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Question 1
Incorrect
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A 32 weeks pregnant woman, who is G2 P0, presents to the emergency department with vaginal bleeding. She had suffered from severe nausea and vomiting earlier in the pregnancy which has now resolved. She has no abdominal pain, no vaginal discharge, no headache, and no pruritus. On abdominal examination, purple striae were noted on the abdomen as well as a dark line running vertically down the middle of the abdomen. A transverse lie is noticed and there is no fetal engagement. The symphyseal-fundal height is 33cm.
What is the best gold standard investigation to perform?Your Answer: Cardiotocography
Correct Answer: Transvaginal ultrasound scan
Explanation:It is not advisable to conduct a digital vaginal examination in cases of suspected placenta praevia without first performing an ultrasound, as this could potentially trigger a dangerous hemorrhage.
Understanding Placenta Praevia
Placenta praevia is a condition where the placenta is located wholly or partially in the lower uterine segment. It is a relatively rare condition, with only 5% of women having a low-lying placenta when scanned at 16-20 weeks gestation. However, the incidence at delivery is only 0.5%, as most placentas tend to rise away from the cervix.
There are several factors associated with placenta praevia, including multiparity, multiple pregnancy, and embryos implanting on a lower segment scar from a previous caesarean section. Clinical features of placenta praevia include shock in proportion to visible loss, no pain, a non-tender uterus, abnormal lie and presentation, and a usually normal fetal heart. Coagulation problems are rare, and small bleeds may occur before larger ones.
Diagnosis of placenta praevia should not involve digital vaginal examination before an ultrasound, as this may provoke severe haemorrhage. The condition is often picked up on routine 20-week abdominal ultrasounds, but the Royal College of Obstetricians and Gynaecologists recommends the use of transvaginal ultrasound for improved accuracy and safety. Placenta praevia is classified into four grades, with grade IV being the most severe, where the placenta completely covers the internal os.
In summary, placenta praevia is a rare condition that can have serious consequences if not diagnosed and managed appropriately. It is important for healthcare professionals to be aware of the associated factors and clinical features, and to use appropriate diagnostic methods for accurate grading and management.
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This question is part of the following fields:
- Obstetrics
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Question 2
Incorrect
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You are conducting a study on the hypothalamic–pituitary–gonadal axis in pregnant women. Some of the hormone concentrations are observed to increase during this stage. Your team observes that one hormone in particular shows a more significant increase than the others. Which hormone is most likely to display this greater increase?
Your Answer: Luteinising hormone (LH)
Correct Answer: Oestriol
Explanation:Hormonal Changes During Pregnancy
During pregnancy, there are significant hormonal changes that occur in a woman’s body. One of the most notable changes is the increase in concentration of oestriol, which is the least potent of the three oestrogens. Oestrogen plays a crucial role in controlling other hormones such as FSH and LH, stimulating and controlling the growth of the placenta, and promoting the growth of maternal breast tissue in preparation for lactation.
Another hormone that increases during pregnancy is oestradiol, which is approximately 50-fold higher. Oestrone also increases, but oestradiol is more potent as it acts on a wider range of receptors.
On the other hand, LH and FSH are downregulated during pregnancy due to the high levels of oestrogen. The release of FSH is inhibited as follicles do not need to be stimulated during pregnancy.
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This question is part of the following fields:
- Obstetrics
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Question 3
Incorrect
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You are urgently called to the labour ward to attend to a 23-year-old woman who has undergone an artificial rupture of membranes. She is at 39-weeks gestation and has had an uneventful pregnancy thus far. The midwife reports an abnormal foetal heart rate. Upon examination, you detect the presence of the umbilical cord. You promptly order a caesarean section. What medication can you administer while waiting to prevent any complications?
Your Answer: Oxytocin
Correct Answer: Terbutaline
Explanation:Terbutaline is the correct choice for managing a patient with an umbilical cord prolapse as it is a tocolytic drug that can reduce uterine contractions while awaiting emergency caesarean section. On the other hand, benzylpenicillin is not relevant in this case as it is given to mothers intrapartum with group B Streptococcus to prevent neonatal sepsis. Oxytocin is also not appropriate as it would increase uterine contractions, which could worsen the prolapse. Similarly, pethidine is not the next step in managing an umbilical cord prolapse, although the patient may be offered analgesia.
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 4
Incorrect
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A 29-year-old woman who is 20-weeks pregnant comes to the emergency department after noticing a vesicular rash on her torso this morning. Upon further questioning, you discover that her 5-year-old daughter developed chickenpox last week and the patient cannot recall if she has had the condition before. She seems at ease while resting.
Serological testing for varicella zoster virus reveals the following results:
Varicella IgM Positive
Varicella IgG Negative
What is the most suitable course of action?Your Answer: No treatment required
Correct Answer: Oral acyclovir
Explanation:Chickenpox exposure in pregnancy can pose risks to both the mother and fetus, including fetal varicella syndrome. Post-exposure prophylaxis (PEP) with varicella-zoster immunoglobulin (VZIG) or antivirals should be given to non-immune pregnant women, with timing dependent on gestational age. If a pregnant woman develops chickenpox, specialist advice should be sought and oral acyclovir may be given if she is ≥ 20 weeks and presents within 24 hours of onset of the rash.
