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A woman has an intrapartum stillbirth.

Despite extensive discussion and


explanation of the management of the pregnancy and delivery with her
consultant, she still expresses dissatisfaction. She indicates that she
wishes to explore further whether the stillbirth should have been avoided.
On a ward round she asks you whom she should contact for help.
To which of the following organisations would you direct her in the first
instance?
Care Quality Commission
Clinical Commissioning Group
General Medical Council
Patient Advice and Liaison Service
Patient Association
Correct
The correct answer is the Patient Advice and Liaison Service. If a patient
has a complaint or concern, it is best dealt with by the provider of the
health care in the first instance. Other organisations may be appropriate if
the initial response is not satisfactory.
A pregnant woman with a BMI of 25 sees her midwife at 24 weeks of
gestation. A single symphysis fundal height (SFH) measurement is
undertaken which is less than expected for this gestation.
What is the most appropriate management?
Reassess in 2 weeks time by the same clinician and refer if SFH is still
less than expected
Refer if there is a discrepancy of 1 cm compared with gestational age
Refer if SFH measurement on a customised chart plots below the 10th
centile
Refer if the SFH measurement on a population-based chart plots on
the 10th centile
Refer if there is a discrepancy of 2 cm compared with gestational age
Correct
The correct answer is refer if SFH measurement on a customised chart
plots below the 10th centile. Abdominal palpation is poor at predicting
small-for-gestational-age (SGA) babies, especially in a mixed risk
population. SFH using a customised growth chart which takes into
account maternal height, weight, parity and ethnic group improves the
prediction of SGA babies, but there is wide variation in the predictive
accuracy ranging from a sensitivity of 2786% and a specificity of 80
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93%. See Royal College of Obstetricians and Gynaecologists. The


investigation and management of the smallforgestationalage fetus.
Green-top guideline 31. London: RCOG. 2014.
A woman who is 24 weeks pregnant contacts the maternity day unit
reporting possible exposure to facial shingles 4 days earlier. The pregnant
woman believes she has had chickenpox when she was a child.
What advice should she be given?
Offer testing for varicella zoster virus (VZV) immunity and, if nonimmune, offer varicella zoster immunoglobulin (VZIG)
Offer testing for VZV immunity and, if non-immune, offer varicella
vaccination
Reassure her that no further action is necessary as she is likely to be
immune
Tell her to report the development of a rash, and if it develops, offer
her treatment with oral aciclovir
Tell her to report the development of a rash and, if it develops, offer
her treatment with VZIG
Correct
The correct answer is offer testing for varicella zoster virus (VZV)
immunity and, if non-immune, offer varicella zoster immunoglobulin
(VZIG). VZV is highly contagious and can be transmitted by respiratory
droplets, direct personal contacts or fomites. It is possible to catch it from
both chickenpox and herpes zoster (HZ) but it is highly unlikely if the HZ is
in non-exposed sites. VZIG is effective when given up to 10 days after
contact. The pregnant woman should then be considered as infectious for
8 to 28 days after receiving VZIG.
You are asked to repair a vaginal tear following a normal delivery. The
mothers weight is 60 kg. She is otherwise well with no allergies.
What is the maximum dose of lidocaine 1% without epinephrine that you
can use for perineal infiltration?
8 ml (80 mg)
12 ml (120 mg)
18 ml (180 mg)
24 ml (240 mg)
36 ml (360 mg)
Correct
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The correct answer is 18 ml (180 mg). The maximum dose of lidocaine is


3 mg/kg. As the woman's weight is 60 kg, the dose is 3 x 60 = 180 mg
total dose. 1% lidocaine contains 1 x 10 mg/ml = 10 mg/ml. Therefore the
maximum volume is 180 /10 = 18 ml of 1% lidocaine. See StratOG Core
Training eTutorial on Obstetric analgesia and
anaesthesia and Anaesthesia UK. Pharmacology of regional anaesthesia.
Accessed online 27 January 2015.
A woman attends the antenatal clinic at 30 weeks of gestation and
discloses that she had suspected whooping cough 2 months earlier.
What is the single best recommendation regarding pertussis
immunisation?
Maternal pertussis antibodies should be measured
Maternal vaccination should be given now
Maternal vaccination should be given postnatally
Maternal vaccination should be deferred until 38 weeks of gestation
Neonatal immunisation should be given
Correct
The correct answer is that maternal vaccination should be given now.
Despite high vaccination coverage in Britain since the 1990s, pertussis
continues to display 34 yearly peaks in activity. In 2012 there was a
major leap in pertussis, with levels above those reported in the previous
20 years. It was seen in all age groups. Infants under 3 months are at
highest risk of complications and death. In view of the outbreak in 2012 all
pregnant women are offered pertussis vaccination during pregnancy.
The obstetric team are conducting a study to evaluate whether there has
been any effect on patient satisfaction following the establishment of an
outpatient induction of labour (IOL) programme. Women undergoing
inpatient IOL and women undergoing outpatient IOL were asked to rate
their overall satisfaction with the process using a visual analogue scale
from 1 (least satisfied) to 10 (most satisfied).
What is the most appropriate statistical test to assess whether there is a
significant difference in satisfaction between the two groups?
Chi squared test
Kruskal Wallis test
Mann Whitney U test
Students t test
Wilcoxon matched pairs signed rank test
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Correct
The correct answer is the Mann Whitney U test. See Campbell MJ,
Machin D, Walters SJ. Medical statistics: a textbook for the health
sciences (medical statistics). Wiley-Blackwell. 2007.
A 42-year-old primigravid woman presents in spontaneous labour at 37
weeks of gestation. She develops central crushing chest pain which
radiates to her left jaw.
Which of the following cardiac biomarkers is most reliable for diagnosing
acute myocardial infarction during labour and delivery?
Creatinine kinase
Isoenzyme MB
LDH (lactate dehydrogenase)
Myoglobin
Troponin I
Correct
The correct asnwer is Troponin I. Troponin I is unaffected by labour,
anaesthesia or delivery. SeeWuntakal R, Shetty N, Ioannou E, Sharma S,
Kurian J. Myocardial infarction and pregnancy. The Obstetrician &
Gynaecologist 2013;15:24755.
A 25-year-old primigravida woman is admitted to the labour ward with
regular contractions and draining clear liquor. She is a known carrier for
Streptococcus B in this pregnancy. Shortly after being given a loading
dose of benzylpenicillin, she becomes wheezy, develops a rash and has
difficulty breathing.
What is the most appropriate initial dose of intramuscular adrenaline?
0.01 mg (0.1 ml of 1:10000)
0.05 mg (0.5 ml of 1:10000)
0.1 mg (0.1 ml of 1:1000)
0.5 mg (0.5 ml of 1:1000)
10 mg (10 ml of 1:1000)
Correct
The correct answer is 0.5 mg (0.5 ml of 1:1000). The correct dose of
intramuscular (im) adrenaline in anaphylactic shock is 0.5mg. Doses of
0.01 mg, 0.05mg and 0.1 mg are too small for therapeutic effect in
circulatory collapse by im route and would be more appropriate doses for
iv route. 10mg is too large for an initial dose but if there is a suboptimal
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response to initial dose, then injections should be repeated every 10


minutes and may therefore reach an accumulative dose of 10 mg. See
the British National Formulary.
A 28-year-old woman dies at 47 days postpartum following aspiration
during an epileptic seizure. She had a 10 year history of epilepsy.
What is the classification of this maternal death?
Early direct maternal death
Early indirect maternal death
Late coincidental maternal death
Late direct maternal death
Late indirect maternal death
Correct
The correct answer is late indirect maternal death. A maternal death that
occurs 6 weeks following child birth is termed as late maternal death. If
death occurs of a pre-existing medical condition it is called an indirect
maternal death. See Maternal, Newborn and Infant Clinical Outcome
Review Programme. Saving Lives, Improving Mother's Care. Lessons
learned to inform future maternity care from the UK and Ireland
Confidential Enquiries into Maternal Deaths and Morbidity 20092012.
Oxford: National Perinatal Epidemiology Unit, University of Oxford. 2014.
A 40-year-old woman is seen in the antenatal clinic at 20 weeks of
gestation. Both her booking and anomaly scan are normal. She has a BMI
of 24. She had a previous vaginal delivery at 39 weeks of gestation of a
baby weighing 1.8 kg. She smokes 20 cigarettes per day.
What is the next most appropriate investigation?
Early growth scan at 2628 weeks of gestation
Liquor volume scan at 2628 weeks of gestation
Middle cerebral artery Doppler at 32 weeks of gestation
Umbilical artery Doppler at 2628 weeks of gestation
Uterine artery Doppler at 2024 weeks of gestation
Correct
The correct answer is umbilical artery Doppler at 2628 weeks of
gestation. If women have a major risk factor for fetal growth restriction
they should have serial umbilical artery Doppler scans from 2628 weeks
of gestation. This woman has several risk factors including two major
factors: smoking >11 cigarettes/day and a previous small-for-gestational5

