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Question 1
Correct
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A 30-year-old pregnant woman who has been receiving treatment for pre-eclampsia deteriorates and arrives at the Emergency Department. Upon evaluating the patient, you decide to admit her due to the development of HELLP syndrome.
Which of the following is NOT an acknowledged complication of HELLP syndrome? Select ONE option.Your Answer: Polycythaemia
Explanation:HELLP syndrome is a condition that occurs in approximately 0.5% of pregnancies. It is characterized by haemolysis, elevated liver enzymes, and a low platelet count. While it typically occurs in the late third trimester, it has also been reported in the late second trimester. Around 33% of patients with HELLP syndrome will present shortly after giving birth.
The initial symptoms of HELLP syndrome can be vague and include nausea, headaches, malaise, and pain in the upper right quadrant of the abdomen. Upon examination, raised blood pressure, proteinuria, and edema may be observed. Further investigations may reveal haemolysis on a blood film, elevated liver enzymes, low platelets, raised LDH, and raised bilirubin.
Delivery of the baby is the main treatment for HELLP syndrome. However, complications can arise, such as disseminated intravascular coagulation (DIC), renal failure, liver failure, and pulmonary edema. It is crucial to tightly control blood pressure, and magnesium sulfate is often used to reduce the risk of progression to eclampsia. If DIC occurs, treatment with fresh frozen plasma is necessary.
Without prompt recognition, approximately 25% of individuals with HELLP syndrome may experience severe complications, including placental abruption, liver failure, retinal detachment, and renal failure. With treatment, the mortality rate for the mother is around 1%, while the mortality rate for the baby ranges from 5-10%, depending on the gestational age at the time of delivery.
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This question is part of the following fields:
- Obstetrics & Gynaecology
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Question 2
Correct
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You assess a patient who has experienced a minor antepartum bleeding. You have a conversation with the obstetric team about the necessity of rhesus-D prophylaxis.
Which ONE statement about anti-D is accurate?Your Answer: Routine antenatal prophylaxis is recommended for RhD negative women at 28 and 34 weeks
Explanation:Anti-D is an antibody of the IgG class that targets the Rhesus D (RhD) antigen. It is specifically administered to women who are RhD negative, meaning they do not have the RhD antigen on their red blood cells. When a RhD negative woman is exposed to the blood of a RhD positive fetus, she may develop antibodies against RhD that can cross the placenta and attack the red blood cells of the fetus, leading to a condition called hemolytic disease of the newborn. Anti-D is given to bind to the fetal red blood cells in the mother’s circulation and neutralize them before an immune response is triggered.
RhD should be administered in the event of a sensitizing event, which can include childbirth, antepartum hemorrhage, miscarriage, ectopic pregnancy, intrauterine death, amniocentesis, chorionic villus sampling, or abdominal trauma. It is important to administer Anti-D as soon as possible after a sensitizing event, but it can still provide some benefit even if given outside of the recommended 72-hour window, according to the British National Formulary (BNF).
For RhD negative women, routine antenatal prophylaxis with Anti-D is recommended at 28 and 34 weeks of pregnancy, regardless of whether they have already received Anti-D earlier in the same pregnancy due to a sensitizing event.
In cases of uncomplicated miscarriage before 12 weeks of gestation, confirmed by ultrasound, or mild and painless vaginal bleeding, prophylactic Anti-D is not necessary because the risk of feto-maternal hemorrhage is extremely low. However, in cases of therapeutic termination of pregnancy, whether through surgical or medical methods, confirmed RhD negative women who are not known to be sensitized to RhD should receive 250 IU of prophylactic Anti-D immunoglobulin.
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This question is part of the following fields:
- Obstetrics & Gynaecology
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Question 3
Correct
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A 25-year-old woman who is 32-weeks pregnant in her first pregnancy is brought in by ambulance after a car accident. She has noticeable bruising on her lower abdomen and is experiencing intense abdominal pain. During the examination, you are unable to feel the top of the uterus and can easily feel the baby's body parts. Blood samples have been sent to the lab and the patient has an IV line in place.
What is the MOST LIKELY diagnosis?Your Answer: Primary uterine rupture
Explanation:Uterine rupture can occur in two forms: primary, which happens without any previous uterine surgery or trauma, and secondary, which occurs when there is scar dehiscence. In secondary rupture, the rupture can range from the peritoneum to the endometrium, or the peritoneum may remain intact while the underlying uterine tissue ruptures.
There are several risk factors associated with uterine rupture, including multiparity, a uterine scar from a previous Caesarean section, previous uterine surgery, dysfunctional labor, and augmented labor with medications like oxytocin or prostaglandins.
The clinical features of uterine rupture include abdominal pain and tenderness, abdominal guarding and rigidity, inability to feel the uterine fundus (in cases of fundal rupture), cessation of uterine contractions, chest pain or shoulder tip pain, vaginal bleeding, abnormal fetal lie (such as oblique or transverse), easy palpation of fetal parts outside the uterus, absent fetal heart sounds, and abnormal CTG findings like late decelerations and reduced variability. Maternal shock can also occur and may be severe.
Immediate resuscitation is crucial and should involve intravenous fluids and/or blood transfusion. This should be followed by a laparotomy. After the baby is delivered, the uterus should be repaired or a hysterectomy may be performed. The decision between these two management options depends on factors such as the site and extent of the rupture, as well as the mother’s condition, age, and parity.
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This question is part of the following fields:
- Obstetrics & Gynaecology
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Question 4
Incorrect
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You evaluate a 32-year-old woman who is 14-weeks pregnant. During the examination, you observe a soft early systolic murmur that is most audible at the left sternal edge. Apart from this finding, the patient appears to be in good health, and the rest of the examination was unremarkable.
What is the SINGLE most probable diagnosis?Your Answer: Mitral regurgitation
Correct Answer: Functional murmur
Explanation:Functional murmurs, also referred to as physiological or flow murmurs, are frequently observed during pregnancy and other conditions associated with increased blood flow. These murmurs arise as a result of the heightened resting cardiac output and do not necessitate any additional examination.