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This question is part of the following fields:
- Obstetrics
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Question 5
Correct
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As the obstetrics FY2 doctor, you are reviewing the labour ward patient list. What discovery in one of the patients, who is slightly older, would prompt you to initiate continuous CTG monitoring during labour?
Your Answer: New onset vaginal bleed while in labour
Explanation:Continuous CTG monitoring is recommended during labour if any of the following conditions are present or develop: suspected chorioamnionitis or sepsis, a temperature of 38°C or higher, severe hypertension with a reading of 160/110 mmHg or above, use of oxytocin, or significant meconium. In addition, the 2014 update to the guidelines added fresh vaginal bleeding as a new point of concern, as it may indicate placental rupture or placenta previa, both of which require monitoring of the baby.
Cardiotocography (CTG) is a medical procedure that measures pressure changes in the uterus using either internal or external pressure transducers. It is used to monitor the fetal heart rate, which normally ranges between 100-160 beats per minute. There are several features that can be observed during a CTG, including baseline bradycardia (heart rate below 100 beats per minute), which can be caused by increased fetal vagal tone or maternal beta-blocker use. Baseline tachycardia (heart rate above 160 beats per minute) can be caused by maternal pyrexia, chorioamnionitis, hypoxia, or prematurity. Loss of baseline variability (less than 5 beats per minute) can be caused by prematurity or hypoxia. Early deceleration, which is a decrease in heart rate that starts with the onset of a contraction and returns to normal after the contraction, is usually harmless and indicates head compression. Late deceleration, on the other hand, is a decrease in heart rate that lags behind the onset of a contraction and does not return to normal until after 30 seconds following the end of the contraction. This can indicate fetal distress, such as asphyxia or placental insufficiency. Variable decelerations, which are independent of contractions, may indicate cord compression.
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This question is part of the following fields:
- Obstetrics
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Question 6
Incorrect
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You are requested to evaluate a 28-year-old patient in a joint medical/obstetric clinic who has recently been diagnosed with gestational diabetes. Her pregnancy has been complicated by a diagnosis of gestational diabetes through routine screening and she now takes metformin 500 mg three times a day.
She is currently 26 weeks pregnant and has just undergone a scan that revealed an estimated foetal weight of 900g (99th percentile). She reports feeling well and has been tolerating the metformin without any issues. A fasting blood glucose level is taken at the clinic and compared to her previous results:
6 weeks ago: 6.0mmol/L
4 weeks ago: 6.1 mmol/L
Today: 7.5mmol/L
Based on the above information, what changes would you make to the management of this patient?Your Answer: Take high dose folic acid daily
Correct Answer: Continue metformin and add insulin
Explanation:If blood glucose targets are not achieved through diet and metformin in gestational diabetes, insulin should be added to the treatment plan. This patient was initially advised to make lifestyle changes and follow a specific diet for two weeks, as her fasting blood glucose was below 7 mmol/L. However, since she did not meet the targets, she was started on metformin monotherapy. Insulin therapy was not initiated earlier because her fasting blood glucose was below 7 mmol/L. According to NICE guidelines, if metformin monotherapy fails to achieve the desired results, insulin should be started, and lifestyle changes should be emphasized. Therefore, the correct answer is to continue metformin and add insulin to the patient’s treatment plan. The other options, such as increasing the dose of metformin, stopping metformin and starting insulin, adding gliclazide, or prescribing high-dose folic acid, are incorrect.
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 7
Incorrect
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A 28-year-old woman presents to the antenatal clinic for a routine visit and is found to have a blood pressure of 165/111 mmHg and ++proteinuria on urinalysis. Her doctor suspects pre-eclampsia and admits her to the obstetrics assessment unit. She has recently moved to the area and her medical records are not available. She is otherwise healthy and only uses blue and brown inhalers for her asthma, for which she recently completed a 5-day course of steroids after being hospitalized for a severe exacerbation. What medication should be used to manage her hypertension?
Your Answer: Hydralazine
Correct Answer: Nifedipine
Explanation:Nifedipine is the recommended initial treatment for pre-eclampsia in women with severe asthma. The patient’s medical history indicates that she has severe asthma, making beta blockers like Labetalol unsuitable for her. Additionally, the use of Ramipril during pregnancy has been associated with a higher incidence of birth defects in infants.
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 8
Incorrect
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A pregnant woman who is slightly older is admitted to the Emergency department with symptoms of nausea, vomiting, and lethargy. She is in her 38th week of pregnancy and has never been pregnant before. Upon examination, she appears to be clinically jaundiced and has a temperature of 37.7ºC. Her blood pressure and heart rate are normal.
