6/16/2018 Obstetrics page 1 | StratOG

6/16/2018 Obstetrics page 1 | StratOG

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A 40-year-old woman is seen in the antenatal clinic at 20 weeks ofgesta�on. Both her booking and anomaly scan are normal. She has a BMI of24. She had a previous vaginal delivery at 39 weeks of gesta�on of a babyweighing 1.8 kg. She smokes 20 cigare�es per day. What is the next mostappropriate inves�ga�on?

Q

Your answer:

Correct answer:

AUmbilical artery Doppler at 26–28 weeks of gesta�on>

Umbilical artery Doppler at 26–28 weeks of gesta�on>

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The correct answer is umbilical artery Doppler at 26–28 weeks ofgesta�on. If women have a major risk factor for fetal growthrestric�on they should have serial umbilical artery Doppler scansfrom 26–28 weeks of gesta�on. This woman has several risk factorsincluding two major factors: smoking >11 cigare�es/day and aprevious small-for-gesta�onal-age baby. Note that women withthree or more minor risk factors for fetal growth restric�on shouldbe referred for uterine artery doppler at 20–24 weeks of gesta�on.See Royal College of Obstetricians and Gynaecologists. Theinves�ga�on and management of the small-for-gesta�onal-agefetus. Green-top Guideline 31. London: RCOG. 2013.(h�ps://www.rcog.org.uk/en/guidelines-research-services/guidelines/gtg31/)

A 28-year-old woman dies at 47 days postpartum following aspira�onduring an epilep�c seizure. She had a 10 year history of epilepsy. What isthe classifica�on of this maternal death?

Q

Your answer:

Correct answer:

The correct answer is late indirect maternal death. A maternal deaththat occurs 6 weeks following child birth is termed as late maternaldeath. If death occurs of a pre-exis�ng medical condi�on it is calledan indirect maternal death. See Maternal, Newborn and InfantClinical Outcome Review Programme. Saving Lives, ImprovingMother's Care. Lessons learned to inform future maternity care fromthe UK and Ireland Confiden�al Enquiries into Maternal Deaths andMorbidity 2009–2012. Oxford: Na�onal Perinatal Epidemiology Unit,University of Oxford. 2014. (h�p://www.npeu.ox.ac.uk/mbrrace-uk/reports)

ALate indirect maternal death>

Late indirect maternal death>

https://www.rcog.org.uk/en/guidelines-research-services/guidelines/gtg31/

http://www.npeu.ox.ac.uk/mbrrace-uk/reports



A 25-year-old primigravida woman is admi�ed to the labour ward withregular contrac�ons and draining clear liquor. She is a known carrier forStreptococcus B in this pregnancy. Shortly a�er being given a loading doseof benzylpenicillin, she becomes wheezy, develops a rash and has difficultybreathing. What is the most appropriate ini�al dose of intramuscularadrenaline?

Q

Your answer:

Correct answer:

The correct answer is 0.5 mg (0.5 ml of 1:1000). The correct dose ofintramuscular (im) adrenaline in anaphylac�c shock is 0.5mg. Dosesof 0.01 mg, 0.05mg and 0.1 mg are too small for therapeu�c effectin circulatory collapse by im route and would be more appropriatedoses for iv route. 10mg is too large for an ini�al dose but if there isa subop�mal response to ini�al dose, then injec�ons should berepeated every 10 minutes and may therefore reach anaccumula�ve dose of 10 mg. See the Bri�sh Na�onal Formulary(h�p://www.bnf.org/bnf/index.htm).

A0.5 mg (0.5 ml of 1:1000)>

0.5 mg (0.5 ml of 1:1000)>

A 42-year-old primigravid woman presents in spontaneous labour at 37weeks of gesta�on. She develops central crushing chest pain which radiatesto her le� jaw. Which of the following cardiac biomarkers is most reliablefor diagnosing acute myocardial infarc�on during labour and delivery?

Q

Your answer:

Correct answer:

The correct asnwer is Troponin I. Troponin I is unaffected by labour,anaesthesia or delivery. See Wuntakal R, She�y N, Ioannou E,Sharma S, Kurian J. Myocardial infarc�on and pregnancy. TheObstetrician & Gynaecologist 2013;15:247–55.(h�p://onlinelibrary.wiley.com/doi/10.1111/tog.12052/full)

ATroponin I>

Troponin I>

http://www.bnf.org/bnf/index.htm

http://onlinelibrary.wiley.com/doi/10.1111/tog.12052/full



The obstetric team are conduc�ng a study to evaluate whether there hasbeen any effect on pa�ent sa�sfac�on following the establishment of anoutpa�ent induc�on of labour (IOL) programme. Women undergoinginpa�ent IOL and women undergoing outpa�ent IOL were asked to ratetheir overall sa�sfac�on with the process using a visual analogue scale from1 (least sa�sfied) to 10 (most sa�sfied). What is the most appropriatesta�s�cal test to assess whether there is a significant difference insa�sfac�on between the two groups?

Q

Your answer:

Correct answer:

The correct answer is the Mann Whitney U test. See Campbell MJ,Machin D, Walters SJ. Medical sta�s�cs: a textbook for the healthsciences (medical sta�s�cs). Wiley-Blackwell. 2007.

AMann Whitney U test>

Mann Whitney U test>

A woman a�ends the antenatal clinic at 30 weeks of gesta�on and disclosesthat she had suspected whooping cough 2 months earlier. What is thesingle best recommenda�on regarding pertussis immunisa�on?

Q

Your answer:

Correct answer:

The correct answer is that maternal vaccina�on should be givennow. Despite high vaccina�on coverage in Britain since the 1990s,pertussis con�nues to display 3–4 yearly peaks in ac�vity. In 2012there was a major leap in pertussis, with levels above thosereported in the previous 20 years. It was seen in all age groups.Infants under 3 months are at highest risk of complica�ons anddeath. In view of the outbreak in 2012 all pregnant women areoffered pertussis vaccina�on during pregnancy.

AMaternal vaccina�on should be given now>

Maternal vaccina�on should be given now>



You are asked to repair a vaginal tear following a normal delivery. Themother’s weight is 60 kg. She is otherwise well with no allergies. What isthe maximum dose of lidocaine 1% without epinephrine that you can usefor perineal infiltra�on?

Q

Your answer:

Correct answer:

The correct answer is 18 ml (180 mg). The maximum dose oflidocaine is 3 mg/kg. As the woman's weight is 60 kg, the dose is 3 x60 = 180 mg total dose. 1% lidocaine contains 1 x 10 mg/ml = 10mg/ml. Therefore the maximum volume is 180 /10 = 18 ml of 1%lidocaine. See StratOG Core Training eTutorial on Obstetric analgesiaand anaesthesia (h�ps://stratog-live.rcog.org.uk/tutorials/core-training/management-labour-and-delivery/obstetric-analgesia-and-anaesthesia) and Anaesthesia UK. Pharmacology of regionalanaesthesia. Accessed online 27 January 2015(h�p://www.frca.co.uk/ar�cle.aspx?ar�cleid=100816).

A18 ml (180 mg)>

18 ml (180 mg)>

A woman who is 24 weeks pregnant contacts the maternity day unitrepor�ng possible exposure to facial shingles 4 days earlier. The pregnantwoman believes she has had chickenpox when she was a child. What adviceshould she be given?

