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  • Question 1 - A 28-year-old primigravida at 37 weeks presents to the antenatal unit with complaints...

    Incorrect

    • A 28-year-old primigravida at 37 weeks presents to the antenatal unit with complaints of right-sided abdominal pain and vomiting. She denies any abnormal discharge and reports normal fetal movements. Her blood pressure is 148/97 mmHg and her blood results show Hb of 93 g/l, platelets of 89 * 109/l, WBC of 9.0 * 109/l, urate of 0.49 mmol/l, bilirubin of 32 µmol/l, ALP of 203 u/l, ALT of 190 u/l, and AST of 233 u/l. What is the most likely diagnosis?

      Your Answer: Acute fatty liver

      Correct Answer: HELLP syndrome

      Explanation:

      The most probable diagnosis in this case is HELLP syndrome, which is a severe form of pre-eclampsia characterized by haemolysis, elevated liver enzymes, and low platelets. While hypertension, vomiting, and abdominal pain can support the diagnosis, they are not mandatory. The abdominal pain may indicate liver inflammation and stretching of the liver capsule.

      Intense pruritus is the primary symptom of obstetric cholestasis, and a rise in serum bile acids is the most sensitive marker. Acute fatty liver is another severe condition associated with pre-eclampsia, which causes higher elevations in liver enzymes and deep jaundice. Hyperuricaemia can be a useful marker of pre-eclampsia and does not necessarily indicate gout. Urate levels increase due to reduced kidney function and clearance. Hyperemesis gravidarum is unlikely to present for the first time this late in pregnancy and should be a diagnosis of exclusion.

      Pre-eclampsia is a condition that occurs during pregnancy and is characterized by high blood pressure, proteinuria, and edema. It can lead to complications such as eclampsia, neurological issues, fetal growth problems, liver involvement, and cardiac failure. Severe pre-eclampsia is marked by hypertension, proteinuria, headache, visual disturbances, and other symptoms. Risk factors for pre-eclampsia include hypertension in a previous pregnancy, chronic kidney disease, autoimmune disease, diabetes, chronic hypertension, first pregnancy, and age over 40. Aspirin may be recommended for women with high or moderate risk factors. Treatment involves emergency assessment, admission for observation, and medication such as labetalol, nifedipine, or hydralazine. Delivery of the baby is the most important step in management, with timing depending on the individual case.

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      • Obstetrics
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  • Question 2 - A 28-year-old woman who is 35 weeks pregnant presents to the Emergency Department...

    Correct

    • A 28-year-old woman who is 35 weeks pregnant presents to the Emergency Department with fever, abdominal pain, and anxiety. She reports experiencing night sweats for the past few days and has a history of uterine fibroids. She has been sexually active throughout her pregnancy. During the examination, there is significant uterine tenderness and a foul-smelling brown vaginal discharge is observed. The patient's blood pressure is 134/93 mmHg, and her heart rate is 110 beats per minute. Her white blood cell count is 18.5 * 109/l. The fetal heart rate is 170 beats per minute. What is the most likely diagnosis?

      Your Answer: Chorioamnionitis

      Explanation:

      The patient’s symptoms suggest an infectious process, as evidenced by her fever, rapid heartbeat, and elevated levels of neutrophils (which are already higher than normal during pregnancy). Chorioamnionitis is a clinical diagnosis that may be indicated by uterine tenderness and a foul-smelling discharge, and the presence of a baseline fetal tachycardia supports this diagnosis. The likely cause of the infection is prolonged premature rupture of membranes. Although the patient has a history of uterine fibroids, this is not relevant to her current condition, as fibroids typically cause symptoms earlier in pregnancy. Acute placental abruption would cause sudden abdominal pain, which is not present in this case. While pyelonephritis is a possible differential diagnosis, the absence of dysuria makes it less likely.

      Understanding Chorioamnionitis

      Chorioamnionitis is a serious medical condition that can affect both the mother and the foetus during pregnancy. It is caused by a bacterial infection that affects the amniotic fluid, membranes, and placenta. This condition is considered a medical emergency and can be life-threatening if not treated promptly. It is more likely to occur when the membranes rupture prematurely, but it can also happen when the membranes are still intact.

      Prompt delivery of the foetus is crucial in treating chorioamnionitis, and a cesarean section may be necessary. Intravenous antibiotics are also administered to help fight the infection. This condition affects up to 5% of all pregnancies, and it is important for pregnant women to be aware of the symptoms and seek medical attention immediately if they suspect they may have chorioamnionitis.

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  • Question 3 - A 30-year-old Caucasian woman who is 26 weeks pregnant with her first child...