The results of her blood tests are as follows:
- Bilirubin: 80 µmol/l
- ALP: 240 u/l
- ALT: 550 u/l
- AST: 430 u/l
- γGT: 30 u/l
- INR: 1.8
- Hb: 110 g/l
- Platelets: 331 * 109/l
- WBC: 12.5 * 109/l
An acute viral hepatitis screen comes back negative. An urgent US doppler liver shows steatosis with patent hepatic and portal vessels. What is the most likely diagnosis?Your Answer: Cholestasis of pregnancy
Correct Answer: Acute fatty liver of pregnancy
Explanation:Based on the presented symptoms, the most probable diagnosis is acute fatty liver of pregnancy. This is supported by the presence of jaundice, mild fever, elevated liver function tests, increased white blood cell count, coagulopathy, and steatosis on imaging. Acute fatty liver of pregnancy typically presents with non-specific symptoms such as fatigue, malaise, and nausea, whereas cholestasis of pregnancy is characterized by severe itching. The absence of abnormalities in hemoglobin, platelet count, and viral screening makes the diagnosis of HELLP syndrome or viral hepatitis unlikely. Additionally, pre-eclampsia is characterized by hypertension and proteinuria. It is important to note that placental ALP can cause an increase in serum ALP levels during pregnancy.
Liver Complications During Pregnancy
During pregnancy, there are several liver complications that may arise. One of the most common is intrahepatic cholestasis of pregnancy, which occurs in about 1% of pregnancies and is typically seen in the third trimester. Symptoms include intense itching, especially in the palms and soles, as well as elevated bilirubin levels. Treatment involves the use of ursodeoxycholic acid for relief and weekly liver function tests. Women with this condition are usually induced at 37 weeks to prevent stillbirth, although maternal morbidity is not typically increased.
Another rare complication is acute fatty liver of pregnancy, which may occur in the third trimester or immediately after delivery. Symptoms include abdominal pain, nausea and vomiting, headache, jaundice, and hypoglycemia. Severe cases may result in pre-eclampsia. ALT levels are typically elevated, and support care is the primary management until delivery can be performed once the patient is stabilized.
Finally, conditions such as Gilbert’s and Dubin-Johnson syndrome may be exacerbated during pregnancy. Additionally, HELLP syndrome, which stands for haemolysis, elevated liver enzymes, and low platelets, is a serious complication that can occur in the third trimester and requires immediate medical attention. Overall, it is important for pregnant women to be aware of these potential liver complications and to seek medical attention if any symptoms arise.
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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 35-year-old woman presents with a significant obstetric hemorrhage due to uterine atony. What is the initial medical management after stabilization and general measures?
Your Answer: Ergometrine
Correct Answer: Syntocinon
Explanation:To treat postpartum haemorrhage caused by uterine atony, medical options include oxytocin, ergometrine, carboprost, and misoprostol.
The leading cause of primary postpartum haemorrhage is uterine atony. The RCOG has issued guidelines (Green-top Guideline No.52) for managing primary PPH due to uterine atony. The first-line treatment recommended is 5U of IV Syntocinon (oxytocin), followed by 0.5 mg of ergometrine.
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 10
Incorrect
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A 28-year-old woman contacts her GP via telephone. She is currently 20 weeks pregnant and has had no complications thus far. However, she is now concerned as she recently spent time with her niece who has developed a rash that her sister suspects to be chickenpox. The patient is unsure if she had chickenpox as a child, but she had no symptoms until the past 24 hours when she developed a rash. She feels fine otherwise but is worried about the health of her baby. What is the most appropriate course of action at this point?
Your Answer: Urgent blood test to determine varicella antibody status
Correct Answer: Oral acyclovir
Explanation:When pregnant women who are at least 20 weeks along contract chickenpox, they are typically prescribed oral acyclovir if they seek treatment within 24 hours of the rash appearing. This is in accordance with RCOG guidelines and is an important topic for exams. If the patient is asymptomatic after being exposed to chickenpox and is unsure of their immunity, a blood test should be conducted urgently. If the test is negative, VZIG should be administered. However, if the patient is certain that they are not immune to chickenpox, VZIG should be given without the need for a blood test. It is incorrect to administer both VZIG and oral acyclovir once symptoms of chickenpox have appeared, as VZIG is no longer effective at that point. Intravenous acyclovir is only necessary in cases of severe chickenpox.
Chickenpox exposure in pregnancy can pose risks to both the mother and fetus, including fetal varicella syndrome. Post-exposure prophylaxis (PEP) with varicella-zoster immunoglobulin (VZIG) or antivirals should be given to non-immune pregnant women, with timing dependent on gestational age. If a pregnant woman develops chickenpox, specialist advice should be sought and oral acyclovir may be given if she is ≥ 20 weeks and presents within 24 hours of onset of the rash.