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This question is part of the following fields:
- Obstetrics & Gynaecology
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Question 5
Incorrect
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You review a 62-year-old woman who presents with vaginal discharge. She has been experiencing these symptoms for the past six weeks and describes the discharge as having a slight odor. The patient is not sexually active and has never had a similar discharge before. Additionally, she reports a single episode of visible blood in her urine one week ago but has not experienced any further episodes or discomfort while urinating.
What would be the MOST SUITABLE next course of action for managing this patient?Your Answer: Urgent referral to gynaecology service (to be seen within 2 weeks)
Correct Answer: Organise a direct access ultrasound scan
Explanation:According to the latest NICE guidance, it is recommended that women aged 55 and over with unexplained symptoms of vaginal discharge should undergo a direct access ultrasound scan to assess for endometrial cancer. This recommendation applies to women who are experiencing these symptoms for the first time or who have thrombocytosis, haematuria (blood in the urine), visible haematuria, low haemoglobin levels, or high blood glucose levels. For more information, please refer to the NICE referral guidelines on the recognition and referral of suspected cancer.
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This question is part of the following fields:
- Obstetrics & Gynaecology
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Question 6
Correct
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A 28-year-old woman comes in with lower abdominal pain, painful urination, painful intercourse, and thick, yellowish vaginal discharge. A pregnancy test done today is negative. She has a temperature of 39.1°C, and there is tenderness in her abdomen during the examination.
What is the MOST suitable treatment plan?Your Answer: IV ceftriaxone and metronidazole plus oral doxycycline
Explanation:Pelvic inflammatory disease (PID) is a pelvic infection that affects the upper female reproductive tract, including the uterus, fallopian tubes, and ovaries. It is typically caused by an ascending infection from the cervix and is commonly associated with sexually transmitted diseases like chlamydia and gonorrhea. In the UK, genital Chlamydia trachomatis infection is the most common cause of PID seen in genitourinary medicine clinics.
PID can often be asymptomatic, but when symptoms are present, they may include lower abdominal pain and tenderness, fever, painful urination, painful intercourse, purulent vaginal discharge, abnormal vaginal bleeding, and tenderness in the cervix and adnexa. It is important to note that symptoms of ectopic pregnancy can be similar to those of PID, so a pregnancy test should be conducted for all patients with suspicious symptoms.
To investigate a possible case of PID, endocervical swabs should be taken to test for C. trachomatis and N. gonorrhoeae using nucleic acid amplification tests if available. Mild to moderate cases of PID can usually be managed in primary care or outpatient settings, while patients with severe disease should be admitted to the hospital for intravenous antibiotics. Signs of severe disease include a fever above 38°C, signs of a tubo-ovarian abscess, signs of pelvic peritonitis, or concurrent pregnancy.
Empirical antibiotic treatment should be initiated as soon as a presumptive diagnosis of PID is made clinically, without waiting for swab results. The current recommended outpatient treatment for PID is a single intramuscular dose of ceftriaxone 500 mg, followed by oral doxycycline 100 mg twice daily and oral metronidazole 400 mg twice daily for 14 days. An alternative regimen is oral ofloxacin 400 mg twice daily and oral metronidazole 400 mg twice daily for 14 days.
For severely ill patients in the inpatient setting, initial treatment includes intravenous doxycycline, a single-dose of intravenous ceftriaxone, and intravenous metronidazole. This is then followed by a switch to oral doxycycline and metronidazole to complete a 14-day treatment course. If a patient fails to respond to treatment, laparoscopy is necessary to confirm the diagnosis or consider alternative diagnoses.
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This question is part of the following fields:
- Obstetrics & Gynaecology
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Question 7
Correct
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A 28-year-old woman comes in with lower abdominal pain, dyspareunia, and purulent vaginal discharge. A pregnancy test done today is negative and her last period was four weeks ago. Her temperature today is 38.6°C.
What is the MOST LIKELY diagnosis?Your Answer: Pelvic inflammatory disease
Explanation:Pelvic inflammatory disease (PID) is an infection that affects the upper female reproductive tract, including the uterus, fallopian tubes, and ovaries. It is typically caused by an ascending infection from the cervix. The most common culprits are sexually transmitted diseases like chlamydia and gonorrhea, with chlamydia being the most prevalent infection seen in UK genitourinary medicine clinics.
PID can often be asymptomatic, but when symptoms do occur, they may include lower abdominal pain and tenderness, fever, painful urination, painful intercourse, purulent vaginal discharge, abnormal vaginal bleeding, and tenderness in the cervix and adnexa. It’s important to note that symptoms of ectopic pregnancy can be mistaken for PID, so a pregnancy test should always be conducted in patients with suspicious symptoms.
To investigate a potential case of PID, endocervical swabs are taken to test for chlamydia and gonorrhea using nucleic acid amplification tests. It is recommended to start empirical antibiotic treatment as soon as a presumptive diagnosis of PID is made, without waiting for swab results.
Mild to moderate cases of PID can usually be managed in primary care or outpatient settings. However, patients with severe disease should be admitted to the hospital for intravenous antibiotics. Signs of severe disease include a fever above 38°C, signs of a tubo-ovarian abscess, signs of pelvic peritonitis, or concurrent pregnancy.
The current recommended treatment for outpatient cases of PID is a single intramuscular dose of ceftriaxone 500 mg, followed by oral doxycycline 100 mg twice daily and oral metronidazole 400 mg twice daily for 14 days. An alternative regimen is oral ofloxacin 400 mg twice daily and oral metronidazole 400 mg twice daily for 14 days.
For severely ill patients in the inpatient setting, initial treatment consists of intravenous doxycycline, a single-dose of intravenous ceftriaxone, and intravenous metronidazole. Afterward, the treatment is switched to oral doxycycline and metronidazole to complete a 14-day course.
If a patient fails to respond to treatment, laparoscopy is necessary to confirm the diagnosis or consider alternative diagnoses.
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This question is part of the following fields:
- Obstetrics & Gynaecology
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Question 8
Incorrect
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A 32-year-old patient comes in with a complaint of excessive menstrual bleeding. The periods are not excessively painful. A recent ultrasound scan showed the presence of small fibroids, all measuring less than 2-3 cm in diameter. During the examination, a slightly enlarged uterus is palpated. The patient expresses a strong desire to start a family soon.