age baby. Note that women with three or more minor risk factors for fetal
growth restriction should be referred for uterine artery doppler at 2024
weeks of gestation. See Royal College of Obstetricians and
Gynaecologists. The investigation and management of the small-forgestational-age fetus. Green-top Guideline 31. London: RCOG. 2013.
A 36-year-old woman attends the antenatal clinic at 20 weeks of
gestation. She has had three previous caesarean sections and has a
normal placental site. She consented for another caesarean section.
What is the most likely surgical complication?
Bladder injury
Blood transfusion
Bowel injury
Fetal laceration
Hysterectomy
Correct
The correct answer is blood transfusion. Elective repeat caesarean
section is associated with increasing risks that rise with each successive
pregnancy. Blood transfusion rises from 7.9% with a third caesarean
section to 14.1% with the fifth caesarean. See Royal College of
Obstetricians and Gynaecologists. Birth after previous caesarean birth.
Green-top Guideline 45. London: RCOG; 2007.
A 35-year-old woman has recently undergone gastric bypass surgery. She
is planning a pregnancy.
How long should she be advised to delay conception for?
1 year
2 years
3 years
4 years
5 years
Correct
The correct answer is 1 year. The majority of bariatric surgery is carried
out on women of childbearing years. Current advice is to delay conception
for a year. However, data to support this recommendation is lacking, with
many studies showing no difference in outcomes in those women
conceiving earlier than 12 months and those conceiving later. See Khan R
, Dawlatly B, Chappatte O. Pregnancy outcome following bariatric
surgery. The Obstetrician & Gynaecologist 2013;15:3743.
A 29-year-old primigravida presents with chest pain and is diagnosed with
myocardial infarction. Her BMI is 29 and she does not have any significant
medical or family history.
What is the most likely cause of acute myocardial infarction in this case?
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Coronary artery atherosclerosis


Coronary artery dissection
Coronary artery embolism
Coronary artery spasm
Coronary artery thrombosis
Correct
The correct answer is coronary artery dissection. Cardiac disease remains
a significant cause of maternal death with 54 deaths per 100 000
maternities in the most recent triennial report (20092012). There are
profound physiological changes in pregnancy that affect the heart. The
most common cause is atherosclerosis, and diabetes and smoking are
significant risk factors. In women with no cardiovascular risk factors,
coronary artery dissection may occur. It is thought that this results from
changes in the vessel wall related to high progesterone levels.
See Wuntakal R, Shetty N, Ioannou E, Sharma S, Kurian J. Myocardial
infarction and pregnancy. The Obstetrician & Gynaecologist 2013;15:247
55.
A 32-year-old woman is in labour in her second pregnancy. Her previous
delivery was by caesarean section.
What is the most consistent indicator of uterine rupture for this woman?
Abnormal CTG
Acute onset of scar tenderness
Haematuria
Loss of station of the presenting part
Severe abdominal pain
Correct
The correct answer is abnormal CTG. Vaginal birth after an uncomplicated
lower segment caesarean section is successful in 7276% of women. The
risk of uterine rupture is 2274/10 000 (0.220.74%). This is lower if the
woman labours preterm (34/10 000 vs 74/10 000). An abnormal CTG is
the most consistent finding in dehiscence, occurring in 5587% of cases.
See Royal College of Obstetricians and Gynaecologists. Birth after
previous caesarean birth. Green-top Guideline 45. London: RCOG; 2007.
A 25-year-old primigravida presents at 32 weeks of gestation with itching.
Following a blood test, she is diagnosed with obstetric cholestasis.
Which pharmacological agent would be the most effective treatment?
Dexamethasone
S-adenosyl methionine
Topical emollients
Ursodeoxycholic acid
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Vitamin K
Correct
The correct answer is ursodeoxycholic acid. Pruritis in pregnancy is
common, affecting nearly a quarter of pregnant women. Obstetric
cholestasis is diagnosed when abnormal liver function tests are found in
association with pruritis. Normal pregnancy values should be used with an
upper limit of normal 20% below nonpregnant levels for transaminases, glutamyl transferase and bilirubin. Alkaline phosphatase is generally
raised in pregnancy due to placental production.
Topical emollients may provide temporary relief of pruritis. S-adenosyl
methionine is not recommended and dexamethasone should only be used
as part of a trial. Vitamin K should be prescribed if the prothrombin time is
prolonged, but is not an effective treatment. See Royal College of
Obstetricians and Gynaecologists. Obstetric cholestasis. Green-top
Guideline 43.London: RCOG; 2011.
A pregnant woman is identified as being susceptible to rubella from her
first trimester booking blood results.
When discussing this result at the next antenatal clinic appointment, what
is the most appropriate advice that she should be given?
A single dose of MMR (mumps measles rubella vaccine) should be
offered at the six-week postnatal check
A single dose of MMR should be offered immediately postnatally
A single dose of rubella immunoglobulin should be offered as soon as
possible
A single dose of rubella vaccine should be offered as soon as possible
A single dose of MMR should be offered immediately postnatally with
a second dose at the six-week postnatal check
Correct
The correct answer is a single dose of MMR should be offered
immediately postnatally with a second dose at the six-week postnatal
check. The clinical diagnosis of rubella is unreliable and since the risk to
the fetus is in the first 16 weeks of pregnancy it is important that the
woman is immunised before she can become pregnant again. Between
2005 and 2009 there were six cases of congenital rubella, five of whom
were born to mothers who were born outside the UK. See theNHS
Screening Programme website: Infectious diseases in pregnancy
(accessed 02/07/2015) and the HPA Guidance on viral rash in pregnancy
(accessed 19/11/2014).
A 30-year-old woman books in the antenatal clinic at 12 weeks of
gestation with a BMI of 40. This is her first baby and she is normally fit and
well with no family history of note.
With regard to her BMI, which complication of pregnancy is the highest
risk compared to women with a normal BMI?
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Emergency caesarean
Gestational diabetes
Postpartum haemorrhage
Stillbirth
Venous thromboembolism
Correct
The correct answer is venous thromboembolism. The risk of diabetes is
about three times higher. The risk of hypertensive disease is two-to-three
times higher. Caesarean section, stillbirth and postpartum haemorrhage
are about twice as likely in women with a high BMI. Venous
thromboembolism is, however, nine times higher in this group. See
the CMACE/RCOG Joint Guideline. Management of women with obesity
in pregnancy. CMACE. 2010.
A 27-year-old primigravida presents at 36 weeks of gestation in labour.
She reports watery vaginal discharge for a while. On examination her
temperature, pulse and blood pressure are normal. She is contracting
moderately and clear liquor can be seen draining. The fetal heart rate is
136 bpm. On vaginal examination the cervix is 3 cm dilated. Membranes
are absent.
What is the most appropriate management to reduce the risk of early
onset neonatal infection?
Intrapartum antibiotic prophylaxis if rupture of membranes occurred 18
hours before onset of labour
Intrapartum antibiotic prophylaxis if rupture of membranes occurred 24
hours before onset of labour
Intrapartum antibiotics if the mother develops signs of infection
Neonatal antibiotic prophylaxis
Prescribe intrapartum antibiotic prophylaxis with any duration of
prelabour rupture of membranes
Correct
The correct answer is prescribe intrapartum antibiotic prophylaxis with any
duration of prelabour rupture of membranes. In preterm labour, antibiotics
should be considered if membranes rupture at any time prior to the onset
of labour. If the woman is at term, antibiotics should only be given if the
woman has had a positive culture for GBS in this pregnancy or has clinical
signs of infection. SeeNational Institute for Health and Clinical
Excellence. Antibiotics for early onset neonatal infection: antibiotics for the
prevention and treatment of early-onset neonatal infection. London: NICE;
2012.
A 28-year-old woman attends for prepregnancy counselling. Her maternal
grandfather and her mother's brother have haemophilia A. Her husband is
healthy but she has been screened and is a carrier.
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What is the risk that her future son would inherit this disease?
0%
25%
50%
75%
100%
Correct
The correct answer is 50%. Haemophilia A is an X-linked recessive
disorder so 50% of her sons will be affected and 50% of her daughters will
be carriers.
Gestational diabetes is a common complication of pregnancy.
What hormonal factor is predominantly responsible?
Cortisol
Estrogen
Human chorionic gonadotrophin
Human placental lactogen
Progesterone
Correct
The corerct answer is human placental lactogen. See Nelson-Piercy C.
Handbook of obstetric medicine. Fourth edition. CRC Press. 2010.
A 25-year-old woman is found to have a platelet count of 110 x 10*9/l
when tested routinely at 28 weeks of gestation. Her platelet count at 12
weeks of gestation was 352 x 10*9/l. She has no history of illness.
What is the most likely diagnosis from the list below?
Gestational thrombocytopenia
HIV
Immune thrombocytopenia
Thrombocytosis
Vitamin B12 deficiency
Correct
The correct answer is gestational thrombocytopenia. Gestational
thrombocytopaenia occurs in up to 1 in 20 pregnancies. If the count is
greater than 100 x 109/l no further investigations are required but other
disorders should be considered. If the count falls below this, further
investigations are indicated including blood film, coagulation screen, renal
and liver function tests, antiphospholipid antibodies and anti-DNA
antibodies. See Pavord S, Fairlie F. Obstetric haematology manual.
In:Dewhursts textbook of obstetrics and gynaecology, 7th edition. WileyBlackwell. 2007.
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A woman presents for booking in the first trimester, she is taking lithium
for her mental health.
How often should her serum lithium levels be checked?
Every 1 week until 36 weeks of gestation
Every 2 weeks until 36 weeks of gestation
Every 4 weeks until 36 weeks of gestation
Every 8 weeks until 36 weeks of gestation
Once in each trimester
Correct
The correct answer is every 4 weeks until 36 weeks of gestation. Lithium
is an important drug in maintaining mental health but taking it in
pregnancy is not without risks as the incidence of fetal heart defects are
increased. If it is not for the woman to stop taking the drug prior to
conception, lithium levels should be monitored every 4 weeks until 36
weeks of gestation, and then weekly until delivery. Lithium levels should
be checked again within 24 hours of delivery and the dose should be
adjusted to maintain a level in the lower part of the therapeutic range.
See National Institute for Health and Clinical Excellence. Antenatal and
postnatal mental health. CG45. London: NICE; 2007.
A 34-year-old primigravida presents to the maternity assessment unit with
a second episode of decreased fetal movements at 34+4 weeks of
gestation. She is known to be low risk and has had an otherwise
uneventful pregnancy.
What is the most appropriate management option?
Advise formal kick counting and review in two days
Arrange a biophysical profile and, if normal, reassure
Offer two doses of Betamethasone 12 hours apart and deliver within
48 hours
Perform a CTG and arrange a scan
Perform a CTG and, if normal, reassure
Correct
The correct answer is to perform a CTG and arrange a scan. Counselling
of women in the antenatal period about the significance of fetal
movements and relationship of this to still births is increasingly being
offered in UK. Delivery would not be warranted unless further testing
reveals an abnormality, e.g. an abnormal Doppler scan or a pathological
CTG. There is no evidence that any formal definition of reduced fetal
movements is of greater value than subjective maternal perception in the
detection of fetal compromise. Biophysical profiling has not shown to be of
benefit. See Unterscheider J, Horgan R, O'Donoghue K, Greene R.
Reduced fetal movements. The Obstetrician &
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Gynaecologist 2009;11:24551 and Royal College of Obstetricians and