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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 28-year-old woman presents to the clinic for her lab results. She is currently 20 weeks pregnant and has undergone a glucose tolerance test. The findings are as follows:
- Fasting glucose 6.9 mmol/L
- 2-hour glucose 8.5 mmol/L
What is the best course of action to take next?Your Answer: Dietary advice
Correct Answer: Insulin
Explanation:Immediate insulin (with or without metformin) should be initiated if the fasting glucose level is >= 7 mmol/l at the time of gestational diabetes diagnosis. In this case, the patient has gestational diabetes and requires prompt insulin therapy. The diagnosis of gestational diabetes is based on a fasting plasma glucose level of > 5.6 mmol/L or a 2-hour plasma glucose level of >/= 7.8 mmol/L. Although dietary advice is important, insulin therapy is necessary when the fasting glucose level is greater than 7 mmol/L. Gliclazide is not recommended for pregnant women due to the risk of neonatal hypoglycaemia. Metformin can be used in gestational diabetes, but insulin is the most appropriate next step when the fasting glucose level is >=7 mmol/L. Insulin and metformin can be used together to manage gestational diabetes. There is no need to repeat the test as the results are conclusive for gestational diabetes.
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 12
Incorrect
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A 28-year-old woman with gestational diabetes delivered at 39+2 weeks’ gestation by an uncomplicated elective Caesarean section for macrosomia. The baby weighed 4.8 kg at delivery. The Apgar score at 1 and 5 minutes was 10. Eight hours later, she pulls the emergency alarm because her baby became lethargic and started shaking.
What is the most probable reason for this newborn's seizure activity and lethargy?Your Answer: Benign familial neonatal seizures
Correct Answer: Hypoglycaemia
Explanation:Neonatal Seizures: Likely Causes and Differential Diagnosis
Neonatal seizures can be a cause of concern for parents and healthcare providers. The most common cause of neonatal seizures is hypoglycaemia, which can occur in neonates born to mothers with gestational diabetes. Hypoglycaemia can lead to significant morbidity and mortality if left untreated. Other possible causes of neonatal seizures include hypoxic ischaemic encephalopathy, neonatal sepsis, intracranial haemorrhage, and benign familial neonatal seizures. However, in the absence of prematurity or complicated delivery, hypoglycaemia is the most likely cause of neonatal seizures in a term baby born to a mother with gestational diabetes. Diagnosis and treatment should be prompt to prevent long-term complications.
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This question is part of the following fields:
- Obstetrics
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Question 13
Incorrect
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A 28-year-old woman presents to the maternity unit 3 days after delivering a healthy baby at 39 weeks gestation. She had a normal third stage of labour and has been experiencing intermittent vaginal bleeding and brown discharge, with an estimated blood loss of 120 ml. The patient has a history of asthma.
On examination, her temperature is 37.2ºC, heart rate is 92 bpm, and blood pressure is 120/78 mmHg. There is no abdominal tenderness and a pelvic and vaginal exam are unremarkable.
What is the next appropriate step in managing this patient?Your Answer: Admit and give IM carboprost
Correct Answer: Reassure and advise sanitary towel use
Explanation:After a vaginal delivery, the loss of blood exceeding 500 ml is referred to as postpartum haemorrhage.
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 14
Correct
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A 27-year-old woman presents to the Emergency Department with vaginal bleeding and acute abdominal pain. She appears to be in distress and a pregnancy test comes back positive. During a vaginal examination, there are indications of tissue being expelled from the uterus. The patient is diagnosed with a miscarriage.
What type of miscarriage is she experiencing?Your Answer: Inevitable miscarriage
Explanation:Types of Miscarriage: Understanding the Differences
Miscarriage is a devastating experience for any woman. It is important to understand the different types of miscarriage to help manage the situation and provide appropriate care. Here are the different types of miscarriage and their characteristics:
Inevitable Miscarriage: This occurs when the products of conception are being passed vaginally, and the cervical os is open. It is an inevitable event.
Complete Miscarriage: This occurs when all the products of conception have been passed, and the cervical os is closed.
Threatened Miscarriage: This is characterised by vaginal bleeding and cramps, but the patient is not passing tissue vaginally. The uterus is of the right size for dates, and the cervical os is closed.
Septic Miscarriage: This occurs when there are retained products of conception in the uterus or cervical canal, leading to infection. The cervical os is likely to be open.
Missed Miscarriage: This is when the fetus dies in utero but is not expelled from the uterus. The uterus is small for dates, and the cervical os is closed.
Understanding the different types of miscarriage can help healthcare providers provide appropriate care and support to women experiencing this difficult event.
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This question is part of the following fields:
- Obstetrics
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Question 15
Incorrect
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A fit and well 36-week pregnant patient is admitted for a planned Caesarean section. Blood tests show the following:
Investigation Result Normal value
Haemoglobin 102 g/l 115–155 g/l
Mean corpuscular volume (MCV) 89 fl 82–98 fl
Platelets 156 × 109/l 150–400 × 109/l
White cell count (WCC) 11 × 109/l 4–11 × 109/l
With which of the following are these findings consistent?Your Answer:
Correct Answer: Dilutional anaemia of pregnancy
Explanation:Understanding Dilutional Anaemia of Pregnancy
Dilutional anaemia of pregnancy is a common condition that occurs during pregnancy. It is characterized by a normal mean cell volume (MCV) and is caused by a disproportional rise in plasma volume, which dilutes the red blood cells. This condition is the most likely option for a patient with a normal MCV.