What would be the most appropriate initial treatment option to consider in this case?Your Answer: Mirena IUS
Correct Answer: Tranexamic acid
Explanation:Tranexamic acid is the best choice for this patient because her periods are heavy, but not very painful, and her fibroids are small. Additionally, she wants to start a family soon, so contraceptive options are not as suitable. For more information, you can refer to the NICE guidelines on the assessment and management of heavy menstrual bleeding.
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This question is part of the following fields:
- Obstetrics & Gynaecology
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Question 9
Correct
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A 25-year-old woman is brought in by ambulance following a car accident where she was a passenger in a car hit by a truck at high speed. She is 32 weeks pregnant. Her vital signs are as follows: heart rate 120, blood pressure 98/62, oxygen saturation 97% on high-flow oxygen, respiratory rate 24, temperature 36.8°C. Her cervical spine is immobilized. The airway is clear, and her chest examination is normal. She has experienced a small amount of vaginal bleeding and is experiencing abdominal pain and tenderness. Two large IV needles have been inserted in her arm, and a complete set of blood tests have been sent to the laboratory, including a request for a blood type and cross-match. She has also had a small amount of vaginal bleeding and is complaining of abdominal pain. It is noted from her initial blood tests that she is rhesus D negative.
Which of the following adjustments should be made during the initial assessment?Your Answer: The mother should be log rolled to her left side at a 15-30-degree angle
Explanation:During pregnancy, the vena cava can be compressed by the uterus, leading to a decrease in venous return to the heart. This can worsen the shock state in cases of trauma by reducing cardiac output. To alleviate pressure on the inferior vena cava, the ATLS guidelines recommend manually displacing the uterus to the left side during the primary survey.
If spinal immobilization is necessary, the mother should be log rolled to her left side at a 15-30-degree angle, raising the right side by 10-15 cm. To maintain spinal motion restriction while decompressing the vena cava, a bolstering device like a Cardiff wedge should be used to support the mother.
Pregnancy causes an increase in intravascular volume, which means that pregnant patients can lose a significant amount of blood before showing signs of hypovolemia such as tachycardia and hypotension. Despite stable vital signs, the placenta may not receive adequate perfusion, putting the fetus at risk. Therefore, it is crucial to initiate fluid resuscitation, starting with crystalloid fluids and then using type-specific blood if necessary. Vasopressors should only be used as a last resort to restore maternal blood pressure, as they can further reduce uterine blood flow and lead to fetal hypoxia.
If the mother is rhesus D negative, anti-D immunoglobulin should be administered within 72 hours. However, this is not a priority during the primary survey.
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This question is part of the following fields:
- Obstetrics & Gynaecology
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Question 10
Incorrect
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You evaluate a 45-year-old woman who presents with lower abdominal and pelvic pain. During a bimanual vaginal examination, you detect a significant pelvic mass. She has no significant medical history or gynecological issues, such as uterine fibroids.
What would be the MOST suitable next step in managing this patient?Your Answer: Arrange an urgent ultrasound scan and review with results
Correct Answer: Urgent referral to gynaecology service (for an appointment within 2 weeks)
Explanation:Women who are 18 years or older and have a pelvic mass that is not clearly uterine fibroids should be promptly referred for assessment. In this case, an abdominal X-ray would not provide much useful information, and it is not advisable to take no action at this point. For more information, please refer to the NICE referral guidelines for suspected cancer.
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This question is part of the following fields:
- Obstetrics & Gynaecology
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Question 11
Incorrect
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A 3 year old is brought to the emergency department due to concern that the patient has developed a fever, symptoms of a cold, and a widespread rash with blisters. You diagnose the child with chickenpox and advise the mother on how to manage the condition. The mother informs you that she is 12 weeks pregnant and is worried about the potential consequences of contracting chickenpox during pregnancy.
What is the most significant complication of chickenpox infection for the mother during pregnancy?Your Answer: Myocarditis
Correct Answer: Pneumonitis
Explanation:Pregnant women who contract chickenpox for the first time are more likely to develop pneumonitis, a condition characterized by inflammation of the lungs. Additionally, these women face a five-fold increased risk of pneumonitis compared to non-pregnant individuals. Furthermore, the fetus is at risk of developing fetal varicella syndrome, a condition associated with chickenpox infection during pregnancy.
Further Reading:
Chickenpox exposure during pregnancy poses risks to both the mother and the fetus. The mother has a 5 times greater risk of developing pneumonitis, a potentially serious complication. The fetus is at risk of developing fetal varicella syndrome (FVS) if the maternal exposure occurs before 20 weeks gestation. The risk of FVS is around 1% in these cases and includes features such as skin scarring, eye defects, limb hypoplasia, microcephaly, and learning disabilities. There have been very few cases of FVS reported between 20-28 weeks gestation and none following 28 weeks.
Other risks to the fetus include the development of shingles in infancy, which has a 1-2% risk if the maternal exposure occurs in the second or third trimester. There is also a risk of severe neonatal varicella if the mother develops a rash between 5 days before and 2 days after birth. This condition can be fatal to the newborn child in around 20% of cases.
In the management of chickenpox exposure during pregnancy, it is important to determine if the mother is immune to varicella. If there is any doubt, maternal blood should be urgently checked for varicella antibodies. If the pregnant woman is not immune, she should be given varicella zoster immunoglobulin (VZIG) as soon as possible. VZIG is considered effective up to 10 days post-exposure. Consensus guidelines also recommend the use of oral aciclovir if the pregnant woman presents with chickenpox within 24 hours of the rash onset.
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This question is part of the following fields:
- Obstetrics & Gynaecology
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Question 12
Incorrect
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A 28-year-old woman who is 30 weeks pregnant is experiencing breathlessness and is undergoing investigation. A blood gas test is being conducted to aid in her management.