Gynaecologists. Reduced fetal movements. Green-top Guideline 57.
London: RCOG; 2011.
A 28-year-old primigravida, presents at 36+3 weeks of gestation in the
antenatal clinic with a breech presentation. There are no obstetric or fetal
contraindications to external cephalic version (ECV). An initial ECV
without tocolysis failed two days earlier.
What is the most appropriate management option?
Another ECV with tocolysis
Another ECV without tocolysis
Caesarean section at 38 weeks of gestation
Postural management
Vaginal breech delivery
Correct
The correct answer is another ECV with tocolysis. ECV should be offered
after 37 weeks of gestation in multiparous women and after 36 weeks of
gestation in primiparous women. Another ECV can be offered if the first
one fails. The use of tocolysis increases the success rate after a failed
initial attempt. If a caesarean secton is offered it needs to be after 38+6
weeks of gestation. Breech delivery may not be the most appropriate
management considering she is primiparous. There is insufficient
evidence to support the use of postural management or Moxibustion as a
method of promoting spontaneous version over ECV. See Royal College
of Obstetricians and Gynaecologists. External cephalic version (ECV) and
reducing the incidence of breech presentation. Green-top Guideline 20a.
London: RCOG; 2010.
A 30-year-old pregnant woman who is at 28 weeks of gestation presents
to the Day Assessment Unit complaining of flu-like symptoms. She tells
you that she recently went on holiday to Kenya.
What is the most appropriate test for the diagnosis of malaria?
Blood culture
Polymerase chain reaction (PCR) on maternal serum
Rapid diagnostic test
Serology for antibody detection
Thick and thin blood film for parasites
Correct
The correct answer is thick and thin blood film for parasites. The gold
standard is thick and thin blood films in pregnancy rather than a rapid
diagnostic test. Serology is only useful in syphilis. SeeRoyal College of
Obstetricians and Gynaecologists. The diagnosis and treatment of malaria
in pregnancy. Green-top Guideline 45B. London; RCOG: 2010.
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A 30-year-old primigravida attends the delivery suite at 40 weeks of


gestation with prelabour rupture of membranes. On reviewing the notes
she has a positive result for group B streptococcus (GBS) in her urine one
week ago. She has no known drug allergies.
According to the NICE guidelines which antibiotic should she receive?
Ampicillin orally
Benzyl penicillin intravenously
Benzyl penicillin orally
Cefalexin orally
Cefuroxime intravenously
Correct
The correct answer is benzyl penicillin intravenously. GBS (streptococcus
agalactiae) is an important cause of neonatal morbidity and mortality.
Studies have shown that both ampicillin and benzyl penicillin reduce the
incidence of early onset disease, but benzyl penicillin is recommended
because it is less likely to promote antibiotic resistance. If penicillins are
contraindicated, clindamycin is recommended unless there is evidence of
local resistance patterns that would suggest using an alternative.
See Mugglestone MA, Murphy MS, Visintin C, Howe DT, Turner MA.
Antibiotics for early-onset neonatal infection: a summary of the NICE
guideline 2012. The Obstetrician & Gynaecologist 2014;16:8792.
A primigravida wishes to opt for epidural analgesia in labour at term but
she has heard that regional analgesia increases the risk of operative
vaginal delivery which she is keen to avoid.
Assuming she opts for an epidural analgesia, how can the second stage
of labour be managed to reduce this risk for her?
Allow up to two hours for passive descent
Commence oxytocin infusion at full dilatation
Discontinue epidural at the onset of the second stage
Use a partogram to monitor progress
Use the lithotomy position to deliver
Correct
The correct answer is allow up to two hours for passive descent.
Primiparous women are likely to have fewer rotational or mid-cavity
operative deliveries when pushing is delayed for 12 hours or until they
have a strong urge to push. Although a small trial suggested that starting
oxytocin at full dilatation reduced the operative delivery rate, NICE
concluded it should not be used on the basis of one study. See National
Institute for Health and Clincial Excellence. Intrapartum care. CG190.
London: NICE; 2014 and Royal College of Obstetricians and
Gynaecologists. Operative vaginal delivery. Green-top Guideline 26.
London: RCOG; 2011.
13

