussion with the patient and radiologist.
When comparing CTPA to V/Q scanning in pregnancy, it is important to note that CTPA slightly increases the lifetime risk of maternal breast cancer (up to 13.6%, with a background risk of 1/200 for the study population). Pregnancy makes breast tissue particularly sensitive to the effects of radiation. On the other hand, V/Q scanning carries a slightly increased risk of childhood cancer compared to CTPA (1/50,000 versus less than 1/1,000,000). It is also important to note that D-dimer is of limited use in the investigation of thromboembolism during pregnancy as it is often raised in pregnant women.
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This question is part of the following fields:
- Obstetrics
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Question 30
Correct
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A 20-year-old G3P2 woman presents to the Emergency Department with vaginal bleeding. She reports no pain or fever and has not received prenatal care for this pregnancy. Her last menstrual period was 8 weeks ago. Upon examination, her heart rate is 76 bpm, blood pressure is 112/68 mmHg, and temperature is 37.1 ºC. A serum β-human chorionic gonadotropin level is 10,000 iu. A pelvic exam reveals a closed cervical os. A bedside ultrasound confirms the presence of an intrauterine gestational sac with cardiac activity. What is the diagnosis?
Your Answer: Threatened miscarriage
Explanation:Differentiating between types of miscarriage: A case study
A patient presents with vaginal bleeding and cramping at 8 weeks gestation. An ultrasound shows a viable pregnancy with fetal cardiac activity and a gestational sac within the uterus. The cervical os is closed. What type of miscarriage is this?
Threatened miscarriage is the most likely diagnosis in this case. The patient can be reassured with precautions, as over 75% of pregnancies with threatened miscarriage do not abort. However, there is an increased risk of growth restriction and abnormal placentation in the third trimester.
Ectopic pregnancy can be ruled out as the ultrasound has established the gestational sac within the uterus, not within the adnexa. Septic miscarriage is also unlikely as the patient does not demonstrate signs of infection, such as fever, and the cervical os is closed.
A missed miscarriage can be ruled out as fetal cardiac activity was seen on ultrasound. In a complete miscarriage, the uterus would not have a gestational sac.
In conclusion, differentiating between types of miscarriage is important in determining appropriate management and counseling for patients. In this case, a diagnosis of threatened miscarriage allows for reassurance and monitoring of potential complications later in pregnancy.
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This question is part of the following fields:
- Obstetrics
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