Iron deficiency anaemia, on the other hand, is microcytic and gives a low MCV. Pancytopenia, which is the term for low haemoglobin, white cells, and platelets, is not applicable in this case as the patient’s white cells and platelets are in the normal range.
Folic acid or B12 deficiency would give rise to macrocytic anaemia with raised MCV, which is not the case for this patient. Myelodysplasia, an uncommon malignant condition that usually occurs in patients over 60, is also unlikely.
In conclusion, understanding dilutional anaemia of pregnancy is important for healthcare professionals to provide appropriate care and management for pregnant patients.
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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 in her second pregnancy has been diagnosed with pre-eclampsia and is taking labetalol twice daily. She presents to the Antenatal Assessment Unit with abdominal pain that began earlier this morning, followed by a brown discharge. The pain is constant and radiates to the back. During the examination, the uterus is hard and tender, and there is a small amount of dark red blood on the pad she presents to you. Which investigation is more likely to diagnose the cause of this patient's antepartum bleeding?
Your Answer:
Correct Answer: Transabdominal ultrasound scan
Explanation:When a patient presents with symptoms that suggest placental abruption, a transabdominal ultrasound scan is the most appropriate first-line investigation. This is especially true if the patient has risk factors such as pre-eclampsia and age over 35. The ultrasound scan can serve a dual purpose by assessing the position of the placenta and excluding placenta praevia, as well as assessing the integrity of the placenta and detecting any blood collection or haematoma that may indicate placental abruption. However, in some cases, the ultrasound scan may be normal even in the presence of placental abruption. In such cases, a magnetic resonance imaging (MRI) scan may be necessary for a more accurate diagnosis.
Before performing a bimanual pelvic examination, it is essential to rule out placenta praevia, as this can lead to significant haemorrhage and fetal and maternal compromise. A full blood count is also necessary to assess the extent of bleeding and anaemia, but it is not diagnostic of placental abruption.
An abdominal CT scan is not used as a first-line investigation for all women with antepartum haemorrhage, as it exposes the fetus to a significant radiation dose. It is only used in the assessment of pregnant women who have suffered traumatic injuries. Urinalysis is important in the assessment of women with antepartum haemorrhage, as it can detect genitourinary infections, but it does not aid in the diagnosis of placental abruption.
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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 35-year-old first-time mother is brought to the GP by her partner, who is worried about her current mood. He reports that she has been sleeping and eating very little since the birth of their baby, which was a month ago. What would be the most appropriate course of action to take next?
Your Answer:
Correct Answer: Ask the mother to complete the 'Edinburgh depression scale'
Explanation:The Edinburgh Scale is a useful tool for screening postnatal depression. The fact that the husband is bringing his wife to the GP practice a month after giving birth suggests that her mood change is not due to baby blues, which typically resolve within three days of giving birth. It is more likely that she is suffering from postnatal depression, but it is important to assess her correctly before offering any treatment such as ECT. The Edinburgh depression scale can be used to assess the patient, with a score greater than 10 indicating possible depression. If there is no immediate harm to the mother or baby, watchful waiting is usually the first step in managing this condition. There is no indication in this question that the mother is experiencing domestic abuse.
Understanding Postpartum Mental Health Problems
Postpartum mental health problems can range from mild ‘baby-blues’ to severe puerperal psychosis. To screen for depression, healthcare professionals may use the Edinburgh Postnatal Depression Scale, which is a 10-item questionnaire that indicates how the mother has felt over the previous week. A score of more than 13 indicates a ‘depressive illness of varying severity’, with sensitivity and specificity of more than 90%. The questionnaire also includes a question about self-harm.
‘Baby-blues’ is seen in around 60-70% of women and typically occurs 3-7 days following birth. It is more common in primips, and mothers are characteristically anxious, tearful, and irritable. Reassurance and support from healthcare professionals, particularly health visitors, play a key role in managing this condition. Most women with the baby blues will not require specific treatment other than reassurance.
Postnatal depression affects around 10% of women, with most cases starting within a month and typically peaking at 3 months. The features are similar to depression seen in other circumstances, and cognitive behavioural therapy may be beneficial. Certain SSRIs such as sertraline and paroxetine may be used if symptoms are severe. Although these medications are secreted in breast milk, they are not thought to be harmful to the infant.
Puerperal psychosis affects approximately 0.2% of women and requires admission to hospital, ideally in a Mother & Baby Unit. Onset usually occurs within the first 2-3 weeks following birth, and features include severe swings in mood (similar to bipolar disorder) and disordered perception (e.g. auditory hallucinations). There is around a 25-50% risk of recurrence following future pregnancies. Paroxetine is recommended by SIGN because of the low milk/plasma ratio, while fluoxetine is best avoided due to a long half-life.
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This question is part of the following fields:
- Obstetrics
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Question 18
Incorrect
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A 26-year-old woman who is 25 weeks pregnant with her second child is scheduled for a blood glucose check at the antenatal clinic due to her history of gestational diabetes during her first pregnancy. After undergoing the oral glucose tolerance test, her fasting glucose level is found to be 7.2mmol/L and her 2hr glucose level is 8 mmol/L. What is the best course of action for management?