Q

Your answer:

Correct answer:

The correct answer is offer tes�ng for varicella zoster virus (VZV)immunity and, if non-immune, offer varicella zoster immunoglobulin(VZIG). VZV is highly contagious and can be transmi�ed byrespiratory droplets, direct personal contacts or fomites. It ispossible to catch it from both chickenpox and herpes zoster (HZ) butit is highly unlikely if the HZ is in non-exposed sites. VZIG is effec�ve

AOffer tes�ng for varicella zoster virus (VZV) immunity and, if non-immune, offer varicella zoster immunoglobulin (VZIG)

>

Offer tes�ng for varicella zoster virus (VZV) immunity and, if non-immune, offer varicella zoster immunoglobulin (VZIG)

>

https://stratog-live.rcog.org.uk/tutorials/core-training/management-labour-and-delivery/obstetric-analgesia-and-anaesthesia

http://www.frca.co.uk/article.aspx?articleid=100816



when given up to 10 days a�er contact. The pregnant womanshould then be considered as infec�ous for 8 to 28 days a�erreceiving VZIG.

A pregnant woman with a BMI of 25 sees her midwife at 24 weeks ofgesta�on. A single symphysis fundal height (SFH) measurement isundertaken which is less than expected for this gesta�on. What is the mostappropriate management?

Q

Your answer:

Correct answer:

The correct answer is refer if SFH measurement on a customisedchart plots below the 10th cen�le. Abdominal palpa�on is poor atpredic�ng small-for-gesta�onal-age (SGA) babies, especially in amixed risk popula�on. SFH using a customised growth chart whichtakes into account maternal height, weight, parity and ethnic groupimproves the predic�on of SGA babies, but there is wide varia�on inthe predic�ve accuracy ranging from a sensi�vity of 27–86% and aspecificity of 80–93%. See Royal College of Obstetricians andGynaecologists. The inves�ga�on and management of the small–for–gesta�onal–age fetus. Green-top guideline 31. London: RCOG.2014. (h�ps://www.rcog.org.uk/en/guidelines-research-services/guidelines/gtg31/)

ARefer if SFH measurement on a customised chart plots below the10th cen�le

>

Refer if SFH measurement on a customised chart plots below the10th cen�le

>

A woman has an intrapartum s�llbirth. Despite extensive discussion andexplana�on of the management of the pregnancy and delivery with herconsultant, she s�ll expresses dissa�sfac�on. She indicates that she wishesto explore further whether the s�llbirth should have been avoided. On award round she asks you whom she should contact for help. To which of thefollowing organisa�ons would you direct her in the first instance?

Q




Your answer:

Correct answer:

The correct answer is the Pa�ent Advice and Liaison Service. If apa�ent has a complaint or concern, it is best dealt with by theprovider of the health care in the first instance. Other organisa�onsmay be appropriate if the ini�al response is not sa�sfactory.

APa�ent Advice and Liaison Service>

Pa�ent Advice and Liaison Service>

Royal College of Obstetricians and Gynaecologists© 2018

Registered charity no. 21328027 Sussex Place Regent's Park London NW1 4RG UK

Tel +44 20 7772 6200Fax +44 20 7723 0575



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Gesta�onal diabetes is a common complica�on of pregnancy. Whathormonal factor is predominantly responsible?Q

Your answer:

Correct answer:

The corerct answer is human placental lactogen. See Nelson-PiercyC. Handbook of obstetric medicine. Fourth edi�on. CRC Press. 2010.

AHuman placental lactogen>

Human placental lactogen>







A 28-year-old woman a�ends for prepregnancy counselling. Her maternalgrandfather and her mother's brother have haemophilia A. Her husband ishealthy but she has been screened and is a carrier. What is the risk that herfuture son would inherit this disease?

Q

Your answer:

Correct answer:

The correct answer is 50%. Haemophilia A is an X-linked recessivedisorder so 50% of her sons will be affected and 50% of herdaughters will be carriers.

A50%>

50%>

A 27-year-old primigravida presents at 36 weeks of gesta�on in labour. Shereports watery vaginal discharge for a while. On examina�on hertemperature, pulse and blood pressure are normal. She is contrac�ngmoderately and clear liquor can be seen draining. The fetal heart rate is 136bpm. On vaginal examina�on the cervix is 3 cm dilated. Membranes areabsent. What is the most appropriate management to reduce the risk ofearly onset neonatal infec�on?

Q

Your answer:

Correct answer:

The correct answer is prescribe intrapartum an�bio�c prophylaxiswith any dura�on of prelabour rupture of membranes. In pretermlabour, an�bio�cs should be considered if membranes rupture atany �me prior to the onset of labour. If the woman is at term,an�bio�cs should only be given if the woman has had a posi�veculture for GBS in this pregnancy or has clinical signs of infec�on.See Na�onal Ins�tute for Health and Clinical Excellence. Neontalinfec�on (early onset): an�bio�cs for preven�on and treatment.CG149. London: NICE; 2012.(h�p://www.nice.org.uk/guidance/cg149)

APrescribe intrapartum an�bio�c prophylaxis with anydura�on of prelabour rupture of membranes

>

Prescribe intrapartum an�bio�c prophylaxis with anydura�on of prelabour rupture of membranes

>

http://www.nice.org.uk/guidance/cg149



A 30-year-old woman books in the antenatal clinic at 12 weeks of gesta�onwith a BMI of 40. This is her first baby and she is normally fit and well withno family history of note. With regard to her BMI, which complica�on ofpregnancy is the highest risk compared to women with a normal BMI?

Q

Your answer:

Correct answer:

The correct answer is venous thromboembolism. The risk ofdiabetes is about three �mes higher. The risk of hypertensivedisease is two-to-three �mes higher. Caesarean sec�on, s�llbirthand postpartum haemorrhage are about twice as likely in womenwith a high BMI. Venous thromboembolism is, however, nine �meshigher in this group. See the CMACE/RCOG Joint Guideline.Management of women with obesity in pregnancy. CMACE. 2010(h�ps://www.rcog.org.uk/globalassets/documents/guidelines/cmacercogjointguidelinemanagementwomenobesitypregnancya.pdf).

AVenous thromboembolism>

Venous thromboembolism>

A pregnant woman is iden�fied as being suscep�ble to rubella from herfirst trimester booking blood results. When discussing this result at the nextantenatal clinic appointment, what is the most appropriate advice that sheshould be given?

Q

Your answer:

Correct answer:

AA single dose of MMR should be offered immediately postnatallywith a second dose at the six-week postnatal check

>

A single dose of MMR should be offered immediately postnatallywith a second dose at the six-week postnatal check

>

https://www.rcog.org.uk/globalassets/documents/guidelines/cmacercogjointguidelinemanagementwomenobesitypregnancya.pdf



The correct answer is a single dose of MMR should be offeredimmediately postnatally with a second dose at the six-weekpostnatal check. The clinical diagnosis of rubella is unreliable andsince the risk to the fetus is in the first 16 weeks of pregnancy it isimportant that the woman is immunised before she can becomepregnant again. Between 2005 and 2009 there were six cases ofcongenital rubella, five of whom were born to mothers who wereborn outside the UK. See the NHS Screening Programme website:Infec�ous diseases in pregnancy(h�p://webarchive.na�onalarchives.gov.uk/20150408175925/h�p://infec�ousdiseases.screening.nhs.uk/rubella) (accessed02/07/2015) and the HPA Guidance on viral rash in pregnancy(h�ps://www.gov.uk/government/uploads/system/uploads/a�achment_data/file/322688/Viral_rash_in_pregnancy_guidance.pdf)(accessed 19/11/2014).