A 25-year-old pregnant woman with sickle cell disease attends the


antenatal clinic at 8 weeks of gestation.
What prenatal testing should be discussed in the first instance?
Amniocentesis
Chorionic villus biopsy
Fetal sexing at 10 weeks of gestation
Noninvasive prenatal testing
Partner testing
Correct
The correct answer is partner testing. Ideally this will have been
ascertained this in advance. Preconception counselling is very important if
the couple are identified as an 'at risk couple'. This is not just if her partner
carries HbS, but also if there are other conditions detected, e.g. thalassaemia or HbC.
The midwives on the postnatal ward are concerned about the behaviour of
a first time mother, who they are about to discharge home. They ask you
to review her. She had an elective caesarean section for a breech
presentation 3 days ago. She is otherwise fit and well, but has a past
history of depression.
Which symptoms would concern you the most and lead you to the
diagnosis of postpartum psychosis?
Bewilderment and perplexity
Insomnia and worthlessness
Irritability and anxiety
Mood swings ranging from elation to sadness
Tearfulness and crying spells
Correct
The correct answer is bewilderment and perplexity. Most of these
symptoms are features of 'baby blues' which affects 3080% of births in
the first week postpartum. Confusion, bewilderment and perplexity are
worrying symptoms and should alert you to the diagnosis of postpartum
psychosis. See Di Florio A, Smith S, Jones I. Postpartum psychosis. The
Obstetrician & Gynaecologist2013;15:14550.
You are asked to review a woman following a forceps delivery. She
presents with left lateral calf paraesthesia, sensory loss between her first
and second toes and foot drop with inversion.
Which nerve compression is the likely cause of her symptoms?
Common peroneal nerve
Lateral cutaneous nerve of thigh
Lateral femoral nerve
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Obturator nerve
Perianeal nerve
Correct
The correct answer is the common peroneal nerve. The common peroneal
nerve is prone to compression at the fibular head during positioning in
stirrups. See Kuponiyi O, Alleemudder DI, Latunde-Dada A, Eedarapalli P.
Nerve injuries associated with gynaecological surgery. The Obstetrician &
Gynaecologist 2014;16:2936.
A 25-year-old woman with sickle cell disease is considering having a child
with her partner who has sickle cell trait.
What is the probability that the child will have sickle cell disease?
25%
33%
50%
75%
100%
Correct
The correct answer is 50%. Following screening, this couple is identified
as 'at risk'. They need counselling and advice about their reproductive
options, including the methods and risks of prenatal screening and
termination of pregnancy. See Royal College of Obstetricians and
Gynaecologists. Management of sickle cell disease in pregnancy. Greentop Guideline 61. London: RCOG; 2011.
A 35-year-old woman presents at 16 weeks in her first pregnancy with a
severe throbbing headache lasting for the last 5 days, which is aggravated
with eye movements and associated with occasional blurred vision,
nausea and photophobia. The only abnormalities on examination are
bilateral papilloedema and squint of the left eye, which turns inwards. A
computer tomography scan shows no abnormality.
What is the most likely diagnosis?
Cerebral venous thrombosis
Idiopathic intracranial hypertension (IIH)
Migraine
Severe pre-eclampsia
Trigeminal neuralgia
Correct
The correct answer is idiopathic intracranial hypertension (IHH). IHH is a
diagnosis of exclusion in a pregnant woman with a headache. It is more
wommen in women, with a female:male ratio of 8:1. IHH is also more
comment in obese women, with an incidence of 19/100 000 compared
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with <1/100 000 in non-obese women. Rising obesity rates will therefore
lead to an increasing incidence of IHH. See Thirumalaikumar L,
Ramalingam K, Heafield T. Idiopathic intracranial hypertension in
pregnancy. The Obstetrician & Gynaecologist 2014;16:9397.
An 18-year-old woman is pregnant with a male fetus. She has cystic
fibrosis and her partner is a carrier. She is worried that the baby will inherit
cystic fibrosis.
What is the likelihood that the baby will be affected?
0%
25%
50%
75%
100%
Correct
The correct answer is 50%. The woman is heterozygous so will inevitably
pass on the CF gene and there is a 50% chance of her baby acquiring the
gene from her partner. The child will be either a carrier or affected.
A 28-year-old woman attends for pre-pregnancy counselling. Her maternal
grandfather and her mother's brother have haemophilia A. Her husband is
healthy and there is no history of haemophilia in the family.
What is the risk that any daughter of hers will have haemophilia A?
0%
25%
50%
75%
Correct
The correct answer is 0%. The patients mother must be a carrier. She will
have inherited the gene from her father. However the patients
grandmother must also be a carrier since the patients uncle has the
disease but her mother did not inherit the gene since she is well. The
patient has a 50% chance of being a carrier, but with a healthy husband it
is very unlikely any daughter of hers will have the disease since she will
only inherit an affected gene from her mother unless her husbands sperm
has a new mutation.
A primigravida presents at the antenatal clinic with a monochorionic
diamniotic (MCDA) twin pregnancy at 24 weeks of gestation. Ultrasound
shows that twin 1 has oligohydramnios with absent end-diastolic flow in
the umbilical artery (UA) doppler. Twin 2 has polyhydramnios with positive
end-diastolic flow in the UA doppler.
What would be the best management for this finding?
Preparation for immediate delivery
16

Repeat UA doppler in one week


Urgent referral for amniotic septostomy
Urgent referral for laser ablation of the placental bed
Urgent referral for selective amnio-reduction
Correct
The correct answer is urgent referral for laser ablation of the placental
bed. The twins have developed twin to twin transfusion syndrome (TTTS)
due to vascular placental anastomoses which are almost universal in
monochorionic twin pregnancies. Despite the anastomoses being almost
universal TTTS only occurs in 1015% of pregnancies. It is more common
in MCDA twins compared with monochorionic monoamniotic twins, but the
latter has a very high risk of cord entanglement. The randomised trial
comparing amnio-reduction and septostomy was stopped early. Although
there were better outcomes in both groups significantly more babies (RR
1.66) were alive without neurological deficit at 6 months of age in the laser
ablation group. The septostomy randomised trial was also prematurely
halted because there was no difference with the control group. See Royal
College of Obstetricians and Gynaecologists. Management of
monochorionic twin pregnancy. Green-top Guideline 51. London: RCOG:
2008.
A 35-year-old woman presents to the antenatal clinic in her first pregnancy
at 28 weeks of gestation with daily headaches. Her BMI was noted to be
36. The pain is mainly at the back of her eyes, and gets worse on eye
movements. She describes her headaches as throbbing in nature. She
also notices transient visual disturbances. Ophthalmological examination
revealed papilledema. Neurological examination was normal.
Which of the following is the most appropriate intervention?
Acetazolamide
Low molecular weight heparin
Nifedepine
Propranolol
Sumatripan
Correct
The correct answer is acetazolamide. Idiopathic intracranial hypertension
(IIH) is a rare but important cause of headache in pregnancy. A detailed
history and examination is essential. IIH tends to present in the first half of
pregnancy and women with IIH are often overweight. The diagnosis is
made using the modified Dandy criteria. See Thirumalaikumar L,
Ramalingam K, Heafield T. Idiopathic intracranial hypertension in
pregnancy. The Obstetrician & Gynaecologist2014;16:937.
An ST5 trainee performs an elective Caesarean section for a primigravida
with a breech presentation. The patient's BMI is 23. She has had no
previous abdominal surgery. A straight transverse abdominal incision is
17

made 3 cm below the level of the anterior superior iliac spines. The
subcutaneous tissue and rectus sheath are opened in the midline and
extended laterally with blunt finger dissection. Blunt dissection is used to
separate the rectus muscles and enter the peritoneum.
Which transverse abdominal incision is described above?
Cherney
Joel-Cohen
Kstner
Maylard
Pfannenstiel
Correct
The correct answer is Joel-Cohen. Pfannenstiel and Kustner are curved
incisions using sharp dissection. Cherney and Maylard are muscle cutting
incisions. Raghavan R, Arya P, Arya P, China S. Abdominal incisions and
sutures in obstetrics and gynaecology. The Obstetrician &
Gynaecologist 2014;16:1318.
You have been asked to review a postnatal woman with known type 1
insulin dependent diabetes mellitus who was successfully delivered
overnight. She is now eating and drinking normally and the postdelivery
capillary blood glucose readings are all between 4 and 7 mmol/l. The plan
is to stop the intravenous insulin/dextrose sliding scale and recommence
subcutaneous insulin. She wishes to breastfeed her baby.
What is the most appropriate advice for the woman regarding
recommencing her subcutaneous insulin?
Reduce the dose of insulin she was taking prior to induction by 25%
Continue on the dose of insulin she was taking prior to her induction
Increase her prepregnancy dose by 25%
Reduce her prepregnancy insulin dose by 25%
Revert to her prepregnancy dose of insulin
Correct
The correct answer is to reduce her prepregnancy insulin dose by 25%.
Once women with type 1 diabetes are eating normally, subcutaneous
insulin should be recommenced at a 25% lower dose of her prepregnancy
dose if she intends to breastfeed. Breastfeeding is associated with
increased energy expenditure. Nelson-Piercy C. Handbook of obstetric
medicine. Fourth edition. CRC Press. 2010.
At the evening handover of a busy labour ward, you are informed that a
cord prolapse has been diagnosed after amniotomy with the presenting
part at 3 station. On CTG, the baseline is 115 bpm with 10 bpm
variability and one variable deceleration lasting less than 30 seconds over
the last 10 minutes. The obstetric emergency theatre is currently being
used for a manual removal of the placenta.
18

What is the most appropriate management for this woman?