Your Answer:
Correct Answer: Insulin
Explanation:The correct answer for the management of gestational diabetes is insulin. If the fasting glucose level is equal to or greater than 7 mmol/L at the time of diagnosis, insulin should be initiated. Diet and exercise/lifestyle advice alone is not sufficient for managing gestational diabetes and medication is necessary. Empagliflozin and glibenclamide are not appropriate treatments for gestational diabetes. Glibenclamide may only be considered if the patient has declined insulin.
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 19
Incorrect
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You are examining the blood test results of a middle-aged pregnant woman. What result would suggest the requirement for regular antenatal administration of anti-D prophylaxis at 28 weeks?
Your Answer:
Correct Answer: Rhesus negative mothers who are not sensitised
Explanation: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 20
Incorrect
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A 32-year-old pregnant woman comes for a routine check at 28 weeks gestation. During the examination, her symphysis-fundal height measures 23 cm. What is the most crucial investigation to confirm these findings?
Your Answer:
Correct Answer: Ultrasound
Explanation:The symphysis-fundal height measurement in centimetres should correspond to the foetal gestational age in weeks with an accuracy of 1 or 2 cm from 20 weeks gestation. Hence, it can be deduced that the woman is possibly experiencing fetal growth restriction. Therefore, it is crucial to conduct an ultrasound to verify if the foetus is indeed small for gestational age.
The symphysis-fundal height (SFH) is a measurement taken from the pubic bone to the top of the uterus in centimetres. It is used to determine the gestational age of a fetus and should match within 2 cm after 20 weeks. For example, if a woman is 24 weeks pregnant, a normal SFH would be between 22 and 26 cm. Proper measurement of SFH is important for monitoring fetal growth and development during pregnancy.
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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 32-year-old woman gives birth to her second child. The baby is born via normal vaginal delivery and weighs 3.8 kg. The baby has a normal Newborn and Infant Physical Examination (NIPE) after birth and the mother recovers well following the delivery. The mother wishes to breastfeed her baby and is supported to do so by the midwives on the ward.
They are visited at home by the health visitor two weeks later. The health visitor asks how they have been getting on and the mother explains that she has been experiencing problems with breastfeeding and that her baby often struggles to latch on to her breast. She explains that this has made her very anxious that she is doing something wrong and has made her feel like she is failing as a mother. When her baby does manage to latch on to feed he occasionally gets reflux and vomits afterward. The health visitor weighs the baby who is now 3.4kg.
What is the next most appropriate step?Your Answer:
Correct Answer: Refer her to a midwife-led breastfeeding clinic
Explanation:If a baby loses more than 10% of its birth weight, it is necessary to refer the mother and baby to a midwife for assistance in increasing the baby’s weight.
Breastfeeding Problems and Their Management
Breastfeeding is a natural process, but it can come with its own set of challenges. Some of the minor problems that breastfeeding mothers may encounter include frequent feeding, nipple pain, blocked ducts, and nipple candidiasis. These issues can be managed by seeking advice on proper positioning, trying breast massage, and using appropriate medication.
Mastitis is a more serious problem that affects around 1 in 10 breastfeeding women. It is characterized by symptoms such as fever, nipple fissure, and persistent pain. Treatment involves the use of antibiotics, such as flucloxacillin, for 10-14 days. Breastfeeding or expressing milk should continue during treatment to prevent complications such as breast abscess.
Breast engorgement is another common problem that causes breast pain in breastfeeding women. It occurs in the first few days after birth and affects both breasts. Hand expression of milk can help relieve the discomfort of engorgement. Raynaud’s disease of the nipple is a less common problem that causes nipple pain and blanching. Treatment involves minimizing exposure to cold, using heat packs, and avoiding caffeine and smoking.
If a breastfed baby loses more than 10% of their birth weight in the first week of life, it may be a sign of poor weight gain. This should prompt consideration of the above breastfeeding problems and an expert review of feeding. Monitoring of weight should continue until weight gain is satisfactory.
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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 31-year-old woman arrives at the obstetric department in the initial stages of labour. She is 36+4 weeks pregnant and has been experiencing polyhydramnios during this pregnancy. During examination, the foetal head is palpable on the right side of the maternal pelvis, while the buttocks are palpable on the left side. The amniotic sac remains intact. What is the best course of action for managing this patient?
Your Answer:
Correct Answer: Offer external cephalic version
Explanation:The recommended course of action for a patient in early labour with a transverse foetal lie and intact amniotic sac is to offer external cephalic version (ECV) before considering other management options. Conservative management is not appropriate as it poses a high risk of maternal and foetal death. Offering an elective caesarean section is also not the first choice, as ECV should be attempted first. An immediate caesarean section is not necessary if there are no contraindications to ECV.
Understanding Transverse Lie in Foetal Presentation
Foetal lie refers to the position of the foetus in relation to the longitudinal axis of the uterus. There are three types of foetal lie: longitudinal, oblique, and transverse. Transverse lie is a rare abnormal foetal presentation where the foetal longitudinal axis is perpendicular to the long axis of the uterus. This means that the foetal head is on the lateral side of the pelvis, and the buttocks are opposite. Transverse lie is more common in women who have had previous pregnancies, have fibroids or other pelvic tumours, are pregnant with twins or triplets, have prematurity, polyhydramnios, or foetal abnormalities.