A 25-year-old primigravida presents at 32 weeks of gesta�on with itching.Following a blood test, she is diagnosed with obstetric cholestasis. Whichpharmacological agent would be the most effec�ve treatment?

Q

Your answer:

Correct answer:

The correct answer is ursodeoxycholic acid. Pruri�s in pregnancy iscommon, affec�ng nearly a quarter of pregnant women. Obstetriccholestasis is diagnosed when abnormal liver func�on tests arefound in associa�on with pruri�s. Normal pregnancy values shouldbe used with an upper limit of normal 20% below nonpregnantlevels for transaminases, γ-glutamyl transferase and bilirubin.Alkaline phosphatase is generally raised in pregnancy due toplacental produc�on.

Topical emollients may provide temporary relief of pruri�s. S-adenosyl methionine is not recommended and dexamethasoneshould only be used as part of a trial. Vitamin K should beprescribed if the prothrombin �me is prolonged, but is not aneffec�ve treatment. See Royal College of Obstetricians and

AUrsodeoxycholic acid>

Ursodeoxycholic acid>

http://webarchive.nationalarchives.gov.uk/20150408175925/http://infectiousdiseases.screening.nhs.uk/rubella

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/322688/Viral_rash_in_pregnancy_guidance.pdf




Gynaecologists. Obstetric cholestasis. Green-top Guideline 43.London: RCOG; 2011. (h�ps://www.rcog.org.uk/en/guidelines-research-services/guidelines/gtg43/)

A 32-year-old woman is in labour in her second pregnancy. Her previousdelivery was by caesarean sec�on. What is the most consistent indicator ofuterine rupture for this woman?

Q

Your answer:

Correct answer:

The correct answer is abnormal CTG. Vaginal birth a�er anuncomplicated lower segment caesarean sec�on is successful in 72–76% of women. The risk of uterine rupture is 22–74/10 000 (0.22–0.74%). This is lower if the woman labours preterm (34/10 000 vs74/10 000). An abnormal CTG is the most consistent finding indehiscence, occurring in 55–87% of cases. See Royal College ofObstetricians and Gynaecologists. Birth a�er previous caesareanbirth. Green-top Guideline 45. London: RCOG; 2007.(h�ps://www.rcog.org.uk/en/guidelines-research-services/guidelines/gtg45/)

AAbnormal CTG>

Abnormal CTG>

A 29-year-old primigravida presents with chest pain and is diagnosed withmyocardial infarc�on. Her BMI is 29 and she does not have any significantmedical or family history. What is the most likely cause of acute myocardialinfarc�on in this case?

Q

Your answer:

Correct answer:

ACoronary artery dissec�on>

Coronary artery dissec�on>





The correct answer is coronary artery dissec�on. Cardiac diseaseremains a significant cause of maternal death with 54 deaths per100 000 materni�es in the most recent triennial report (2009–2012). There are profound physiological changes in pregnancy thataffect the heart. The most common cause is atherosclerosis, anddiabetes and smoking are significant risk factors. In women with nocardiovascular risk factors, coronary artery dissec�on may occur. It isthought that this results from changes in the vessel wall related tohigh progesterone levels. See Wuntakal R, She�y N, Ioannou E,Sharma S, Kurian J. Myocardial infarc�on and pregnancy. TheObstetrician & Gynaecologist 2013;15:247–55(h�p://onlinelibrary.wiley.com/doi/10.1111/tog.12052/full).

A 35-year-old woman has recently undergone gastric bypass surgery. She isplanning a pregnancy. How long should she be advised to delay concep�onfor?

Q

Your answer:

Correct answer:

The correct answer is 1 year. The majority of bariatric surgery iscarried out on women of childbearing years. Current advice is todelay concep�on for a year. However, data to support thisrecommenda�on is lacking, with many studies showing nodifference in outcomes in those women conceiving earlier than 12months and those conceiving later. See Khan R , Dawlatly B,Chappa�e O. Pregnancy outcome following bariatric surgery. TheObstetrician & Gynaecologist 2013;15:37–43(h�p://onlinelibrary.wiley.com/doi/10.1111/j.1744-4667.2012.00142.x/full).

A1 year>

1 year>

A 36-year-old woman a�ends the antenatal clinic at 20 weeks of gesta�on.She has had three previous caesarean sec�ons and has a normal placentalsite. She consented for another caesarean sec�on. What is the most likely

Q


http://onlinelibrary.wiley.com/doi/10.1111/j.1744-4667.2012.00142.x/full



surgical complica�on?

Your answer:

Correct answer:

The correct answer is blood transfusion. Elec�ve repeat caesareansec�on is associated with increasing risks that rise with eachsuccessive pregnancy. Blood transfusion rises from 7.9% with a thirdcaesarean sec�on to 14.1% with the fi�h caesarean. See RoyalCollege of Obstetricians and Gynaecologists. Birth a�er previouscaesarean birth. Green-top Guideline 45. London: RCOG; 2007(h�ps://www.rcog.org.uk/en/guidelines-research-services/guidelines/gtg45/).

ABlood transfusion>

Blood transfusion>



Tel +44 20 7772 6200Fax +44 20 7723 0575




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Obstetrics page 3

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AssessmentHistory




You are asked to review a woman following a forceps delivery. She presentswith le� lateral calf paraesthesia, sensory loss between her first and secondtoes and foot drop with inversion. Which nerve compression is the likelycause of her symptoms?

Q

Your answer:

Correct answer:

The correct answer is the common peroneal nerve. The commonperoneal nerve is prone to compression at the fibular head duringposi�oning in s�rrups. See Kuponiyi O, Alleemudder DI, Latunde-

ACommon peroneal nerve>

Common peroneal nerve>





http://onlinelibrary.wiley.com/doi/10.1111/tog.12064/abstract



Dada A, Eedarapalli P. Nerve injuries associated with gynaecologicalsurgery. The Obstetrician & Gynaecologist 2014;16:29–36(h�p://onlinelibrary.wiley.com/doi/10.1111/tog.12064/abstract).

The midwives on the postnatal ward are concerned about the behaviour ofa first �me mother, who they are about to discharge home. They ask you toreview her. She had an elec�ve caesarean sec�on for a breech presenta�on3 days ago. She is otherwise fit and well, but has a past history ofdepression. Which symptoms would concern you the most and lead you tothe diagnosis of postpartum psychosis?

Q

Your answer:

Correct answer:

The correct answer is bewilderment and perplexity. Most of thesesymptoms are features of 'baby blues' which affects 30–80% ofbirths in the first week postpartum. Confusion, bewilderment andperplexity are worrying symptoms and should alert you to thediagnosis of postpartum psychosis. See Di Florio A, Smith S, Jones I.Postpartum psychosis. The Obstetrician & Gynaecologist2013;15:145–50(h�p://onlinelibrary.wiley.com/doi/10.1111/tog.12041/full).

ABewilderment and perplexity>

Bewilderment and perplexity>

A 25-year-old pregnant woman with sickle cell disease a�ends theantenatal clinic at 8 weeks of gesta�on. What prenatal tes�ng should bediscussed in the first instance?