What type of acid-base imbalance would you anticipate as a result of pregnancy?Your Answer: Metabolic alkalosis
Correct Answer: Respiratory alkalosis
Explanation:Respiratory alkalosis can be caused by hyperventilation, such as during periods of anxiety. It can also be a result of conditions like pulmonary embolism, CNS disorders (such as stroke or encephalitis), altitude, pregnancy, or the early stages of aspirin overdose.
Respiratory acidosis is often associated with chronic obstructive pulmonary disease (COPD) or life-threatening asthma. Other causes include pulmonary edema, sedative drug overdose (such as opiates or benzodiazepines), neuromuscular disease, obesity, or certain medications.
Metabolic alkalosis can occur due to vomiting, potassium depletion (often caused by diuretic usage), Cushing’s syndrome, or Conn’s syndrome.
Metabolic acidosis with a raised anion gap can be caused by conditions like lactic acidosis (which can result from hypoxemia, shock, sepsis, or infarction) or ketoacidosis (commonly seen in diabetes, starvation, or alcohol excess). Other causes include renal failure or poisoning (such as late stages of aspirin overdose, methanol, or ethylene glycol).
Metabolic acidosis with a normal anion gap can be attributed to conditions like renal tubular acidosis, diarrhea, ammonium chloride ingestion, or adrenal insufficiency.
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This question is part of the following fields:
- Obstetrics & Gynaecology
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Question 13
Incorrect
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A 28-year-old woman comes in with lower abdominal pain, painful urination, pain during intercourse, and thick, yellowish vaginal discharge. Based on the clinical findings, you diagnose her with pelvic inflammatory disease (PID).
When would hospitalization be necessary in this case?Your Answer: Abnormal vaginal bleeding
Correct Answer: Concurrent pregnancy
Explanation:Pelvic inflammatory disease (PID) is a pelvic infection that affects the upper female reproductive tract, including the uterus, fallopian tubes, and ovaries. It is typically caused by an ascending infection from the cervix and is commonly associated with sexually transmitted diseases like chlamydia and gonorrhea. In the UK, genital Chlamydia trachomatis infection is the most common cause of PID seen in genitourinary medicine clinics.
PID can often be asymptomatic, but when symptoms are present, they may include lower abdominal pain and tenderness, fever, painful urination, painful intercourse, purulent vaginal discharge, abnormal vaginal bleeding, and tenderness in the cervix and adnexa. It is important to note that symptoms of ectopic pregnancy can be similar to those of PID, so a pregnancy test should be conducted for all patients with suspicious symptoms.
To investigate a possible case of PID, endocervical swabs should be taken to test for C. trachomatis and N. gonorrhoeae using nucleic acid amplification tests if available. Mild to moderate cases of PID can usually be managed in primary care or outpatient settings, while patients with severe disease should be admitted to the hospital for intravenous antibiotics. Signs of severe disease include a fever above 38°C, signs of a tubo-ovarian abscess, signs of pelvic peritonitis, or concurrent pregnancy.
Empirical antibiotic treatment should be initiated as soon as a presumptive diagnosis of PID is made clinically, without waiting for swab results. The current recommended outpatient treatment for PID is a single intramuscular dose of ceftriaxone 500 mg, followed by oral doxycycline 100 mg twice daily and oral metronidazole 400 mg twice daily for 14 days. An alternative regimen is oral ofloxacin 400 mg twice daily and oral metronidazole 400 mg twice daily for 14 days.
For severely ill patients in the inpatient setting, initial treatment includes intravenous doxycycline, a single-dose of intravenous ceftriaxone, and intravenous metronidazole. This is then followed by a switch to oral doxycycline and metronidazole to complete a 14-day treatment course. If a patient fails to respond to treatment, laparoscopy is necessary to confirm the diagnosis or consider alternative diagnoses.
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This question is part of the following fields:
- Obstetrics & Gynaecology
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Question 14
Incorrect
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You evaluate a 58-year-old woman who presents with postmenopausal bleeding. She has been experiencing these symptoms for approximately one month. The patient is currently on hormone replacement therapy (HRT) to alleviate vasomotor symptoms.
What would be the MOST SUITABLE next course of action for managing this patient?Your Answer: Stop her HRT and ask her GP to review her 6 weeks
Correct Answer: Urgent referral to gynaecology service (for an appointment within 2 weeks)
Explanation:If you are a woman under the age of 55 and experiencing postmenopausal bleeding, it is important to seek medical attention promptly. One possible cause of this symptom could be endometrial cancer. To ensure timely diagnosis and treatment, it is recommended to follow the suspected cancer pathway referral guidelines provided by NICE. These guidelines aim to facilitate recognition and referral of suspected cancer cases. By adhering to these guidelines, you can increase the likelihood of securing an appointment for further evaluation within two weeks. to the NICE referral guidelines on recognition and referral of suspected cancer.
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This question is part of the following fields:
- Obstetrics & Gynaecology
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Question 15
Correct
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A 25-year-old woman is brought in by ambulance following a car accident where she was a passenger in a car hit by a truck at high speed. She is 32 weeks pregnant. Her vital signs are as follows: HR 98, BP 120/80, SaO2 99% on high-flow oxygen, RR 20, temperature 36.8°C. Her cervical spine is triply immobilized. The airway is clear, and her chest examination is unremarkable. She has experienced a small amount of vaginal bleeding and is experiencing abdominal pain. On examination, the uterus is tender and there are frequent uterine contractions.
What is the SINGLE most likely diagnosis?Your Answer: Abruptio placentae
Explanation:The primary cause of fetal death in trauma during pregnancy is maternal shock and maternal death. The second most common cause of fetal death is placental abruption. Abruptio placentae can be identified by the following signs: vaginal bleeding (present in 70% of cases), uterine tenderness, frequent uterine contractions, uterine tetany, and uterine irritability. While uterine ultrasonography can be helpful in diagnosing abruptio placentae, it is not definitive. A CT scan may also show signs of abruptio placenta. It is important to note that abruption can occur even after minor injuries later in pregnancy.
Uterine rupture is a much rarer occurrence but is a catastrophic event that leads to rapid maternal and fetal death without immediate surgical intervention. Signs that suggest uterine rupture include vaginal hemorrhage, abdominal tenderness, abdominal guarding and rigidity, rebound tenderness, profound shock, abnormal fetal lie (such as oblique or transverse lie), easy palpation of fetal parts due to their location outside the uterus, and difficulty in palpating the uterine fundus when there is a rupture.