Ask a midwife to elevate the fetal presenting part and arrange a
category 1 section in the second theatre
Fill up the bladder via a urinary catheter and keep woman in a kneechest position until the case in theatre is finished
Give tocolysis and wait for the emergency theatre to become free
Open the second emergency theatre for a category 1 section
Open the second emergency theatre for a category 2 section
Correct
The correct answer is to open the second emergency theatre for a
category 2 section. A category 2 caesarean section is appropriate for
women in whom the fetal heart rate pattern is normal. However, if the
CTG becomes abnormal it should be re-categorised to category 1.
See Royal College of Obstetricians and Gynaecologists. Umbilical cord
prolapse. Green-top Guideline 50. London: RCOG; 2014.
A 32- year-old primigravid woman attends the antenatal clinic complaining
of persistent mild pruritus due to atopic eruption of pregnancy.
Which is the first line treatment in reducing pruritus and providing relief of
her symptoms?
Emollients
Oral antihistamines
Oral prednisolone
Topical hydrocortisone
Ultraviolet B phototherapy
Correct
The correct answer is emollients. The two most common skin problems in
pregnancy are atopic eruption of pregnancy and polymorphic eruption of
pregnancy. In about half of all women who complain of skin problems in
pregnancy it is an exacerbation of a pre-existing condition. Atopic eruption
of pregnancy may require topical steroids and antihistamines, but can
often be managed with emollients. See Vaughan Jones S, AmbrosRudolph C, Nelson-Piercy C. Skin disease in
pregnancy. BMJ 2014;348:2630 [Abstract only].
You see a patient who is 35 weeks pregnant in your day assessment unit.
She presents with itching causing insomnia of the palms of hands and
soles of feet. There are scratch marks but no rash. Her alanine
transaminase is 78 IU/l (normal range 1035) and bile acids are 42
micromol/l (normal range 110).
Which of the following contraceptives should be avoided postnatally?
Condoms
19

Depo Provera
Combined oral contraceptive pill
Progestogen only pill
Levonorgestrel-releasing intrauterine system
Correct
The correct answer is the combined oral contraceptive pill. Estrogencontaining contraceptives should be avoided in women who have had
obstetric cholestasis. See Royal College of Obstetricians and
Gynaecologists. Obstetric cholestasis. Green-top Guideline 43. London:
RCOG; 2011.
You see a patient who is 35 weeks pregnant in your day assessment unit.
She presents with itching. Your differential diagnosis is polymorphic
eruption of pregnancy.
What clinical feature is most helpful in diagnosing this condition?
Facial pigmentation
Inflamed abdominal striae
Itching of palms of hands
Itching of soles of feet
Umbilical rash
Correct
The correct answer is inflamed abdominal striae. Polymorphic eruption of
pregnancy classically affects the abdominal striae, sparing the umbilicus.
The differential diagnosis is intrahepatic cholestasis of pregnancy, atopic
eruption of pregnancy and pemphigoid gestationis. See Nelson-Piercy
C. Handbook of obstetric management, 4th edition. CRC Press 2010
and Maharajan A, Aye C, Ratnavel R, Burova E. Skin eruptions specific to
pregnancy: an overview. The Obstetrician & Gynaecologist 2013;15:233
40.
You see a patient who is 35 weeks pregnant in your day assessment unit.
She presents with itching. Your differential diagnosis is obstetric
cholestasis. Your ST1 asks you if she should prescribe vitamin K but is
not sure how it works.
Vitamin K is responsible for manufacturing which of the following
coagulation factors?
Factor V
Factor VIII
Factor X
Factor XI
Factor XII
20

Correct
The correct answer is factor X. Vitamin K is required for manufacturing
coagulation factors II, VII, IX, X. See Royal College of Obstetricians and
Gynaecologists. Obstetric cholestasis. Green-top Guideline 43. London:
RCOG; 2011.
You see a woman who is 35 weeks pregnant in your day assessment unit.
She presents with nausea, anorexia and generalised malaise. Her liver
function test demonstrates an alanine transaminase (ALT) of 634.
Which of the following features is most useful in distinguishing acute fatty
liver of pregnancy (AFLP) from HELLP syndrome?
Deranged renal function
Epigastric pain
Hypertension
Hypoglycaemia
Proteinuria
Correct
The correct answer is hypoglycaemia. Liver disorders are common in
pregnancy, but rarely cause long term problems. AFLP is a rare but
serious condition which will share many common features with HELLP.
However hypoglycaemia is common in AFLP and can be severe, but is
extremely unlikely in HELLP. See Nelson-Piercy C. Handbook of obstetric
management, 4th edition. CRC Press. 2010.
A 35-year-old woman with persistent tachycardia has thyroid function tests
at 18 weeks of gestation. The results are TSH <0.02 mU/l (normal range
0.45.0) and T4 of 67 pmol/l (normal range 1020).
What is the most likely cause for her hyperthyroidism?
Graves disease
Hashimoto thyroiditis
Subacute thyroiditis
Thyrotropic activity of HCG
Toxic multinodular goitre
Correct
The correct answer is Graves disease. 95% of cases of hyperthyroidism in
pregnancy are due to Graves disease. Thyroxine production increases in
pregnancy due to an increase in thyroxine binding globulin to maintain a
steady free thyroxine level (both T3 and T4). In assessing thyroid function
in pregnancy, free T3 and T4 levels reflect thyroid function rather than
total T3 and T4 levels. In monitoring hypo- and hyperthyroid disease the
TSH level may take longer to return to normal so free T3 and T4 levels are
a more accurate reflection. Hyperthyroidism is common in women of
reproductive years and is seen in approximately 1 in 500 pregnancies.
See Nelson-Piercy C. Handbook of obstetric medicine, 4th edition. CRC
21

Press. 2010.
A primigravida presents at 41 weeks into an uncomplicated pregnancy.
You arrange induction of labour.
According to NICE guidelines (2008), what is the rate of spontaneous
vaginal delivery following induction with prostaglandins alone?
3140%
4150%
5160%
6170%
7180%
Correct
The correct answer is 6170%. Induction of labour should only be offered
to women in specific circumstances since there is an increased risk of
caesarean section. See National Institute for Health and Clinical
Excellence. Induction of labour. Clinical guideline 70. London: NICE.
2008.
A 19-year-old woman is 28 weeks into her first pregnancy. On routine
blood tests, her haemoglobin is 95 g/l.
What is the best test to diagnose iron deficiency anaemia?
Blood film
Serum ferritin
Serum iron levels
Serum soluble transferrin receptor
Total iron binding capacity
Correct
The correct answer is serum ferritin. Although an approximation of iron
deficiency can be assessed by the mean corpuscular volume, serum
ferritin will give an accurate test of iron stores. See British Committee for
Standards in Haematology. UK guidelines on the management of iron
deficiency in pregnancy. London: BCSH: 2011.
A 26-year-old P1+0 woman booked under midwife-led care develops a
confirmed chickenpox infection at 38+6 weeks of gestation. She is a nonsmoker and is otherwise low risk. Clinically, the fetus appears
appropriately grown for gestation and is in a cephalic presentation. She
previously had an uncomplicated normal delivery of a 3.7 kg baby
following induction for postmaturity.
What is the most appropriate advice for her ongoing management?
Await the onset of spontaneous labour and give the newborn varicella
zoster immunoglobulin (VZIG)
Await the onset of spontaneous labour and give the newborn varicella
22

zoster immunoglobulin if delivered within 7 days following the onset of the


maternal rash
Give the mother varicella zoster immunoglobulin and await the onset
of spontaneous labour
Give the mother varicella zoster immunoglobulin and induce the
following day at 39 weeks of gestation
Induce labour the following day at 39 weeks of gestation and give the
newborn varicella zoster immunoglobulin
Correct
The correct answer is await the onset of spontaneous labour and give the
newborn varicella zoster immunoglobulin if delivered within 7 days
following the onset of the maternal rash. VZIG has no effect once
chickenpox has developed. If the woman presents within 24 hours (at over
20 weeks of gestation) it is worth prescribing acyclovir. The baby is at
most risk if delivered within a week of the development of the infection.
After 7 days the maternal antibodies will protect the baby. See Royal
College of Obstetricians and Gynaecologists. Chickenpox in pregnancy.
Green-top Guideline 13. London: RCOG; 2007.
A couple attend for pre-pregnancy genetic counselling because the
partner is known to have haemophilia A. They are seeking information
about their future baby's risk of inheriting the condition.
Which of the following statements regarding the heritability of haemophilia
A is correct?
Approximately 50% of newly diagnosed patients have no family history
Daughters of males with haemophilia have a 50% chance of being
carriers
Haemophilia cannot arise following a spontaneous mutation
Sons of males with haemophilia will inherit the disease
The background risk of carriership is approximately 1 in 50 000
women
Correct
The correct answer is approximately 50% of newly diagnosed patients
have no family history. Daughters of affected males will always be carriers
but sons will never inherit the disease (the affected gene is on the paternal
X chromosome, which never goes to the sons). Haemophilia can arise as
a spontaneous mutation and the risk of being a carrier is 1 in 20 000. See
Mumford A. Genetic counselling and pre-natal diagnosis. In: Pavord S,
Hunt B (editors). The obstetric haematology manual. Cambridge
University Press. 2010. p 194199.
A recently delivered woman on the postnatal ward tells you that her baby
has a patent ductus arteriosus. She asks what the ductus arteriosus is
connected to when her baby was in utero.
Where does the ductus arteriosus connects in a fetus?
23

Middle cerebral artery to posterior communicating artery


Pulmonary artery to aorta
Right and left atria
Umbilical artery to iliac artery
Umbilical vein to inferior vena cava
Correct
The correct answer is the pulmonary artery to the aorta. An understanding
of fetal circulation and congenital heart defects is important to an
obstetrician. It gives them the ability to discuss any problems with their
patients and is required to understand changes seen on ultrasound and
the effect on the fetus and baby. There are many resources on the
internet e.g. the Atlas of Cardiac Anatomy produced by the University of
Minnesota (accessed 2 July 2015).
The following figure refers to the first question on this page:

Enlarge
Reproduced with permission from Tang T et al. Cochrane Database Syst
Rev 2012;(5):CD003053
This analysis above is taken from a meta-analysis of ovulation rates in
women with polycystic ovarian syndrome (PCOS) taking metformin
compared with clomifene ovulation induction therapy. Subgroup analysis
was also carried out using a cut-off BMI level of 30 kg/m2.
Which statement of the following best describes the above findings?
Metformin is equally as effective as clomifene in the obese group (BMI
> 30)
Metformin is less effective than clomifene in the non-obese group
(BMI <30)
Metformin is less effective than clomifene in the obese group (BMI
>30)
24

Metformin is more effective than clomifene in the non-obese group


(BMI < 30)
Metformin is more effective than clomifene in the obese group (BMI
>30)
Correct
The correct answer is that metformin is less effective than clomifene in the
obese group (BMI >30). Metformin is less effective than clomifene in the
obese group (BMI >30 kg/m2) as the OR = 0.43 (95% CI 0.360.51) in
favour of clomiphene. See Tang T, Lord JM, Norman RJ, Yasmin E, Balen
AH. Insulin-sensitising drugs (metformin, rosiglitazone, pioglitazone, Dchiro-inositol) for women with polycystic ovary syndrome, oligo
amenorrhoea and subfertility. Cochrane Database Syst
Rev2012;(5):CD003053. Correct interpretation of statistics is essential in
modern clinical practice. This question aims to assess your ability to
interpret a Forest plot.
A 30-year-old woman is referred to the colposcopy clinic with borderline
dyskaryosis, high risk HPV positive. Her colposcopy directed biopsy is
reported as CIN1.
What should she be advised?
To repeat smear with GP in 6 months
To repeat smear with GP in 1 year
To repeat smear with GP in 3 years
To repeat smear and colposcopy in 6 months time
To repeat smear and colposcopy in 1 year
Correct
The correct answer is to repeat smear with GP in 1 year. If the colposcopy
had included treatment for CIN then it would not be correct to repeat the
smear in 6 months. If the colposcopy had been normal with no CIN on
biopsy then it would be correct to repeat the smear in 3 years. Colposcopy
is not indicated other than for follow up for CGIN and, even then, it is
optional. See NHS Cervical screening Programme. Screening protocol
algorithm for HPV triage and test of cure. 2014accessed online July 2015
(this will open as a PDF download).
You are asked to review a 55-year-old woman with overactive bladder
symptoms. She has responded poorly to bladder training and is on
oxybutynin therapy. Her main complaint is nocturia, which is badly
affecting her quality of life.
What is the best treatment for her continuing symptoms?
25

Darifenacin
Desmopressin
Mirabegrone
Tolterodine
Transdermal oxybutynin
Correct
The correct answer is Desmopressin. The use of desmopressin may be
considered specifically to reduce nocturia in women with UI or OAB who
find it a troublesome symptom. Use particular caution in women with
cystic fibrosis and avoid in those over 65 years with cardiovascular
disease or hypertension. See National Institute for Health and Clinical
Excellence. Urinary incontinence in women. CG171. London: NICE; 2013.
A 55-year-old woman is due to come in for total abdominal hysterectomy
and bilateral salpingo-oophorectomy for a large mucinous ovarian cyst.
She takes sequential HRT for menopausal symptoms.
What is the approximate overall risk of serious complications from
abdominal hysterectomy?
1 operation in every 100
2 operations in every 100
3 operations in every 100
4 operations in every 100
5 operations in every 100
Correct
The correct answer is 4 operations in every 100. The overall risk of
serious complications from abdominal hysterectomy is approximately four
women in every 100 (common). See National Institute of Health and
Clinical Excellence. Venous thromboembolism: reducing the risk. Clinical
Guideline 92. London: NICE; 2010 and Royal College of Obstetricians and
Gynaecologists.Abdominal hysterectomy for benign conditions. Consent
Advice 4. London: RCOG; 2009.
A 46-year-old para 2 woman is referred to your gynaecology clinic
complaining of regular but heavy menstrual bleeding which is affecting her
quality of life.
Which of the following associated features indicates the need for
endometrial biopsy?
BMI greater than 30
26

Dysmenorrhoea
Failure of previous medical therapy
Iron deficiency anaemia
Uterus enlarged on vaginal examination
Correct
The correct answer is failure of previous medical therapy. An endometrial
biopsy should be taken if there is persistent intermenstrual bleeding or if
treatment is ineffective in women over 45. An ultrasound is the first line
diagnostic tool for identifying structural abnormalities and should be
performed if the uterus is palpable abdominally, vaginal examination
reveals a pelvic mass or if drug treatment fails. See National Institute for
Health and Clinical Excellence. Heavy menstrual bleeding. London: NICE;
2013.
A woman has been recommended to undergo hysterectomy and bilateral
salpingo-oophorectomy for benign disease. You discuss the risks and
benefits of an open versus a laparoscopic procedure.
Which sort of injury is more common at laparoscopic hysterectomy
compared to an open procedure?
Bowel
Nerve
Ovary
Urinary tract
Vascular
Correct
The correct answer is urinary tract injury. Laparoscopic surgery involves
risks to bowel, urinary tract and major blood vessels. These risks are
higher in women who are obese or significantly underweight, however the
risks of laparotomy are significantly greater in the morbidly obese. Urinary
tract injury and vaginal cuff dehiscence are more common in the
laparoscopic approach with an odds ratio of 2.61 for urinary tract
injury. Royal College of Obstetricians and Gynaecologists. Preventing
entry-related gynaecological laparoscopic injuries. Green-top Guideline
49. London: RCOG; 2008.
A 65-year-old had a hysterectomy for endometrial cancer. She recovered
well but complained of dribbling urine 2 days later and was given a course
of antibiotics for a presumed UTI. On review at 4 weeks she complains of
continued urinary incontinence. She has no dysuria, no sensation of
urgency, needs to wear a pad at night, and intermittently voids good
27

volumes of urine with normal flow. Urinalysis is negative.


What the most likely diagnosis?
Fistula
Occult underlying stress incontinence
Overactive bladder syndrome
Overflow incontinence
Urinary tract infection
Correct
The correct answer is fistula. In the developed world the majority of
urinary tract fistulae occur following hysterectomy (both vaginal and
abdominal) and caesarean section. This is usually due to failure to dissect
the bladder free of the cervix and upper vagina. Leakage starting in the
immediate postoperative period suggests direct damage. Leakage that
starts 1-2 weeks postoperatively is due to avascular necrosis. See
Monaghan JM, Lopes T, Naik R. Bonney's gynaecological surgery. WileyBlackwell. 2004.
A 47-year-old woman seeks advice about continuing the combined oral
contraceptive pill (COCP). She is normotensive and a non-smoker with a
BMI of 25. She has no other medical history and no significant family
history. She is concerned that the COCP may give her additional health
risks.
Which of the following malignancies would you advise she may have a
small additional risk of developing due to taking the COCP?
Breast cancer
Colorectal cancer
Endometrial cancer
Lung cancer
Ovarian cancer
Correct
The correct answer is breast cancer. COCP use provides a protective
effect against ovarian and endometrial cancer that continues for 15 years
or more after stopping the pill. Women can be advised that there may be a
small additional risk of developing breast cancer if they use COCP, which
reduces to no risk 10 years after stopping the pill. See Faculty of Sexual &
Reproductive Healthcare. Contraception for women aged over 40 years.
Clinical Guidance. London: FSRH; 2010.

28

You have been reviewing the NICE guidelines on urinary incontinence.