Q

Your answer:

Correct answer:

APartner tes�ng>

Partner tes�ng>

http://onlinelibrary.wiley.com/doi/10.1111/tog.12064/abstract




The correct answer is partner tes�ng. Ideally this will have beenascertained this in advance. Preconcep�on counselling is veryimportant if the couple are iden�fied as an 'at risk couple'. This isnot just if her partner carries HbS, but also if there are othercondi�ons detected, e.g. β-thalassaemia or HbC.

A primigravida wishes to opt for epidural analgesia in labour at term butshe has heard that regional analgesia increases the risk of opera�ve vaginaldelivery which she is keen to avoid. Assuming she opts for an epiduralanalgesia, how can the second stage of labour be managed to reduce thisrisk for her?

Q

Your answer:

Correct answer:

The correct answer is allow up to two hours for passive descent.Primiparous women are likely to have fewer rota�onal or mid-cavityopera�ve deliveries when pushing is delayed for 1–2 hours or un�lthey have a strong urge to push. Although a small trial suggestedthat star�ng oxytocin at full dilata�on reduced the opera�vedelivery rate, NICE concluded it should not be used on the basis ofone study. See Na�onal Ins�tute for Health and Clincial Excellence.Intrapartum care. CG190. London: NICE; 2014(h�ps://www.nice.org.uk/guidance/cg190) and Royal College ofObstetricians and Gynaecologists. Opera�ve vaginal delivery. Green-top Guideline 26. London: RCOG; 2011(h�ps://www.rcog.org.uk/en/guidelines-research-services/guidelines/gtg26/).

AAllow up to two hours for passive descent>

Allow up to two hours for passive descent>

A 30-year-old primigravida a�ends the delivery suite at 40 weeks ofgesta�on with prelabour rupture of membranes. On reviewing the notesshe has a posi�ve result for group B streptococcus (GBS) in her urine oneweek ago. She has no known drug allergies. According to the NICEguidelines which an�bio�c should she receive?

Q

https://www.nice.org.uk/guidance/cg190




Your answer:

Correct answer:

The correct answer is benzyl penicillin intravenously. GBS(streptococcus agalac�ae) is an important cause of neonatalmorbidity and mortality. Studies have shown that both ampicillinand benzyl penicillin reduce the incidence of early onset disease,but benzyl penicillin is recommended because it is less likely topromote an�bio�c resistance. If penicillins are contraindicated,clindamycin is recommended unless there is evidence of localresistance pa�erns that would suggest using an alterna�ve. SeeMugglestone MA, Murphy MS, Visin�n C, Howe DT, Turner MA.An�bio�cs for early-onset neonatal infec�on: a summary of theNICE guideline 2012. The Obstetrician & Gynaecologist 2014;16:87–92 (h�p://onlinelibrary.wiley.com/doi/10.1111/tog.12085/full).

ABenzyl penicillin intravenously>

Benzyl penicillin intravenously>

A 30-year-old pregnant woman who is at 28 weeks of gesta�on presents tothe Day Assessment Unit complaining of flu-like symptoms. She tells youthat she recently went on holiday to Kenya. What is the most appropriatetest for the diagnosis of malaria?

Q

Your answer:

Correct answer:

The correct answer is thick and thin blood film for parasites. Thegold standard is thick and thin blood films in pregnancy rather thana rapid diagnos�c test. Serology is only useful in syphilis. See RoyalCollege of Obstetricians and Gynaecologists. The diagnosis andtreatment of malaria in pregnancy. Green-top Guideline 45B.London; RCOG: 2010 (h�ps://www.rcog.org.uk/en/guidelines-research-services/guidelines/gtg54b/).

AThick and thin blood film for parasites>

Thick and thin blood film for parasites>


https://www.rcog.org.uk/en/guidelines-research-services/guidelines/gtg54b/



A 28-year-old primigravida, presents at 36+3 weeks of gesta�on in theantenatal clinic with a breech presenta�on. There are no obstetric or fetalcontraindica�ons to external cephalic version (ECV). An ini�al ECV withouttocolysis failed two days earlier. What is the most appropriate managementop�on?

Q

Your answer:

Correct answer:

The correct answer is another ECV with tocolysis. ECV should beoffered a�er 37 weeks of gesta�on in mul�parous women and a�er36 weeks of gesta�on in primiparous women. Another ECV can beoffered if the first one fails. The use of tocolysis increases thesuccess rate a�er a failed ini�al a�empt. If a caesarean secton isoffered it needs to be a�er 38+6 weeks of gesta�on. Breech deliverymay not be the most appropriate management considering she isprimiparous. There is insufficient evidence to support the use ofpostural management or Moxibus�on as a method of promo�ngspontaneous version over ECV. See Royal College of Obstetriciansand Gynaecologists. External cephalic version (ECV) and reducingthe incidence of breech presenta�on. Green-top Guideline 20a.London: RCOG; 2010 (h�ps://www.rcog.org.uk/en/guidelines-research-services/guidelines/gtg20a/).

AAnother ECV with tocolysis>

Another ECV with tocolysis>

A 34-year-old primigravida presents to the maternity assessment unit witha second episode of decreased fetal movements at 34+4 weeks ofgesta�on. She is known to be low risk and has had an otherwise uneven�ulpregnancy. What is the most appropriate management op�on?

Q

Your answer:

Correct answer:

The correct answer is to perform a CTG and arrange a scan.Counselling of women in the antenatal period about the significanceof fetal movements and rela�onship of this to s�ll births is

APerform a CTG and arrange a scan>

Perform a CTG and arrange a scan>

https://www.rcog.org.uk/en/guidelines-research-services/guidelines/gtg20a/



increasingly being offered in UK. Delivery would not be warrantedunless further tes�ng reveals an abnormality, e.g. an abnormalDoppler scan or a pathological CTG. There is no evidence that anyformal defini�on of reduced fetal movements is of greater valuethan subjec�ve maternal percep�on in the detec�on of fetalcompromise. Biophysical profiling has not shown to be of benefit.See Unterscheider J, Horgan R, O'Donoghue K, Greene R. Reducedfetal movements. The Obstetrician & Gynaecologist 2009;11:245–51(h�p://onlinelibrary.wiley.com/doi/10.1576/toag.11.4.245.27527/full) and Royal College of Obstetricians and Gynaecologists. Reducedfetal movements. Green-top Guideline 57. London: RCOG; 2011(h�ps://www.rcog.org.uk/en/guidelines-research-services/guidelines/gtg57/).

A woman presents for booking in the first trimester, she is taking lithium forher mental health. How o�en should her serum lithium levels be checked?Q

Your answer:

Correct answer:

The correct answer is every 4 weeks un�l 36 weeks of gesta�on.Lithium is an important drug in maintaining mental health buttaking it in pregnancy is not without risks as the incidence of fetalheart defects are increased. If it is not for the woman to stop takingthe drug prior to concep�on, lithium levels should be monitoredevery 4 weeks un�l 36 weeks of gesta�on, and then weekly un�ldelivery. Lithium levels should be checked again within 24 hours ofdelivery and the dose should be adjusted to maintain a level in thelower part of the therapeu�c range. See Na�onal Ins�tute forHealth and Clinical Excellence. Antenatal and postnatal mentalhealth. CG45. London: NICE; 2007(h�ps://www.nice.org.uk/guidance/CG45).