    Correct

    • A 30-year-old Caucasian woman who is 26 weeks pregnant with her first child presents to antenatal clinic. She had been invited to attend screening for gestational diabetes on account of her booking BMI, which was 32kg/m². Prior to her pregnancy, she had been healthy and had no personal or family history of diabetes mellitus. She takes no regular medications and has no known allergies.

      During her antenatal visit, she undergoes an oral glucose tolerance test (OGTT), which reveals the following results:
      - Fasting glucose 6.9mmol/L
      - 2-hour glucose 7.8 mmol/L

      An ultrasound scan shows no fetal abnormalities or hydramnios. She is advised on diet and exercise and undergoes a repeat OGTT two weeks later. Due to persistent impaired fasting glucose, she is started on metformin.

      After taking metformin for two weeks, she undergoes another OGTT, with the following results:
      - Fasting glucose 5.8 mmol/L
      - 2-hour glucose 7.2mmol/L

      What is the most appropriate next step in managing her glycaemic control?

      Your Answer: Add insulin

      Explanation:

      If blood glucose targets are not achieved through diet and metformin in gestational diabetes, insulin should be introduced. This patient was diagnosed with gestational diabetes at 25 weeks due to a fasting glucose level above 5.6mmol/L. Despite lifestyle changes and the addition of metformin, her glycaemic control has not improved, and her fasting glucose level remains above the target range. Therefore, NICE recommends adding short-acting insulin to her current treatment. Switching to modified-release metformin may help patients who experience side effects, but it would not improve glycaemic control in this case. Insulin should be added in conjunction with metformin for persistent impaired glycaemic control, rather than replacing it. Sulfonylureas like glibenclamide should only be used for patients who cannot tolerate metformin or as an adjunct for those who refuse insulin treatment, and they are not the best option for this patient.

      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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      • Obstetrics
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  • Question 4 - A 29-year-old woman who is 39-weeks pregnant presents to the labour suite with...

    Correct

    • A 29-year-old woman who is 39-weeks pregnant presents to the labour suite with sporadic contractions. She had noticed a mucous plug in her underwear earlier in the day. Upon examination, she appears to be breathing heavily and experiencing some discomfort. The cardiotocography is normal and progressing smoothly. During a vaginal examination, her cervix is estimated to be dilated at 2 cm. What phase of labour is she currently in?

      Your Answer: Latent 1st stage

      Explanation:

      The correct stage of labour for a woman with a cervix that is just beginning to ripen and dilate is the latent phase of the 1st stage. This stage is characterized by a cervix dilation of 0-3 cm. The active phase of the 1st stage, which is characterized by a cervix dilation of 3-10 cm and more regular contractions, is not applicable in this scenario. The active 2nd stage is also not a descriptive stage of labour, as it only refers to the general stage that ends with the expulsion of the foetus.

      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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  • Question 5 - A 28-year-old primigravida woman is rushed for an emergency caesarean section due to...

    Correct

    • A 28-year-old primigravida woman is rushed for an emergency caesarean section due to fetal distress and hypoxia detected on cardiotocography. She is currently at 31 weeks gestation.
      After delivery, the baby is admitted to the neonatal intensive care unit (NICU) and given oxygen to aid breathing difficulties.
      Several weeks later, during an ophthalmological examination, the baby is found to have bilateral absent red reflex and retinal neovascularisation.
      What is the probable diagnosis?

      Your Answer: Retinopathy of prematurity

      Explanation:

      Risks Associated with Prematurity

      Prematurity is a condition that poses several risks to the health of newborns. The risk of mortality increases with decreasing gestational age. Premature babies are at risk of developing respiratory distress syndrome, intraventricular haemorrhage, necrotizing enterocolitis, chronic lung disease, hypothermia, feeding problems, infection, jaundice, and retinopathy of prematurity. Retinopathy of prematurity is a significant cause of visual impairment in babies born before 32 weeks of gestation. The cause of this condition is not fully understood, but it is believed that over oxygenation during ventilation can lead to the proliferation of retinal blood vessels, resulting in neovascularization. Screening for retinopathy of prematurity is done in at-risk groups. Premature babies are also at risk of hearing problems.

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      • Obstetrics
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  • Question 6 - A 29-year-old female presents 7 weeks postpartum and inquires about safe contraceptive options...

    Incorrect

    • A 29-year-old female presents 7 weeks postpartum and inquires about safe contraceptive options while exclusively breastfeeding her baby. Which method of contraception should she avoid?