You have been asked to perform an audit on management of urinary
incontinence in your department.
What is the main purpose of audit?
Changing practice
Collecting data
Providing patient feedback
Improving quality
Reducing costs
Correct
The correct answer is improving quality. Clinical audit is a quality
improvement process that seeks to improve patient care and outcomes
through systematic review of care against explicit criteria and the
implementation of change. Aspects of the structure, processes and
outcomes of care are selected and systematically evaluated against
explicit criteria. Where indicated, changes are implemented at an
individual, team or service level and further monitoring is used to confirm
improvement in healthcare delivery. See Royal College of Obstetricians
and Gynaecologists.Understanding audit. Clinical Governance Advice 5.
London: RCOG; 2003.
A 35-year-old woman undergoes extensive laparoscopic surgery in the
lithotomy position. She presents after 3 days with unresolved weakness of
right hip extension and right knee flexion. There is associated sensory
impairment below the right knee.
Damage to which nerve is the most likely cause?
Femoral
Ilio-inguinal
Lateral cutaneous of the thigh
Obturator
Sciatic
Correct
The correct answer is the sciatic nerve. See Kuponiyi O, Alleemudder DI,
Latunde-Dada A, Eedarapalli P. Nerve injuries associated with
gynaecological surgery. The Obstetrician & Gynaecologist 2014;16:2936.
You see a 45-year-old nulliparous woman at your gynaecology clinic who
29

is a carrier for the BRCA2 mutation. She wishes to discuss surgery to


reduce her cancer risk.
What is the approximate average cumulative risk of her developing
ovarian-type cancer by the age of 70?
10%
25%
40%
55%
70%
Correct
The correct answer is 10%. BRCA1 and BRCA2 are highly penetrant
genes that account for 95% of families with both breast and ovarian
cancer. The cumulative risk of ovarian cancer is lower in women with
BRCA2 at 11%, compared with BRCA1 where the risk is 39%. See Devlin
LA, Morrison PJ. Inherited gynaecological cancer syndromes. The
Obstetrician & Gynaecologist2008;10:915 and Antoniou A, Pharoah PD,
Narod S, Risch HA, Eyfjord JE, Hopper JL et al. Average risks of breast
and ovarian cancer associated with BRCA1 or BRCA2 mutations detected
in case Series unselected for family history: a combined analysis of 22
studies. Am J Hum Genet2003;72:111730.
You prescribe hormone replacement therapy (HRT) for vasomotor
instability in a healthy 51-year-old woman who has no significant past
medical or family history. During her appointment you counsel her
regarding the risks of estrogen and progestogen HRT.
How many estimated additional cases of breast cancer are there per 1000
women using HRT for five years?
3 cases per 1000 women
6 cases per 1000 women
9 cases per 1000 women
12 cases per 1000 women
14 cases per 1000 women
Correct
The correct answer is 6 additional cases per 1000 women. Combined
(estrogen and progesterone) HRT is associated with a higher risk of
breast cancer than estrogen-only HRT or tibolone. There are some
discrepancies between the Million Women Study (MWS) and Women's
Health Initiative (WHI) study. Many of the discrepencies can be explained
by the populations studies. The WHI study group was 16 000 women
30

aged 50-79, 45% of whom had a BMI of 30 or more. The MWS looked at 1
084 110 women aged 50-64, only 18% of whom had a BMI of 30 or more
See theBritish National Formulary. Hormone replacement therapy.
Accessed online November 2014.
You see a 48-year-old woman opting for a hysterectomy for management
of her heavy menstrual bleeding. While obtaining her consent for the
operation you explain to her that haemorrhage requiring transfusion is a
'common' procedural risk.
What is the numerical ratio for a complication when it is quoted as
'common'?
1/1 to 1/10
1/10 to 1/100
1/100 to 1/1000
1/1000 to 1/10 000
Less than 1/10 000
Correct
The correct answer is 1/10 to 1/100. See Royal College of Obstetricians
and Gynaecologists.Obtaining valid consent for complex gynaecological
surgery. Clinical Governance Advice 6b. London: RCOG; 2010.
A 36-year old woman undergoes laparoscopic resection of deep infiltrating
endometriosis. You advise her regarding the risk of injury to her ureters
during the surgery and the fact that this may be a direct injury or a thermal
injury related to electrocautery.
If she does receive a thermal injury, when would you expect her to
present?
12 days post surgery
57 days post surgery
1014 days post surgery
34 weeks post surgery
56 weeks post surgery
Correct
The correct answer is 1014 days after surgery. Thermal injuries to the
ureter may result in delayed necrosis and/or fistula formation that will
typically present clinically between 10 and 14 days postoperatively.
See Minas V, Gul N, Aust T, Doyle M, Rowlands D. Urinary tract injuries in
laparoscopic gynaecological surgery; prevention, recognition and
31

management. The Obstetrician & Gynaecologist 2014;16:1928.


A 68-year-old woman with postmenopausal bleeding is attending for a
diagnostic hysteroscopy under general anaesthetic. You discuss the
complications with her.
What is the incidence of serious complications during hysteroscopy?
1 in 50
1 in 100
1 in 500
1 in 1000
1 in 5000
Correct
The correct is 1 in 500. Uterine perforation is uncommon, but a small
postmenopausal uterus is an independent risk factor, especially if the
cervical os is stenosed. The overall risk is reported as 0.76%. See Shakir
F, Diab Y. The perforated uterus. The Obstetrician &
Gynaecologist2013;15:25661 and Rock JA, Jones HW. Te Lindes
Operative Gynaecology. Lippincott Williams and Wilkins. 2011.
A 22-year-old medical student presents with a request for
contraception. Her menstrual cycle is irregular and she complains of acne
and hirsutism. Previous investigation has diagnosed polycystic ovary
syndrome (PCOS). She wishes to have a combined oral contraceptive
with the best risk profile and most impact on her androgenic symptoms.
Which one of the following is the best available option to recommend for
her?
Cilest (ethinyl estradiol/norgestimate)
Loestrin (ethinyl estradiol/levonorgestrol)
Marvelon (ethinyl estradiol/desogestrel)
Microgynon (ethinyl estradiol/norethisterone)
Yasmin (ethinyl estradiol/drosperinone)
Correct
The correct answer is Yasmin (ethinyl estradiol/drosperinone). From the
given list, Yasmin is more beneficial in terms of management of acne and
hirsuitism associated with PCOS. Women with PCOS may also be given
Marvelon or Mercilon as contraception. Yasmin contains 3 mg of
drosperinone, which has some antiandrogenic properties. Dianette is also
useful as it contains cyproterone acetate, which is also an antiandrogenic
32

agent. Care must be taken for women with high body mass index.
See Swingler R, Awala A, Gordon U. Hirsutism in young women. The
Obstetrician & Gynaecologist 2009;11:1017.
A 16-year-old girl presents to the gynaecology outpatient clinic with
primary amenorrhea. She is 148 cm tall and weighs 54 kg (BMI
24.7). Breast development is assessed as Tanner stage 2 and her pubic
hair is noted to be sparse. Further examination identifies cubitus
valgus. She has no other dysmorphic features.
What is the most likely diagnosis?
Congenital adrenal hyperplasia
Down syndrome
Mayer-Rockitansky-Kusterhauser syndrome
Testicular feminisation
Turner syndrome
Correct
The correct answer is Turner syndrome. The karyotype is 45 XO in Turner
syndrome. It is the most common cause of gonadal dysgenesis. These
patients may have additional renal and cardiac anamolies. Some women
may menstruate due to mosaicism, but premature ovarian failure is more
common. See Bondy CA, and for The Turner Syndrome Consensus Study
Group. Care of girls and women with Turner syndrome: a guideline of the
Turner Syndrome Study Group. J Clin Endocrinol Metab 2007;92:1025.
A 48-year-old woman presents 1 week after a total abdominal
hysterectomy. She has persistent weakness of hip flexion and
paraesthesia over the anterior and medial aspects of her left thigh.
Damage to which nerve is the most likely cause?
Femoral
Genito-femoral
Ilio-inguinal
Lateral cutaneous of the thigh
Obturator
Correct
The correct answer is the femoral nerve. Gynaecological surgery,
especially abdominal hysterectomy, is the most common cause of
iatrogenic femoral nerve injury, and injury to the femoral nerve is the most
common nerve injury in gynaecological practice. This is usually caused by
33

compression of the nerve against the pelvic sidewall by a retractor blade.


See Kuponiyi O, Alleemudder DI, Latunde-Dada A, Eedarapalli P. Nerve
injuries associated with gynaecological surgery. The Obstetrician &
Gynaecologist 2014;16:2936.
A 23-year-old woman whose mother died at the age of 56 of cervical
cancer comes to see you. She wants to know how to reduce her own risk
of cervical cancer.
What is the single most important piece of advice you could give her?
To attend regularly for cervical screening
To avoid sexual promiscuity
To stop smoking
To stop smoking
To undergo prophylactic risk-reducing bilateral salpingo-oophorectomy
Correct
The correct asnwer is to attend regularly for cervical screening. The
incidence of cervical carcinoma has drastically reduced in countries with
screening programmes. Only 1% of abnormal smears progress to
malignancy over a long period of time. Most women with cervical cancer
have not had a smear in the last 5 years and many of then have never
had a smear. See Centres for Disease Control and
Prevention. Gynecologic cancers. Accessed online July 2015.
A 23-year-old primigravid woman presents at the emergency department
at 6 weeks of gestation with threatened miscarriage. On examination, her
vital signs were normal and her abdomen was soft with minimal
tenderness on deep palpation. On speculum examination, there was a
small amount of brown (old) blood in the vagina. A transvaginal ultrasound
scan showed an intrauterine gestation sac measuring 18 mm x 15 mm x
12 mm. No yolk sac or fetal pole was visible.
What would be the best management plan for her?
Arrange a repeat scan after 7 days
Arrange a dating scan at 12 weeks of gestation
Arrange serial -HCG levels
Arrange serum progesterone level
Arrange surgical management of miscarriage
Correct
The correct answer is arrange a repeat scan after 7 days. For an
34