AEvery 4 weeks un�l 36 weeks of gesta�on>

Every 4 weeks un�l 36 weeks of gesta�on>

http://onlinelibrary.wiley.com/doi/10.1576/toag.11.4.245.27527/full


https://www.nice.org.uk/guidance/CG45



A 25-year-old woman is found to have a platelet count of 110 x 10*9/lwhen tested rou�nely at 28 weeks of gesta�on. Her platelet count at 12weeks of gesta�on was 352 x 10*9/l. She has no history of illness. What isthe most likely diagnosis from the list below?

Q

Your answer:

View correct answer

AVitamin B12 deficiency>



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A 32-year-old primigravid woman a�ends the antenatal clinic complainingof persistent mild pruritus due to atopic erup�on of pregnancy. Which isthe first line treatment in reducing pruritus and providing relief of hersymptoms?

Q

Your answer:

Correct answer:

The correct answer is emollients. The two most common skinproblems in pregnancy are atopic erup�on of pregnancy andpolymorphic erup�on of pregnancy. In about half of all women who

AEmollients>

Emollients>







complain of skin problems in pregnancy it is an exacerba�on of apre-exis�ng condi�on. Atopic erup�on of pregnancy may requiretopical steroids and an�histamines, but can o�en be managed withemollients. See Vaughan Jones S, Ambros-Rudolph C, Nelson-PiercyC. Skin disease in pregnancy. BMJ 2014;348:26–30 [Abstract only](h�p://www.bmj.com/content/348/bmj.g3489.long).

At the evening handover of a busy labour ward, you are informed that acord prolapse has been diagnosed a�er amniotomy with the presen�ngpart at –3 sta�on. On CTG, the baseline is 115 bpm with 10 bpm variabilityand one variable decelera�on las�ng less than 30 seconds over the last 10minutes. The obstetric emergency theatre is currently being used for amanual removal of the placenta. What is the most appropriatemanagement for this woman?

Q

Your answer:

Correct answer:

The correct answer is to open the second emergency theatre for acategory 2 sec�on. A category 2 caesarean sec�on is appropriate forwomen in whom the fetal heart rate pa�ern is normal. However, ifthe CTG becomes abnormal it should be re-categorised to category1. See Royal College of Obstetricians and Gynaecologists. Umbilicalcord prolapse. Green-top Guideline 50. London: RCOG; 2014(h�ps://www.rcog.org.uk/en/guidelines-research-services/guidelines/gtg50/).

AOpen the second emergency theatre for a category 2 sec�on>

Open the second emergency theatre for a category 2 sec�on>

You have been asked to review a postnatal woman with known type 1insulin dependent diabetes mellitus who was successfully deliveredovernight. She is now ea�ng and drinking normally and the postdeliverycapillary blood glucose readings are all between 4 and 7 mmol/l. The plan isto stop the intravenous insulin/dextrose sliding scale and recommence

Q

http://www.bmj.com/content/348/bmj.g3489.long




subcutaneous insulin. She wishes to breas�eed her baby. What is the mostappropriate advice for the woman regarding recommencing hersubcutaneous insulin?

Your answer:

Correct answer:

The correct answer is to reduce her prepregnancy insulin dose by25%. Once women with type 1 diabetes are ea�ng normally,subcutaneous insulin should be recommenced at a 25% lower doseof her prepregnancy dose if she intends to breas�eed. Breas�eedingis associated with increased energy expenditure. Nelson-Piercy C.Handbook of obstetric medicine. Fourth edi�on. CRC Press. 2010.

AReduce her prepregnancy insulin dose by 25%>

Reduce her prepregnancy insulin dose by 25%>

An ST5 trainee performs an elec�ve Caesarean sec�on for a primigravidawith a breech presenta�on. The woman's BMI is 23. She has had noprevious abdominal surgery. A straight transverse abdominal incision ismade 3 cm below the level of the anterior superior iliac spines. Thesubcutaneous �ssue and rectus sheath are opened in the midline andextended laterally with blunt finger dissec�on. Blunt dissec�on is used toseparate the rectus muscles and enter the peritoneum. Which transverseabdominal incision is described above?

Q

Your answer:

Correct answer:

The correct answer is Joel-Cohen. Pfannens�el and Kustner arecurved incisions using sharp dissec�on. Cherney and Maylard aremuscle cu�ng incisions. Raghavan R, Arya P, Arya P, China S.Abdominal incisions and sutures in obstetrics and gynaecology. TheObstetrician & Gynaecologist 2014;16:13–18(h�p://onlinelibrary.wiley.com/doi/10.1111/tog.12063/full).

AJoel-Cohen>

Joel-Cohen>




A 35-year-old woman presents to the antenatal clinic in her first pregnancyat 28 weeks of gesta�on with daily headaches. Her BMI was noted to be 36.The pain is mainly at the back of her eyes, and gets worse on eyemovements. She describes her headaches as throbbing in nature. She alsono�ces transient visual disturbances. Ophthalmological examina�onrevealed papilledema. Neurological examina�on was normal. Which of thefollowing is the most appropriate interven�on?

Q

Your answer:

Correct answer:

The correct answer is acetazolamide. Idiopathic intracranialhypertension (IIH) is a rare but important cause of headache inpregnancy. A detailed history and examina�on is essen�al. IIH tendsto present in the first half of pregnancy and women with IIH areo�en overweight. The diagnosis is made using the modified Dandycriteria. See Thirumalaikumar L, Ramalingam K, Heafield T.Idiopathic intracranial hypertension in pregnancy. The Obstetrician& Gynaecologist 2014;16:93–7(h�p://onlinelibrary.wiley.com/doi/10.1111/tog.12087/full).

AAcetazolamide>

Acetazolamide>

A primigravida presents at the antenatal clinic with a monochorionicdiamnio�c (MCDA) twin pregnancy at 24 weeks of gesta�on. Ultrasoundshows that twin 1 has oligohydramnios with absent end-diastolic flow inthe umbilical artery (UA) doppler. Twin 2 has polyhydramnios with posi�veend-diastolic flow in the UA doppler. What would be the best managementfor this finding?

Q

Your answer:

Correct answer:

The correct answer is urgent referral for laser abla�on of theplacental bed. The twins have developed twin to twin transfusionsyndrome (TTTS) due to vascular placental anastomoses which arealmost universal in monochorionic twin pregnancies. Despite the

AUrgent referral for laser abla�on of the placental bed>

Urgent referral for laser abla�on of the placental bed>




anastomoses being almost universal TTTS only occurs in 10–15% ofpregnancies. It is more common in MCDA twins compared withmonochorionic monoamnio�c twins, but the la�er has a very highrisk of cord entanglement. The randomised trial comparing amnio-reduc�on and septostomy was stopped early. Although there werebe�er outcomes in both groups significantly more babies (RR 1.66)were alive without neurological deficit at 6 months of age in thelaser abla�on group. The septostomy randomised trial was alsoprematurely halted because there was no difference with thecontrol group. See Royal College of Obstetricians andGynaecologists. Management of monochorionic twin pregnancy.Green-top Guideline 51. London: RCOG: 2008(h�ps://www.rcog.org.uk/en/guidelines-research-services/guidelines/gtg51/).

A 28-year-old woman a�ends for pre-pregnancy counselling. Her maternalgrandfather and her mother's brother have haemophilia A. Her husband ishealthy and there is no history of haemophilia in the family. What is the riskthat any daughter of hers will have haemophilia A?