It is crucial to be aware of these signs and symptoms in order to promptly identify and address any potential complications during pregnancy.
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This question is part of the following fields:
- Obstetrics & Gynaecology
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Question 16
Incorrect
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You review a patient with Sheehan’s syndrome following a postpartum hemorrhage. She would like to ask you some questions about her diagnosis.
Which ONE statement about this condition is accurate?Your Answer: Prolactin levels are usually elevated
Correct Answer: Diabetes insipidus may occur
Explanation:Sheehan’s syndrome is a condition where the pituitary gland becomes damaged due to insufficient blood flow and shock during and after childbirth, leading to hypopituitarism. The risk of developing this syndrome is higher in pregnancies with conditions that increase the chances of bleeding, such as placenta praevia and multiple pregnancies. However, Sheehan’s syndrome is quite rare, affecting only 1 in 10,000 pregnancies.
During pregnancy, the anterior pituitary gland undergoes hypertrophy, making it more vulnerable to ischaemia in the later stages. While the posterior pituitary gland is usually not affected due to its own direct blood supply, there have been rare cases where it is involved. In these instances, central diabetes insipidus, a form of posterior pituitary dysfunction, can occur as a complication of Sheehan’s syndrome.
The clinical features of Sheehan’s syndrome include the absence or infrequency of menstrual periods, the inability to produce milk and breastfeed (galactorrhoea), decreased libido, fatigue and tiredness, loss of pubic and axillary hair, and the potential development of secondary hypothyroidism and adrenal insufficiency. Serum prolactin levels are typically low (less than 5ng/ml). An MRI can be helpful in ruling out other pituitary issues, such as a pituitary tumor.
Treatment for Sheehan’s syndrome involves hormone replacement therapy. With appropriate management, the prognosis for this condition is excellent.
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This question is part of the following fields:
- Obstetrics & Gynaecology
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Question 17
Incorrect
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A 35-year-old woman came in ten days ago with a fever, tenderness in the suprapubic area, and discharge from the vagina. The doctors diagnosed her with pelvic inflammatory disease and started her on antibiotics. She initially got better, but now she is back with intense pain in her lower abdomen and a temperature of 39.5°C.
What is the SINGLE most probable diagnosis?Your Answer: Pyelonephritis
Correct Answer: Tubo-ovarian abscess
Explanation:This patient is highly likely to have developed a tubo-ovarian abscess (TOA), which is a complication of pelvic inflammatory disease. TOA occurs when a pocket of pus forms in the fallopian tube and/or ovary. If the abscess ruptures, it can lead to sepsis and become life-threatening.
The initial imaging modality of choice is transabdominal and endovaginal ultrasound. This imaging technique often reveals multilocular complex retro-uterine/adnexal masses with debris, septations, and irregular thick walls. These masses can be present on both sides.
Urgent hospital admission is necessary, and the usual management involves draining the abscess and administering intravenous antibiotics. The abscess drainage can be guided by ultrasound or CT scanning.
In some cases, laparotomy or laparoscopy may be required to drain the abscess.
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This question is part of the following fields:
- Obstetrics & Gynaecology
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Question 18
Correct
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A 45-year-old woman that is 42-weeks pregnant becomes suddenly very breathless shortly after going into labor. An ambulance is called, and she is ‘blue lighted’ into the resus area of your Emergency Department. She appears cyanosed and states that her heart feels like it is ‘beating very quickly’. Shortly after arriving in the Emergency Department, she becomes unresponsive. You notice a change in rhythm to ventricular fibrillation on the cardiac monitor and are unable to detect a pulse or any signs of life. She receives three stacked shocks and is managed according to the ALS algorithm, but initial attempts at resuscitation are unsuccessful.
Which of the following management options is most likely to improve his likelihood of successful resuscitation?Your Answer: Peri-mortem Caesarean section
Explanation:Based on her presentation, the most probable cause of the cardiac arrest in this case is either a pulmonary embolism or amniotic fluid embolism.
When dealing with a cardiac arrest during pregnancy, there are several adjustments that need to be made compared to a regular cardiac arrest situation. These adjustments include:
– Ensuring the presence of an obstetrician
– Having a paediatrician or neonatologist available
– Manually displacing the uterus to the left in order to relieve caval compression
– Tilting the table to the left side, ideally at a 15-30 degree angle
– Performing early tracheal intubation to reduce the risk of aspiration (it is recommended to seek expert anaesthetic assistance for this)
– Initiating preparations for an emergency Caesarean sectionIn the event of a cardiac arrest, a perimortem Caesarean section should be performed within 5 minutes of the onset. This procedure is crucial as it relieves caval compression, improves the chances of successful resuscitation by increasing venous return during CPR, and maximizes the likelihood of the infant’s survival. The best survival rate for the infant occurs when delivery is achieved within 5 minutes of the mother’s cardiac arrest.
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This question is part of the following fields:
- Obstetrics & Gynaecology
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Question 19
Correct
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A 32-year-old woman who is 39-weeks pregnant is brought to the Emergency Department due to severe headaches, visual disturbances, and abdominal pain. Shortly after arrival, she experiences a seizure and collapses. Her husband mentions that she has been receiving treatment for hypertension during the pregnancy.
What is the most suitable initial treatment in this case?Your Answer: IV magnesium sulphate
Explanation:Eclampsia is the most likely diagnosis in this case. It is characterized by the occurrence of one or more convulsions on top of pre-eclampsia. To control seizures in eclampsia, the recommended treatment is magnesium sulphate. The Collaborative Eclampsia Trial regimen should be followed for administering magnesium sulphate. Initially, a loading dose of 4 g should be given intravenously over 5 to 15 minutes. This should be followed by a continuous infusion of 1 g per hour for 24 hours. If the woman experiences another eclamptic seizure, the infusion should be continued for an additional 24 hours after the last seizure. In case of recurrent seizures, a further dose of 2-4 g should be administered intravenously over 5 to 15 minutes. It is important to note that the only cure for eclampsia is the delivery of the fetus and placenta. Once the patient is stabilized, she should be prepared for an emergency caesarean section.