Transverse lie can be detected during routine antenatal appointments through abdominal examination or ultrasound scan. Complications of transverse lie include preterm rupture membranes, cord-prolapse, and compound presentation. Management options for transverse lie depend on the gestational age of the foetus. Before 36 weeks gestation, no management is required as most foetuses will spontaneously move into longitudinal lie during pregnancy. After 36 weeks gestation, active management through external cephalic version (ECV) or elective caesarian section is necessary. ECV should be offered to all women who would like a vaginal delivery, while caesarian section is the management for women who opt for it or if ECV is unsuccessful or contraindicated. The decision to perform caesarian section over ECV will depend on various factors, including the risks to the mother and foetus, the patient’s preference, and co-morbidities.
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This question is part of the following fields:
- Obstetrics
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Question 23
Incorrect
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Your next patient in an antenatal clinic is a woman who is 32 weeks pregnant. What examination findings would cause you to be concerned?
Your Answer:
Correct Answer: Fundal height growth of 2 cm per week
Explanation:The expected fundal height growth per week after 24 weeks is 1 cm, not 2 cm. If the fundal height is increasing by 2 cm per week, there may be a multiple pregnancy or the baby may be larger than expected, requiring further investigation. The fundus should be palpable at the umbilicus by 20 weeks and at the xiphoid sternum by 36 weeks. The head is typically free on palpation until around 37 weeks for nulliparous women, but may engage earlier in multiparous women. Breech presentation is common before 34 weeks and only becomes a concern if preterm labor occurs.
NICE guidelines recommend 10 antenatal visits for first pregnancies and 7 for subsequent pregnancies if uncomplicated. The purpose of each visit is outlined, including booking visits, scans, screening for Down’s syndrome, routine care for blood pressure and urine, and discussions about labour and birth plans. Rhesus negative women are offered anti-D prophylaxis at 28 and 34 weeks. The guidelines also recommend discussing options for prolonged pregnancy at 41 weeks.
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This question is part of the following fields:
- Obstetrics
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Question 24
Incorrect
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A 28-year-old woman, a smoker, was referred to the Antenatal Unit with a small amount of dark brown vaginal bleeding at 39+2 weeks’ gestation. On admission, a speculum examination showed some old blood in the vagina, but no evidence of active bleeding. The cervix was long, and the os closed. Patient observations were stable, and an ultrasound scan was unremarkable. Two hours later, the emergency alarm is heard. The patient is in distress with extreme abdominal pain and fresh vaginal bleeding. The CTG records a prolonged deceleration of four minutes.
What is the most appropriate next step in the management of this patient?Your Answer:
Correct Answer: Emergency Caesarean section
Explanation:Emergency Caesarean Section for Placental Abruption: Management and Considerations
Placental abruption is a serious obstetric emergency that requires prompt management to prevent maternal and fetal morbidity and mortality. In cases where the abruption is severe and associated with fetal distress, an emergency Caesarean section is often the only option for immediate delivery of the fetus and management of the abruption.
In this scenario, the patient presents with placental abruption and has suddenly deteriorated with severe pain and fresh red bleeding, indicating a further significant abruption of the placenta associated with bleeding. This has caused an abrupt cessation or disruption in the blood flow to the fetus, leading to a prolonged deceleration. A prolonged deceleration of > 3 minutes or acute bradycardia are indications for immediate delivery of the baby.
As the scenario does not tell us whether the patient is in labor and fully dilated, an instrumental delivery cannot be performed. Additionally, there is no time to assess bleeding by vaginal delivery; the patient should be immediately transferred to theatre where an examination can be performed before proceeding with a Caesarean section.
Before going to theatre for an emergency Caesarean section, it is necessary to offer appropriate resuscitation to the mother. Intravenous fluids, a full blood count, oxygen as required, and crossmatch of two units of blood to be used if required is necessary. Intravenous fluid resuscitation can also take place in theatre, managed accordingly by the anaesthetist.
In conclusion, an emergency Caesarean section is the preferred option for immediate delivery of the fetus and management of the abruption in cases of severe placental abruption associated with fetal distress. Prompt management and appropriate resuscitation are crucial to prevent maternal and fetal morbidity and mortality.
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This question is part of the following fields:
- Obstetrics
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Question 25
Incorrect
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A 29-year-old primiparous woman presented to Labour Ward triage at 34+1/40 with upper back/chest pain and a headache. The pregnancy had been uncomplicated up to this point, with only some lower back pain over the past 2 weeks.
Obs: blood pressure 151/102, respiratory rate 18, sats 100% room air, heart rate 60 bpm, afebrile. On examination, she appeared well – PERL. Heart sounds were normal, chest was clear, and there was no shortness of breath (SOB). Her abdomen and uterus were soft and non-tender (SNT), and her calves were also SNT. Reflexes were normal. A urine dip showed nitrate +, leukocytes +, protein 1+. Electrocardiography (ECG) and cardiotocography (CTG) were both normal. Blood tests were taken, and results were pending.