Q

Your answer:

Correct answer:

The correct answer is 0%. The pa�ent’s mother must be a carrier.She will have inherited the gene from her father. However thepa�ent’s grandmother must also be a carrier since the pa�ent’suncle has the disease but her mother did not inherit the gene sinceshe is well. The pa�ent has a 50% chance of being a carrier, but witha healthy husband it is very unlikely any daughter of hers will havethe disease since she will only inherit an affected gene from hermother unless her husband’s sperm has a new muta�on.

A0%>

0%>




An 18-year-old woman is pregnant with a male fetus. She has cys�c fibrosisand her partner is a carrier. She is worried that the baby will inherit cys�cfibrosis. What is the likelihood that the baby will be affected?

Q

Your answer:

Correct answer:

The correct answer is 50%. The woman is heterozygous so willinevitably pass on the CF gene and there is a 50% chance of herbaby acquiring the gene from her partner. The child will be either acarrier or affected.

A50%>

50%>

A 35-year-old woman presents at 16 weeks in her first pregnancy with asevere throbbing headache las�ng for the last 5 days, which is aggravatedwith eye movements and associated with occasional blurred vision, nauseaand photophobia. The only abnormali�es on examina�on are bilateralpapilloedema and squint of the le� eye, which turns inwards. A computertomography scan shows no abnormality. What is the most likely diagnosis?

Q

Your answer:

Correct answer:

The correct answer is idiopathic intracranial hypertension (IHH). IHHis a diagnosis of exclusion in a pregnant woman with a headache. Itis more wommen in women, with a female:male ra�o of 8:1. IHH isalso more comment in obese women, with an incidence of 19/100000 compared with <1/100 000 in non-obese women. Rising obesityrates will therefore lead to an increasing incidence of IHH. SeeThirumalaikumar L, Ramalingam K, Heafield T. Idiopathic intracranialhypertension in pregnancy. The Obstetrician & Gynaecologist2014;16:93–97(h�p://onlinelibrary.wiley.com/doi/10.1111/tog.12087/full).

AIdiopathic intracranial hypertension (IIH)>

Idiopathic intracranial hypertension (IIH)>




A 25-year-old woman with sickle cell disease is considering having a childwith her partner who has sickle cell trait. What is the probability that thechild will have sickle cell disease?

Q

Your answer:

Correct answer:

The correct answer is 50%. Following screening, this couple isiden�fied as 'at risk'. They need counselling and advice about theirreproduc�ve op�ons, including the methods and risks of prenatalscreening and termina�on of pregnancy. See Royal College ofObstetricians and Gynaecologists. Management of sickle cell diseasein pregnancy. Green-top Guideline 61. London: RCOG; 201(h�ps://www.rcog.org.uk/en/guidelines-research-services/guidelines/gtg61/)1.

A50%>

50%>



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A recently delivered woman on the postnatal ward tells you that her babyhas a patent ductus arteriosus. She asks what the ductus arteriosus isconnected to when her baby was in utero. Where does the ductusarteriosus connects in a fetus?

Q

Your answer:

Correct answer:

The correct answer is the pulmonary artery to the aorta. Anunderstanding of fetal circula�on and congenital heart defects isimportant to an obstetrician. It gives them the ability to discuss any

APulmonary artery to aorta>

Pulmonary artery to aorta>







problems with their pa�ents and is required to understand changesseen on ultrasound and the effect on the fetus and baby. There aremany resources on the internet e.g. the Atlas of Cardiac Anatomy(h�p://www.vhlab.umn.edu/atlas/index.shtml) produced by theUniversity of Minnesota (accessed 2 July 2015).

A couple a�end for pre-pregnancy gene�c counselling because the partneris known to have haemophilia A. They are seeking informa�on about theirfuture baby's risk of inheri�ng the condi�on. Which of the followingstatements regarding the heritability of haemophilia A is correct?

Q

Your answer:

Correct answer:

The correct answer is approximately 50% of newly diagnosedpa�ents have no family history. Daughters of affected males willalways be carriers but sons will never inherit the disease (theaffected gene is on the paternal X chromosome, which never goesto the sons). Haemophilia can arise as a spontaneous muta�on andthe risk of being a carrier is 1 in 20 000. See Mumford A. Gene�ccounselling and pre-natal diagnosis. In: Pavord S, Hunt B (editors).The obstetric haematology manual. Cambridge University Press.2010. p 194–199.

AApproximately 50% of newly diagnosed pa�ents have no familyhistory

>

Approximately 50% of newly diagnosed pa�ents have no familyhistory

>

A 26-year-old P1+0 woman booked under midwife-led care develops aconfirmed chickenpox infec�on at 38+6 weeks of gesta�on. She is a non-smoker and is otherwise low risk. Clinically, the fetus appears appropriatelygrown for gesta�on and is in a cephalic presenta�on. She previously had anuncomplicated normal delivery of a 3.7 kg baby following induc�on forpostmaturity. What is the most appropriate advice for her ongoingmanagement?

Q

http://www.vhlab.umn.edu/atlas/index.shtml



Your answer:

Correct answer:

The correct answer is await the onset of spontaneous labour andgive the newborn varicella zoster immunoglobulin if deliveredwithin 7 days following the onset of the maternal rash. VZIG has noeffect once chickenpox has developed. If the woman presents within24 hours (at over 20 weeks of gesta�on) it is worth prescribingacyclovir. The baby is at most risk if delivered within a week of thedevelopment of the infec�on. A�er 7 days the maternal an�bodieswill protect the baby. See Royal College of Obstetricians andGynaecologists. Chickenpox in pregnancy. Green-top Guideline 13.London: RCOG; 2007 (h�ps://www.rcog.org.uk/en/guidelines-research-services/guidelines/gtg13/).

AAwait the onset of spontaneous labour and give the newbornvaricella zoster immunoglobulin if delivered within 7 daysfollowing the onset of the maternal rash

>

Await the onset of spontaneous labour and give the newbornvaricella zoster immunoglobulin if delivered within 7 daysfollowing the onset of the maternal rash

>

A 19-year-old woman is 28 weeks into her first pregnancy. On rou�ne bloodtests, her haemoglobin is 95 g/l. What is the best test to diagnose irondeficiency anaemia?

Q

Your answer:

Correct answer:

The correct answer is serum ferri�n. Although an approxima�on ofiron deficiency can be assessed by the mean corpuscular volume,serum ferri�n will give an accurate test of iron stores. See Bri�shCommi�ee for Standards in Haematology. UK guidelines on themanagement of iron deficiency in pregnancy. London: BCSH: 2011(h�p://www.bcshguidelines.com/documents/UK_Guidelines_iron_deficiency_in_pregnancy.pdf).

ASerum ferri�n>

Serum ferri�n>


http://www.bcshguidelines.com/documents/UK_Guidelines_iron_deficiency_in_pregnancy.pdf



A primigravida presents at 41 weeks into an uncomplicated pregnancy. Youarrange induc�on of labour. According to NICE guidelines (2008), what isthe rate of spontaneous vaginal delivery following induc�on withprostaglandins alone?

Q

Your answer:

Correct answer:

The correct answer is 61–70%. Induc�on of labour should only beoffered to women in specific circumstances since there is anincreased risk of caesarean sec�on. See Na�onal Ins�tute for Healthand Clinical Excellence. Induc�on of labour. Clinical guideline 70.London: NICE. 2008 (h�ps://www.nice.org.uk/guidance/cg70).