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This question is part of the following fields:
- Obstetrics & Gynaecology
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Question 20
Incorrect
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A 32 year old male presents to the emergency department complaining of sudden shortness of breath. During the initial assessment, the patient mentions that he is currently 28 weeks into his partner's pregnancy. While the nurse is still conducting the assessment, the patient suddenly collapses and the nurse urgently calls for your assistance. The patient has no detectable pulse and is not making any effort to breathe. You decide to initiate cardiopulmonary resuscitation (CPR).
What adjustments should be made to the management of cardiac arrest when performing CPR on a pregnant patient?Your Answer: Use chest compression: rescue breath ratio of 15:2
Correct Answer: Hand position for chest compressions 2-3 cm higher
Explanation:When administering CPR to a pregnant patient, it is important to make certain modifications. Firstly, the hand position for chest compressions should be adjusted to be 2-3 cm higher than usual. Additionally, the uterus should be manually displaced to the left in order to minimize compression on the inferior vena cava. If possible, a 15-30 degree left lateral tilt should be implemented. If resuscitation efforts do not result in the return of spontaneous circulation, it is advisable to seek urgent obstetric input for potential consideration of a C-section delivery. Lastly, when inserting an ET tube, it may be necessary to use a size that is 0.5-1.0mm smaller due to potential narrowing of the trachea caused by edema.
Further Reading:
Cardiopulmonary arrest is a serious event with low survival rates. In non-traumatic cardiac arrest, only about 20% of patients who arrest as an in-patient survive to hospital discharge, while the survival rate for out-of-hospital cardiac arrest is approximately 8%. The Resus Council BLS/AED Algorithm for 2015 recommends chest compressions at a rate of 100-120 per minute with a compression depth of 5-6 cm. The ratio of chest compressions to rescue breaths is 30:2.
After a cardiac arrest, the goal of patient care is to minimize the impact of post cardiac arrest syndrome, which includes brain injury, myocardial dysfunction, the ischaemic/reperfusion response, and the underlying pathology that caused the arrest. The ABCDE approach is used for clinical assessment and general management. Intubation may be necessary if the airway cannot be maintained by simple measures or if it is immediately threatened. Controlled ventilation is aimed at maintaining oxygen saturation levels between 94-98% and normocarbia. Fluid status may be difficult to judge, but a target mean arterial pressure (MAP) between 65 and 100 mmHg is recommended. Inotropes may be administered to maintain blood pressure. Sedation should be adequate to gain control of ventilation, and short-acting sedating agents like propofol are preferred. Blood glucose levels should be maintained below 8 mmol/l. Pyrexia should be avoided, and there is some evidence for controlled mild hypothermia but no consensus on this.
Post ROSC investigations may include a chest X-ray, ECG monitoring, serial potassium and lactate measurements, and other imaging modalities like ultrasonography, echocardiography, CTPA, and CT head, depending on availability and skills in the local department. Treatment should be directed towards the underlying cause, and PCI or thrombolysis may be considered for acute coronary syndrome or suspected pulmonary embolism, respectively.
Patients who are comatose after ROSC without significant pre-arrest comorbidities should be transferred to the ICU for supportive care. Neurological outcome at 72 hours is the best prognostic indicator of outcome.
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This question is part of the following fields:
- Obstetrics & Gynaecology
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Question 21
Correct
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A 32-year-old woman who is 38 weeks pregnant is brought to the Emergency Department after experiencing sudden difficulty breathing. Shortly after her arrival, she loses consciousness. The cardiac monitor displays ventricular fibrillation, confirming cardiac arrest.
Which of the following statements about cardiac arrest during pregnancy is correct?Your Answer: Early tracheal intubation should be performed
Explanation:Cardiac arrest during pregnancy is a rare occurrence, happening in approximately 16 out of every 100,000 live births. It is crucial to consider both the mother and the fetus when dealing with cardiac arrest in pregnancy, as the best way to ensure a positive outcome for the fetus is by effectively resuscitating the mother.
The main causes of cardiac arrest during pregnancy include pre-existing cardiac disease, pulmonary embolism, hemorrhage, ectopic pregnancy, hypertensive disorders of pregnancy, amniotic fluid embolism, and suicide. Many cardiovascular problems associated with pregnancy are caused by compression of the inferior vena cava.
To prevent decompensation or potential cardiac arrest during pregnancy, it is important to follow these steps when dealing with a distressed or compromised pregnant patient:
– Place the patient in the left lateral position or manually displace the uterus to the left.
– Administer high-flow oxygen, guided by pulse oximetry.
– Give a fluid bolus if there is low blood pressure or signs of hypovolemia.
– Re-evaluate the need for any medications currently being administered.
– Seek expert help and involve obstetric and neonatal specialists early.
– Identify and treat the underlying cause.In the event of cardiac arrest during pregnancy, in addition to following the standard guidelines for basic and advanced life support, the following modifications should be made:
– Immediately call for expert help, including an obstetrician, anesthetist, and neonatologist.
– Start CPR according to the standard ALS guidelines, but adjust the hand position slightly higher on the sternum.
– Ideally establish IV or IO access above the diaphragm to account for potential compression of the inferior vena cava.
– Manually displace the uterus to the left to relieve caval compression.
– Tilt the table to the left side (around 15-30 degrees of tilt).
– Perform early tracheal intubation to reduce the risk of aspiration (seek assistance from an expert anesthetist).
– Begin preparations for an emergency Caesarean section.A perimortem Caesarean section should be performed within 5 minutes of the onset of cardiac arrest. This delivery will alleviate caval compression and increase the chances of successful resuscitation by improving venous return during CPR. It will also maximize the chances of the infant’s survival, as the best survival rate occurs when delivery is achieved within 5 minutes of the mother’s cardiac arrest.
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This question is part of the following fields:
- Obstetrics & Gynaecology
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Question 22
Correct
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A 32-year-old woman with a previous history of salpingitis presents with excessive vaginal bleeding. Her pregnancy test is positive, and a preliminary diagnosis of an ectopic pregnancy is made.