Considering the likely diagnosis, what would be your first step in management?Your Answer:
Correct Answer: Start po labetalol and admit for monitoring
Explanation:Management of Pre-eclampsia with Hypertension in Pregnancy
Pre-eclampsia is a common condition affecting pregnant women, with hypertension and proteinuria being the main clinical features. The first line of management for hypertension is oral labetalol, with close monitoring of blood pressure. In cases of mild hypertension, induction of labor is not necessary. However, admission for monitoring and commencement of labetalol is recommended. IV magnesium sulfate may be needed later on, but not initially. Discharge home is not appropriate for women with pre-eclampsia. Early recognition and management of pre-eclampsia is crucial for the well-being of both the mother and the baby.
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This question is part of the following fields:
- Obstetrics
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Question 26
Incorrect
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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:
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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This question is part of the following fields:
- Obstetrics
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Question 27
Incorrect
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A 26-year-old female arrives at the emergency department complaining of sporadic abdominal pain and vaginal bleeding. She believes her last menstrual cycle was 8 weeks ago but is uncertain. She has no prior gynecological history and has never been pregnant before. Her vital signs are stable, with a blood pressure of 130/85 mmHg and a pulse rate of 79 bpm. A pregnancy test conducted in the department is positive, and a transvaginal ultrasound confirms a pregnancy in the adnexa with a fetal heartbeat present. What is the most appropriate course of action in this scenario?
Your Answer:
Correct Answer: Surgical management - salpingectomy or salpingostomy
Explanation:The patient has a confirmed ectopic pregnancy, which requires definitive treatment even though there is no evidence of rupture. While expectant management may be an option for those without acute symptoms and decreasing beta-HCG levels, close monitoring is necessary and intervention is recommended if symptoms arise or beta-HCG levels increase. If a fetal heartbeat is present, conservative and medical management are unlikely to be successful and may increase the risk of rupture, which is a medical emergency. Therefore, surgical removal of the ectopic is the most appropriate option. If the opposite tube is healthy, salpingectomy may be the preferred choice. However, if the opposite tube is damaged, salpingostomy may be considered to preserve the functional tube and reduce the risk of future infertility.
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 28
Incorrect
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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:
Correct 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 29
Incorrect
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A 33-year-old woman who is 28 weeks pregnant arrives at the emergency department with painless vaginal bleeding. She had her second baby three years ago, which was delivered via a c-section, but otherwise was a normal pregnancy. Upon obstetric examination, her uterus was non-tender, however, her baby was in breech presentation. The foetal heart rate was also normal, and she denied experiencing any contractions during the bleeding episode. What is the recommended next investigation for the most probable diagnosis?
Your Answer:
Correct Answer: Transvaginal ultrasound
Explanation:Understanding Placenta Praevia
Placenta praevia is a condition where the placenta is located wholly or partially in the lower uterine segment. It is a relatively rare condition, with only 5% of women having a low-lying placenta when scanned at 16-20 weeks gestation. However, the incidence at delivery is only 0.5%, as most placentas tend to rise away from the cervix.
There are several factors associated with placenta praevia, including multiparity, multiple pregnancy, and embryos implanting on a lower segment scar from a previous caesarean section. Clinical features of placenta praevia include shock in proportion to visible loss, no pain, a non-tender uterus, abnormal lie and presentation, and a usually normal fetal heart. Coagulation problems are rare, and small bleeds may occur before larger ones.
Diagnosis of placenta praevia should not involve digital vaginal examination before an ultrasound, as this may provoke severe haemorrhage. The condition is often picked up on routine 20-week abdominal ultrasounds, but the Royal College of Obstetricians and Gynaecologists recommends the use of transvaginal ultrasound for improved accuracy and safety. Placenta praevia is classified into four grades, with grade IV being the most severe, where the placenta completely covers the internal os.
In summary, placenta praevia is a rare condition that can have serious consequences if not diagnosed and managed appropriately. It is important for healthcare professionals to be aware of the associated factors and clinical features, and to use appropriate diagnostic methods for accurate grading and management.
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This question is part of the following fields:
- Obstetrics
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Question 30
Incorrect
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A 35-year-old woman gives birth to twins through vaginal delivery after induction. She experiences a blood loss of 800ml and continues to bleed, but her haemodynamic status remains stable. What should be the next course of action in managing this patient?
Your Answer:
Correct Answer: Uterine massage
Explanation:To manage a postpartum haemorrhage, an ABC approach should be followed, which involves palpating the uterine fundus and catheterising the patient. In this case, the cause of PPH is uterine atony, which is indicated by risk factors such as induction of labour and multiple pregnancy. The ABCDE approach should be used in all emergency situations, but since the patient is haemodynamically stable, the focus should be on addressing the bleeding. According to RCOG guidelines, pharmacological and mechanical measures should be taken to stop bleeding when uterine atony is the perceived cause. Uterine massage is the most appropriate option in accordance with the guidelines.
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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