A61–70%>

61–70%>

A 35-year-old woman with persistent tachycardia has thyroid func�on testsat 18 weeks of gesta�on. The results are TSH <0.02 mU/l (normal range0.4–5.0) and T4 of 67 pmol/l (normal range 10–20). What is the most likelycause for her hyperthyroidism?

Q

Your answer:

Correct answer:

The correct answer is Graves disease. 95% of cases ofhyperthyroidism in pregnancy are due to Graves disease. Thyroxineproduc�on increases in pregnancy due to an increase in thyroxinebinding globulin to maintain a steady free thyroxine level (both T3and T4). In assessing thyroid func�on in pregnancy, free T3 and T4levels reflect thyroid func�on rather than total T3 and T4 levels. Inmonitoring hypo- and hyperthyroid disease the TSH level may takelonger to return to normal so free T3 and T4 levels are a moreaccurate reflec�on. Hyperthyroidism is common in women ofreproduc�ve years and is seen in approximately 1 in 500pregnancies. See Nelson-Piercy C. Handbook of obstetric medicine,4th edi�on. CRC Press. 2010.

AGraves disease>

Graves disease>

https://www.nice.org.uk/guidance/cg70



You see a woman who is 35 weeks pregnant in your day assessment unit.She presents with nausea, anorexia and generalised malaise. Her liverfunc�on test demonstrates an alanine transaminase (ALT) of 634. Which ofthe following features is most useful in dis�nguishing acute fa�y liver ofpregnancy (AFLP) from HELLP syndrome?

Q

Your answer:

Correct answer:

The correct answer is hypoglycaemia. Liver disorders are common inpregnancy, but rarely cause long term problems. AFLP is a rare butserious condi�on which will share many common features withHELLP. However hypoglycaemia is common in AFLP and can besevere, but is extremely unlikely in HELLP. See Nelson-Piercy C.Handbook of obstetric management, 4th edi�on. CRC Press. 2010.

AHypoglycaemia>

Hypoglycaemia>

You see a woman who is 35 weeks pregnant in your day assessment unit.She presents with itching. Your differen�al diagnosis is obstetric cholestasis.Your ST1 asks you if she should prescribe vitamin K but is not sure how itworks. Vitamin K is responsible for manufacturing which of the followingcoagula�on factors?

Q

Your answer:

Correct answer:

The correct answer is factor X. Vitamin K is required formanufacturing coagula�on factors II, VII, IX, X. See Royal College ofObstetricians and Gynaecologists. Obstetric cholestasis. Green-topGuideline 43. London: RCOG; 2011(h�ps://www.rcog.org.uk/en/guidelines-research-services/guidelines/gtg43/).

AFactor X>

Factor X>




You see a woman who is 35 weeks pregnant in your day assessment unit.She presents with itching. Your differen�al diagnosis is polymorphicerup�on of pregnancy. What clinical feature is most helpful in diagnosingthis condi�on?

Q

Your answer:

Correct answer:

The correct answer is inflamed abdominal striae. Polymorphicerup�on of pregnancy classically affects the abdominal striae,sparing the umbilicus. The differen�al diagnosis is intrahepa�ccholestasis of pregnancy, atopic erup�on of pregnancy andpemphigoid gesta�onis. See Nelson-Piercy C. Handbook of obstetricmanagement, 4th edi�on. CRC Press 2010 and Maharajan A, Aye C,Ratnavel R, Burova E. Skin erup�ons specific to pregnancy: anoverview. The Obstetrician & Gynaecologist 2013;15:233–40(h�p://onlinelibrary.wiley.com/doi/10.1111/tog.12051/full).

AInflamed abdominal striae>

Inflamed abdominal striae>

You see a woman who is 35 weeks pregnant in your day assessment unit.She presents with itching causing insomnia of the palms of hands and solesof feet. There are scratch marks but no rash. Her alanine transaminase is 78IU/l (normal range 10–35) and bile acids are 42 micromol/l (normal range1–10). Which of the following contracep�ves should be avoidedpostnatally?

Q

Your answer:

Correct answer:

The correct answer is the combined oral contracep�ve pill.Estrogen-containing contracep�ves should be avoided in womenwho have had obstetric cholestasis. See Royal College of

ACombined oral contracep�ve pill>

Combined oral contracep�ve pill>





Obstetricians and Gynaecologists. Obstetric cholestasis. Green-topGuideline 43. London: RCOG; 2011(h�ps://www.rcog.org.uk/en/guidelines-research-services/guidelines/gtg43/).



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A maternity unit wishes to reduce unnecessary admissions for suspectedpreterm labour. A member of staff inves�gates whether there is a moresuitable bedside test for the predic�on of preterm labour than the onealready in use. Which of the following sta�s�cal parameters of any new testused is most likely to achieve the desired goal?

Q

Your answer:

Correct answer:

AIncreased specificity of the test>

Increased specificity of the test>







The correct answer is increased specificity of the test. In this clinicalcontext it is important to be able to iden�fy women who are not atrisk of progressing to preterm labour with a degree of certainty tobe able to discharge them home. Specificity refers to the ability ofthe test to correctly iden�fy pa�ents who do not have the disease(preterm labour).

A 27-year-old primigravida books at the antenatal clinic. She has a heritablethrombophilia and wishes to discuss the implica�ons for her pregnancy.Which heritable thrombophilia produces the greatest risk for venousthromboembolism in pregnancy?

Q

Your answer:

Correct answer:

The correct answer is Factor V Leiden homozygosity.

AFactor V Leiden homozygosity>

Factor V Leiden homozygosity>

A 28-year-old woman had a primary postpartum haemorrhage 2 hourspreviously a�er delivering a 4.1 kg baby. You are asked to review her as sheappears confused and agitated. There is no sign of ongoing bleeding. Herpulse is recorded as 123 beats per minute, her blood pressure is 89/45mmHg and her booking weight was 71 kg. Approximately how much bloodhas this woman lost?

Q

Your answer:

Correct answer:

The correct answer is 2000–2499 ml. This describes a class IIIhaemorrhage, i.e. 30–40% of circula�ng volume lost (pulse>120<140, BP decreased, agitated and confused mental state).

A2000–2499 ml>

2000–2499 ml>



A pregnant woman with severe von Willebrand’s disease a�ends theantenatal clinic. She is nonsensi�sed Rh-nega�ve. What is the recommendmanagement regarding rou�ne antenatal an�-D prophylaxis?

Q

Your answer:

Correct answer:

The answer is administer intravenous an�-D.

Qureshi H, Massey E, Kirwan D, Davies T, Robson S, White J, et al.BCSH guideline for the use of an�-D immunoglobulin for thepreven�on of haemoly�c disease of the fetus and newborn.Transfus Med 2014;24:8–20.(h�p://onlinelibrary.wiley.com/doi/10.1111/tme.12091/full)

AAdminister intravenous an�-D>

Administer intravenous an�-D>

A mul�parous woman is seen in antenatal clinic at 34 weeks of gesta�onfollowing a scan for placental localisa�on. The scan shows the placenta isanterior with the leading edge encroaching on the internal os. Which of thefollowing is the strongest predisposing risk factor for developing placentapraevia?

Q

Your answer:

Correct answer:

The answer is maternal age of more than 40 years, as it is associatedwith a ninefold risk of placental praevia.