What is the most frequent anatomical site for an ectopic pregnancy to occur?Your Answer: Ampulla of Fallopian tube
Explanation:An ectopic pregnancy happens when the fertilized egg attaches itself outside of the uterus. In over 95% of cases, ectopic pregnancies occur in the Fallopian tubes. Although rare, they can also occur in other locations such as the abdomen, cervix, and ovary.
The most common location for an ectopic pregnancy in the Fallopian tube is the ampulla, accounting for approximately 70% of cases. The isthmus and infundibulum each account for 10-15% of cases, while the uterine part only accounts for 2-5%.
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This question is part of the following fields:
- Obstetrics & Gynaecology
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Question 23
Incorrect
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A 38-year-old woman comes in with a complaint of excessively heavy menstrual periods. Her GP recently ordered a complete blood count, which came back normal. During a vaginal examination, no apparent abnormalities were found. She is content with having finished having children.
Based on the latest NICE guidelines, what would be the most appropriate treatment option for her? Select only ONE response.Your Answer: Hysterectomy
Correct Answer: Mirena IUS
Explanation:The most recent guidelines from the National Institute for Health and Care Excellence (NICE) recommend using a LNG-IUS, such as Mirena IUS, as the initial treatment for heavy menstrual bleeding (HMB) in women who have no identified pathology, fibroids smaller than 3 cm without uterine cavity distortion, or suspected/diagnosed adenomyosis. If a woman declines or cannot use an LNG-IUS, alternative pharmacological treatments can be considered. These include non-hormonal options like Tranexamic acid or NSAIDs, as well as hormonal options like combined hormonal contraception or cyclical oral progestogens. to the NICE guidelines on the assessment and management of heavy menstrual bleeding.
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This question is part of the following fields:
- Obstetrics & Gynaecology
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Question 24
Incorrect
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You assess a 27-year-old patient who is 10-weeks pregnant. She is concerned as she had contact with someone with chickenpox two days ago. She is unsure if she had chickenpox in her childhood.
What is the MOST suitable initial course of action?Your Answer: She should be given varicella zoster immune globulin (VZIG)
Correct Answer: She should have a blood test to check for varicella zoster immunity
Explanation:Varicella can have serious consequences for pregnant women. If a woman contracts varicella during the first 28 weeks of pregnancy, there is a 1% chance that the fetus will be affected and develop foetal varicella syndrome (FVS). FVS is characterized by eye defects, limb underdevelopment, skin scarring, and neurological abnormalities.
Pregnant women who have not had chickenpox or who test negative for VZV IgG should be advised to minimize contact with individuals who have chickenpox or shingles. If they are exposed, they should seek immediate medical help.
If a pregnant woman is exposed to varicella, the first step is to perform a blood test to check for VZV immunity. If she is not immune and the exposure is significant, she should be given VZV immunoglobulin as soon as possible. This treatment is effective within 10 days of exposure.
If a pregnant woman develops chickenpox, she should urgently seek medical assistance. There is an increased risk of pneumonia, encephalitis, and hepatitis for the mother, as well as a 1% risk of the fetus developing FVS.
Acyclovir should be used cautiously before 20 weeks of gestation but is recommended after 20 weeks if the woman seeks medical help within 24 hours of the rash appearing.
If a woman develops any complications of varicella, she must be referred to a hospital. Additionally, she should be referred to a specialized center five weeks after the infection for a detailed ultrasound scan to determine if FVS has occurred.
For more information, refer to the Royal College of Obstetricians and Gynaecologists green-top guidelines for the management of VZV exposure and infection in pregnancy.
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This question is part of the following fields:
- Obstetrics & Gynaecology
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Question 25
Correct
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A 32-year-old woman who is 37-weeks pregnant is brought to the Emergency Department due to severe headaches, visual disturbance, and abdominal pain. Shortly after arrival, she collapses and experiences a seizure. Her husband mentions that she has been receiving treatment for hypertension during the pregnancy.
What is the most probable diagnosis in this case?Your Answer: Eclampsia
Explanation:Eclampsia is the most likely diagnosis in this case. It is characterized by the occurrence of one or more convulsions on top of pre-eclampsia. To control seizures in eclampsia, the recommended treatment is magnesium sulphate. The Collaborative Eclampsia Trial regimen should be followed for administering magnesium sulphate. Initially, a loading dose of 4 g should be given intravenously over 5 to 15 minutes. This should be followed by a continuous infusion of 1 g per hour for 24 hours. If the woman experiences another eclamptic seizure, the infusion should be continued for an additional 24 hours after the last seizure. In case of recurrent seizures, a further dose of 2-4 g should be administered intravenously over 5 to 15 minutes. It is important to note that the only cure for eclampsia is the delivery of the fetus and placenta. Once the patient is stabilized, she should be prepared for an emergency caesarean section.
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This question is part of the following fields:
- Obstetrics & Gynaecology
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Question 26
Incorrect
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A 25-year-old woman presents to the emergency department with severe and persistent nausea and vomiting. She is currently 8 weeks pregnant. She is struggling to keep anything down and has experienced some weight loss over the past couple of weeks. Her vital signs are as follows: heart rate 103 bpm, respiratory rate 14, blood pressure 113/70 mmHg. Upon examination, her abdomen is soft and nontender, and a urine dipstick reveals 3+ ketones.
What is the MOST appropriate initial anti-emetic medication to be used in this case?Your Answer: Ondansetron
Correct Answer: Promethazine
Explanation:Vomiting is a common occurrence during the early stages of pregnancy, typically happening between 7 and 12 weeks. However, there is a more severe condition called hyperemesis gravidarum, which involves uncontrollable and intense nausea and vomiting. This condition can lead to imbalances in fluids and electrolytes, significant ketonuria, malnutrition, and weight loss. It is relatively rare, affecting less than 1% of pregnancies.
For mild cases of nausea and vomiting in early pregnancy, dietary adjustments and non-pharmacological methods like consuming ginger or using P6 wrist acupressure can often provide relief.