      Your Answer: Copper IUD

      Correct Answer: Combined oral contraceptive pill

      Explanation:

      The UK Medical Eligibility Criteria for Contraceptive Use states that women who are breastfeeding and less than 6 weeks postpartum should not use the combined oral contraceptive pill as it can reduce breast milk volume. However, from 6 weeks to 6 months postpartum, it is classified as UKMEC 2 and can be used. It is important to note that exclusive breastfeeding can act as an effective contraceptive method. The Mirena intrauterine system and copper IUD can be used from 4 weeks postpartum, while the progesterone-only pill can be started on or after day 21 postpartum. The progesterone-only implant can be inserted at any time, but contraception is not necessary before day 21 postpartum.

      After giving birth, women need to use contraception after 21 days. The progesterone-only pill (POP) can be started at any time postpartum, according to the FSRH. Additional contraception should be used for the first two days after day 21. A small amount of progesterone enters breast milk, but it is not harmful to the infant. On the other hand, the combined oral contraceptive pill (COCP) is absolutely contraindicated (UKMEC 4) if breastfeeding is less than six weeks post-partum. If breastfeeding is between six weeks and six months postpartum, it is a UKMEC 2. The COCP may reduce breast milk production in lactating mothers. It should not be used in the first 21 days due to the increased venous thromboembolism risk post-partum. After day 21, additional contraception should be used for the first seven days. The intrauterine device or intrauterine system can be inserted within 48 hours of childbirth or after four weeks.

      The lactational amenorrhoea method (LAM) is 98% effective if the woman is fully breastfeeding (no supplementary feeds), amenorrhoeic, and less than six months post-partum. It is important to note that an inter-pregnancy interval of less than 12 months between childbirth and conceiving again is associated with an increased risk of preterm birth, low birth weight, and small for gestational age babies.

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      • Obstetrics
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  • Question 7 - A 32-year-old pregnant woman at 14 weeks gestation presents with a three-week history...

    Correct

    • 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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      • Obstetrics
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  • Question 8 - A 32-year-old woman who is 28-weeks pregnant arrives at the emergency department with...

    Incorrect

    • 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 sent for thrombolysis

      Correct 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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      • Obstetrics
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  • Question 9 - A 24-year-old woman presents to the labour suite after being admitted 45 minutes...

    Incorrect

    • 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: Adopt an all-fours position for vaginal birth

      Correct 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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      • Obstetrics
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  • Question 10 - A 36-year-old overweight gravida 3 para 2 presents with a tender and swollen...

    Incorrect

    • A 36-year-old overweight gravida 3 para 2 presents with a tender and swollen left leg at 32 weeks of gestation. The clinician initiates appropriate treatment and decides to monitor it with a specific blood test. What is the name of this blood test?

      Your Answer: International Normalised Ratio (INR)

      Correct Answer: Anti-Xa activity

      Explanation:

      Venous Thromboembolism in Pregnancy: Risk Assessment and Prophylactic Measures

      Pregnancy increases the risk of developing venous thromboembolism (VTE), a condition that can be life-threatening for both the mother and the fetus. To prevent VTE, it is important to assess a woman’s individual risk during pregnancy and initiate appropriate prophylactic measures. This risk assessment should be done at the first antenatal booking and on any subsequent hospital admission.

      Women with a previous history of VTE are automatically considered high risk and require low molecular weight heparin throughout the antenatal period, as well as input from experts. Women at intermediate risk due to hospitalization, surgery, co-morbidities, or thrombophilia should also be considered for antenatal prophylactic low molecular weight heparin.

      The risk assessment at booking should include factors that increase the likelihood of developing VTE, such as age over 35, body mass index over 30, parity over 3, smoking, gross varicose veins, current pre-eclampsia, immobility, family history of unprovoked VTE, low-risk thrombophilia, multiple pregnancy, and IVF pregnancy.

      If a woman has four or more risk factors, immediate treatment with low molecular weight heparin should be initiated and continued until six weeks postnatal. If a woman has three risk factors, low molecular weight heparin should be initiated from 28 weeks and continued until six weeks postnatal.

      If a diagnosis of deep vein thrombosis (DVT) is made shortly before delivery, anticoagulation treatment should be continued for at least three months, as in other patients with provoked DVTs. Low molecular weight heparin is the treatment of choice for VTE prophylaxis in pregnancy, while direct oral anticoagulants (DOACs) and warfarin should be avoided.

      In summary, a thorough risk assessment and appropriate prophylactic measures can help prevent VTE in pregnancy, which is crucial for the health and safety of both the mother and the fetus.

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SESSION STATS - PERFORMANCE PER SPECIALTY

Obstetrics (5/10) 50%
Passmed