AMaternal age of more than 40 years>

Maternal age of more than 40 years>

http://onlinelibrary.wiley.com/doi/10.1111/tme.12091/full



Jolly M, Sebire N, Harris J, Robinson S, Regan L. The risks associatedwith pregnancy in women aged 35 years or older. Hum Reprod2000;15:2433–7.(h�ps://academic.oup.com/humrep/ar�cle/15/11/2433/635079/The-risks-associated-with-pregnancy-in-women-aged)

A 21-year-old primigravida is admi�ed for induc�on at 35 weeks ofgesta�on. She presents with reduced fetal movements and the fetus isthought to be small for gesta�onal age. An ultrasound scan shows that thees�mated weight is below the 10th cen�le and there is reduced enddiastolic flow. Which condi�on is this baby most at risk of?

Q

Your answer:

Correct answer:

The correct answer is polycythaemia.

APolycythaemia>

Polycythaemia>

A 22-year-old primigravid woman presents at 32 weeks of gesta�on withsigns and symptoms of acute appendici�s. The cardiotocography (CTG) isreassuring. What is the best laparotomy incision for appendicectomy?

Q

Your answer:

Correct answer:

The correct answer is lower midline.

ALower midline>

Lower midline>

https://academic.oup.com/humrep/article/15/11/2433/635079/The-risks-associated-with-pregnancy-in-women-aged



Weston P, Moroz P. Appendici�s in pregnancy: how to manageand whether to deliver. The Obstetrician and Gynaecologist2015;17:105–10.(h�ps://stratog.rcog.org.uk/sites/default/files/Weston_et_al-2015-The_Obstetrician_%26_Gynaecologist_1.pdf)

A 30-year-old woman, Para 0, is referred for a growth scan. The pregnancyhas been uncomplicated so far. The ultrasonographer reports that thees�mated fetal weight is on the 5th cen�le for gesta�on, there is normalliquor and the umbilical artery Doppler waveform is normal but the fetalhead circumference is less than the 1st cen�le for gesta�on. What is themost likely infec�ve cause?

Q

Your answer:

Correct answer:

The answer is cytomegalovirus.

van Zuylen WJ, Hamilton ST, Naing Z, Hall B, Shand A, Rawlinson WD.Congenital cytomegalovirus infec�on: Clinical presenta�on,epidemiology, diagnosis and preven�on. Obstet Med 2014;7:140–6.(h�ps://academic.oup.com/humrep/ar�cle/15/11/2433/635079/The-risks-associated-with-pregnancy-in-women-aged)

ACytomegalovirus>

Cytomegalovirus>

A 35-year-old woman presents 4 days following a normal delivery. Shecomplains of a severe headache, which has been ge�ng worse, andweakness on her le� side. What is the most appropriate inves�ga�on?

Q

Your answer:AMR venogram>

https://stratog.rcog.org.uk/sites/default/files/Weston_et_al-2015-The_Obstetrician_%26_Gynaecologist_1.pdf

https://academic.oup.com/humrep/article/15/11/2433/635079/The-risks-associated-with-pregnancy-in-women-aged



Correct answer:

The answer is MR venogram.

MR venogram>

A school teacher is at 26 weeks of gesta�on in her first pregnancy. One ofher pupils has chickenpox. The lesions have crusted over. She cannot recallhaving chickenpox as a child and wants to know if she is now infected withchickenpox. How long does it usually take for the lesions to crust over fromonset of the rash?

Q

Your answer:

Correct answer:

The answer is 5 days. When the lesions have crusted over, theindividual is no longer infec�ous.

Royal College of Obstetricians and Gynaecologists. Chickenpox inpregnancy. GTG13. London: RCOG Press; 2015.(h�ps://www.rcog.org.uk/globalassets/documents/guidelines/gtg13.pdf)

A5 days>

5 days>


Registered charity no. 213280

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A 44-year-old woman with a BMI of 48 and gesta�onal diabetes presents at30 weeks of gesta�on complaining of lethargy associated with a sore throatand is found to have a temperature of 39.6°C. A venous blood gas reveals ahaemoglobin of 89 g/l. Which of the aspects of her history is not a riskfactor for severe sepsis?

Q

Your answer:

Correct answer:

The answer is her age.

AAge>

Age>







Royal College of Obstetrics and Gynaecology. Bacterial Sepsis inPregnancy. GTG64a. London: RCOG Press; 2015(h�ps://www.rcog.org.uk/en/guidelines-research-services/guidelines/gtg64a/).

A primigravid woman presents to the antenatal diabe�c clinic at 28 weeksof gesta�on. She has just been diagnosed with gesta�onal diabetes on a 75-g 2-hour oral glucose tolerance test. The fas�ng plasma glucose was 7.2mmol/l. The scan has revealed polyhydramnios and a baby that is large forgesta�onal age. What is the most appropriate treatment for this woman?

Q

Your answer:

Correct answer:

The answer is immediate treatment with insulin and/or me�ormin.

Na�onal Ins�tute for Health and Care Excellence. 1.2 Gesta�onaldiabetes. In: Diabetes in Pregnancy: Management fromPreconcep�on to the Postnatal Period.NG3. London: NICE; 2015.(h�ps://www.nice.org.uk/guidance/ng3/chapter/1-recommenda�ons#gesta�onal-diabetes-2)

AImmediate treatment with insulin and/or me�ormin>

Immediate treatment with insulin and/or me�ormin>

A pregnant woman who is known to have poorly controlled epilepsy isfound dead at her home at 22 weeks of gesta�on. According to theMBRRACE 2014 report, what is the most likely cause of her death?

Q

Your answer:

Correct answer:

ASudden unexplained death in pregnancy>

Sudden unexplained death in pregnancy>

https://www.rcog.org.uk/en/guidelines-research-services/guidelines/gtg64a/

https://www.nice.org.uk/guidance/ng3/chapter/1-recommendations#gestational-diabetes-2



The answer is sudden unexplained death in pregnancy.

MBRRACE-UK. Saving Lives, Improving Mothers' Care. Lessons learned to infmaternity care from the UK and Ireland Confiden�al Enquiries into MaternaMorbidity 2009-2012. Oxford: MBRRACE; 2014.(h�ps://www.npeu.ox.ac.uk/downloads/files/mbrrace-uk/reports/Saving%20Lives%20Improving%20Mothers%20Care%20report%

A woman with a spinal cord transec�on presents in labour at term. She ishaving regular, strong uterine contrac�ons but does not experience anypain. What is the level of her spinal cord injury?

Q

Your answer:

Correct answer:

The answer is T10.

Dawood R, Iatrikes EAP, Ribes-Pastor P, Ashworth F. Pregnancyand spinal cord injury. The Obstetrician and Gynaecologist.2014;16:99–107. (h�ps://stratog-live.rcog.org.uk/sites/default/files/Dawood_et_al-2014-The_Obstetrician_%26_Gynaecologist_5_0.pdf)

AT10>

T10>

Royal College of Obstetricians and Gynaecologists

https://www.npeu.ox.ac.uk/downloads/files/mbrrace-uk/reports/Saving%20Lives%20Improving%20Mothers%20Care%20report%202014%20Full.pdf

https://stratog-live.rcog.org.uk/sites/default/files/Dawood_et_al-2014-The_Obstetrician_%26_Gynaecologist_5_0.pdf



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