In severe cases where heavy ketonuria and severe dehydration are present, hospital admission is usually necessary for intravenous fluid rehydration. The NICE Clinical Knowledge Summary (CKS) on nausea and vomiting in pregnancy recommends using oral promethazine, oral cyclizine, or oral prochlorperazine as the first-line treatment if an anti-emetic is needed. After 24 hours, the situation should be reassessed to determine if the initial treatment is effective. If not, a second-line drug like metoclopramide or ondansetron should be considered.
It’s important to exercise caution when using metoclopramide in patients under the age of 20 due to the increased risk of extrapyramidal side effects. Additionally, proton pump inhibitors (e.g., omeprazole) and histamine H2-receptor antagonists (e.g., ranitidine) can be beneficial for women experiencing significant dyspepsia alongside their nausea and vomiting.
For more information, refer to the NICE CKS on nausea and vomiting in pregnancy.
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This question is part of the following fields:
- Obstetrics & Gynaecology
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Question 27
Correct
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A 25-year-old woman comes in with a slight vaginal bleeding and lower abdominal discomfort. Her pregnancy test shows positive results. During the examination, she experiences tenderness in the right iliac fossa and right-sided adnexa. Additionally, she exhibits cervical motion tenderness.
What is the SINGLE most probable diagnosis?Your Answer: Ectopic pregnancy
Explanation:Bleeding in a confirmed early pregnancy, along with adnexal tenderness and cervical motion tenderness, is indicative of an ectopic pregnancy until proven otherwise. The amount of bleeding caused by an ectopic pregnancy can range from no bleeding or slight spotting to a level similar to a normal menstrual period. It is important to note that 90% of patients with an ectopic pregnancy experience abdominal pain. Other clinical features that may be present include shoulder tip pain, which is caused by irritation of the diaphragm, as well as adnexal tenderness, cervical motion tenderness, rebound tenderness, guarding, and adnexal masses in some cases. Additionally, hypotension and shock may occur.
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This question is part of the following fields:
- Obstetrics & Gynaecology
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Question 28
Incorrect
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A 28-year-old woman who is 36 weeks pregnant comes in with intense and continuous lower abdominal pain and vaginal bleeding. She describes the bleeding as lighter than her usual period. A CTG is conducted, revealing reduced variability in the fetal heart rate and late decelerations. During the examination, the uterus feels tender and firm.
What is the MOST probable diagnosis?Your Answer: Placenta praevia
Correct Answer: Placental abruption
Explanation:Placental abruption, also known as abruptio placentae, occurs when the placental lining separates from the wall of the uterus before delivery and after 20 weeks of gestation.
In the early stages, there may be no symptoms, but typically abdominal pain and vaginal bleeding develop. Approximately 20% of patients experience a concealed placental abruption, where the haemorrhage is confined within the uterine cavity and the amount of blood loss can be significantly underestimated.
The clinical features of placental abruption include sudden onset abdominal pain (which can be severe), variable vaginal bleeding, severe or continuous contractions, abdominal tenderness, and an enlarged, tense uterus. The foetus often shows signs of distress, such as reduced movements, increased or decreased fetal heart rate, decreased variability of fetal heart rate, and late decelerations.
In contrast, placenta praevia is painless and the foetal heart is generally normal. The degree of obstetric shock is usually proportional to the amount of vaginal blood loss. Another clue that the cause of bleeding is placenta praevia rather than placental abruption is that the foetus may have an abnormal presentation or lie.
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This question is part of the following fields:
- Obstetrics & Gynaecology
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Question 29
Correct
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A 28-year-old primigravida woman comes in with a moderate amount of vaginal bleeding and lower abdominal discomfort. She reports the bleeding to be heavier than her normal period. She is currently 9 weeks pregnant. During the examination, she experiences mild tenderness in her lower abdomen. A speculum examination is conducted, revealing an open cervical os.
What is the SINGLE most probable diagnosis?Your Answer: Inevitable miscarriage
Explanation:A threatened miscarriage happens when there is bleeding during the first trimester of pregnancy, but no fetal tissue has been expelled, and the opening of the cervix is closed.
If cervical dilatation occurs, a threatened miscarriage can progress to become an inevitable miscarriage. In this case, the pain and bleeding are usually more intense, and upon examination, the cervix will be found to be open.
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This question is part of the following fields:
- Obstetrics & Gynaecology
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Question 30
Incorrect
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A 30-year-old pregnant woman who has been receiving treatment for pre-eclampsia deteriorates and arrives at the Emergency Department. Upon evaluating the patient, you decide to admit her due to the development of HELLP syndrome.
Which of the following signs or symptoms would NOT raise suspicion of HELLP syndrome in a pregnant patient?Your Answer: Right upper quadrant pain
Correct Answer: Symptoms occurring around 16 weeks gestation
Explanation:HELLP syndrome is a condition that occurs in approximately 0.5% of pregnancies. It is characterized by haemolysis, elevated liver enzymes, and a low platelet count. While it typically occurs in the late third trimester, it has also been reported in the late second trimester. Around 33% of patients with HELLP syndrome will present shortly after giving birth.
The initial symptoms of HELLP syndrome can be vague and include nausea, headaches, malaise, and pain in the upper right quadrant of the abdomen. Upon examination, raised blood pressure, proteinuria, and edema may be observed. Further investigations may reveal haemolysis on a blood film, elevated liver enzymes, low platelets, raised LDH, and raised bilirubin.
Delivery of the baby is the main treatment for HELLP syndrome. However, complications can arise, such as disseminated intravascular coagulation (DIC), renal failure, liver failure, and pulmonary edema. It is crucial to tightly control blood pressure, and magnesium sulfate is often used to reduce the risk of progression to eclampsia. If DIC occurs, treatment with fresh frozen plasma is necessary.
Without prompt recognition, approximately 25% of individuals with HELLP syndrome may experience severe complications, including placental abruption, liver failure, retinal detachment, and renal failure. With treatment, the mortality rate for the mother is around 1%, while the mortality rate for the baby ranges from 5-10%, depending on the gestational age at the time of delivery.
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This question is part of the following fields:
- Obstetrics & Gynaecology
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