embryonic pregnancy, if the mean gestational sac diameter is less than


25.0 mm with a transvaginal ultrasound scan and there is no visible fetal
pole, a second scan after a minimum of 7 days should be performed
before making a diagnosis of miscarriage. Once a gestation sac has been
identified, there is no role for testing of serum -HCG or serum
progesterone level. See National Institute for Health and Clinical
Excellence. Ectopic pregnancy and miscarriage: diagnosis and initial
management in early pregnancy of ectopic pregnancy and miscarriage.
CG154. London: NICE; 2012.
A 65-year-old postmenopausal woman attends the clinic having been
found to have a 4.9 cm simple cyst arising from the right ovary. There is
no other abnormality on scan. Her Ca 125 is 29. She is asymptomatic and
the cyst was picked up on investigation for haematuria.
What is the most appropriate management?
Aspiration of the cyst under ultrasound guidance
Laparoscopic aspiration of the cyst
Repeat scan and Ca 125 test in 4 months
Right oophorectomy
Right ovarian cystectomy
Correct
The correct answer is repeat scan and Ca 125 test in 4 months. The risk
of malignancy index (RMI) is zero since the cyst is simple and it measures
less than 5 cm. Therefore, monitoring for 12 months is all that is required.
See Royal College of Obstetricians and Gynaecologists. Ovarian cysts in
postmenopausal women. Green-top Guideline 34. London: RCOG; 2003.
A 17-year-old girl presents with a 12 hour history of lower abdominal pain.
She had unprotected intercourse a week ago, which was 6 days after her
last period. Her pulse is 110 beats per minute, her blood pressure is
110/70 mmHg, her temperature 37.8C and she is tender over her lower
abdomen, especially in the right iliac fossa where there is rebound
tenderness. There is cervical excitation. Her Hb is 137g/l (normal 115
165) and her white cell count 17.6 x 10*9/l (normal 411).
What is the most likely diagnosis?
Acute appendicitis
Acute pelvic inflammatory disease
Ectopic pregnancy
Pelvic endometriosis
Ruptured corpus luteum
Correct
The correct answer is acute appendicitis. The white count and mild
pyrexia suggest an infection and the localisation to the right iliac fossa
35

makes this more likely to be appendicitis.


A 27-year-old woman has had three successive first trimester
miscarriages. Investigations show that she has antiphospholipid
syndrome.
Which treatment option will improve the chance of a successful
pregnancy?
Aspirin and heparin
Corticosteroids and intravenous immunoglobulin
Human chorionic gonadotrophin
Metformin
Progesterone
Correct
The correct answer is aspirin and heparin. Antiphospholipid syndrome is
present in 15% of women with recurrent miscarriage. Without treatment,
the live birth rate has been reported to be as low as 10%. Corticosteroids
and intravenous immunoglobulin are associated with significant maternal
and fetal morbidity. Despite the association between PCOS and
miscarriage that is attributed to insulin resistance and hyperinsulinaemia,
a meta-analysis of 117 randomised controlled trials showed no reduction
in the rate of miscarriage in those women prescribed metformin.
See Royal College of Obstetricians and Gynaecologists. Investigation and
treatment of couples with recurrent miscarriage. Green-top Guideline 17.
London: RCOG; 2011.
A 26-year-old-woman presents to the emergency gynaecology clinic
requesting emergency contraception (EC). She had unprotected sex 6
days ago. She is not currently using any contraception, having not had a
partner for a year. She has a regular 28 day menstrual cycle, which can
be heavy. The first day of her last period was 15 days ago.
What emergency contraception option, if any, would you advise?
A copper bearing intrauterine device
A Mirena coil
It is too late for emergency contraception
Levonelle
Ulipristal acetate
Correct
The correct answer is a copper bearing intrauterine device. The choice of
EC depends on the length of time since unprotected sexual intercourse.
All forms are not effective after 6 days except for the copper-bearing
intrauterine device, and only in the circumstance that it is within 5 days of
the earliest estimated date of ovulation. See Faculty of Sexual and
Reproductive Healthcare.Emergency contraception. Clinical Guidance.
London: FSRH; 2011.
36

A 46-year-old fit and healthy woman has urodynamically confirmed stress


urinary incontinence. She has undergone pelvic floor muscle training
without improvement. On examination she is noted to have a POPQ grade
1 anterior vaginal wall prolapse. In view of the effect of her urinary
symptoms on her quality of life she is requesting definitive treatment.
What is the most appropriate surgical intervention for her?
Anterior colporrhaphy
Artificial urinary sphincter
Intramural bulking agent
Laparoscopic colposuspension
Synthetic mid-urethral tape
Correct
The correct answer is synthetic mid-urethral tape. All women with stress
urinary incontinence should be referred for pelvic floor exercises in the
first instance. If conservative management fails, the first line management
is a synthetic mid-urethral tape procedure. Anterior colporrhaphy is not
indicated since her prolapse is only stage 1 and is therefore
asymptomatic, and it does not treat stress incontinence. See National
Institute for Health and Clinical Excellence. The management of urinary
incontinence in women. Clinical Guideline 171. NICE; 2013.
A 36-year-old woman presents to the early pregnancy assessment unit
with a history of mild bleeding for 3 days and lower abdominal pain. She
has had two vaginal deliveries in the past. She has factor V Leiden
deficiency, which was diagnosed during her first pregnancy. Her last
menstrual period was 7 weeks ago and this is an unplanned pregnancy.
She has no other significant medical or surgical history. She lives with her
husband and children. On ultrasound scan, she was found to have an
intrauterine gestational sac with a fetal pole measuring 8 mm. No fetal
heart beat was seen and was confirmed by two ultrasonographers.
What is the best initial management for this woman?
Book a repeat scan in 710 days
Counsel her regarding expectant management of miscarriage
Discuss medical management of miscarriage and prescribe oral
administration of 600 micrograms of misoprostol
Discuss medical management of miscarriage and prescribe oral
administration of 200 mg mifepristone
Prescribe antibiotics for 7 days and discuss expectant management of
miscarriage
Correct
The correct answer is counsel her regarding expectant management of
miscarriage. Expectant management should be offered as first line
management for all women with a confirmed diagnosis of miscarriage,
37

taking into account if she is at increased risk of haemorrhage (e.g. late


first trimester), has risks associated with haemorrhage (e.g. unable to
have a blood transfusion), evidence of infection, or her personal wishes.
Mifepristone is not indicated in management of a non viable pregnancy.
See National Institute for Health and Clinical Excellence. Ectopic
pregnancy and miscarriage. CG154. NICE; 2012.
A 40-year-old woman presents with severe pelvic pain. She has had a
myomectomy in the past through a vertical abdominal incision to the level
of the umbilicus. To investigate her pelvic pain, she undergoes a
diagnostic laparoscopy using the Palmer point of entry.
Where is Palmers point?
3 cm below the left costal margin in the midaxillary line
3 cm below the left costal margin in the midclavicular line
3 cm below the right costal margin in the midaxillary line
3 cm below the right costal margin in the midclavicular line
3 cm below xiphisternum in the midline
Correct
The correct answer is 3 cm below the left costal margin in the
midclavicular line. Palmers point should be used if there is a high
suspicion of adhesions. Adhesions are found in up to 50% of women
following midline laparotomy but are rarely found in the left upper
quadrant. The usual trocar and cannulae can be inserted under direct
vision or following dissection of any adhesions seen. If there are two failed
attempts at insufflation then utilising Palmers point or the open Hasson
technique should be used. See Royal College of Obstetricians and
Gynaecologists. Preventing entry related gynaecological injuries. Greentop Guideline 49. London: RCOG; 2008.
A 16-year-old girl attends the gynaecology clinic for heavy periods and
confides that she is being forced to undergo female genital mutilation
(FGM) by her parents.
What is the estimated number of children at risk of FGM in the UK?
500
5000
10 000
20 000
50 000
Correct
The correct answer is 20 000. It is estimated that 20 000 girls in the UK
are at risk of FGM, usually through travelling abroad to facilitate the
procedure. It is important that the safeguarding team are informed when a
woman who has undergone FGM themselves delivers a female child.
See Royal College of Obstetricians and Gynaecologists. Female genital
38

mutilation and its management. Green-top Guideline 53. London: RCOG;


2009.
You have informed a 45-year-old that she has stage 3c ovarian cancer.
She is keen to know about her prognosis.
What is the 5-year survival rate in UK for ovarian cancer?
2025%
3035%
40445%
5055%
6065%
Correct
The correct answer is 4045%. As with the majority of cancers, relative
survival for ovarian cancer is improving. Much of the increase occurred
during the 1980s and 1990s, and appears to be leveling off in the 2000s.
The significant increase in 1-year survival is likely to be the result of
greater use of platinum-based chemotherapy. One-year relative survival
rates for ovarian cancer increased from 42% in England and Wales in
19711975 to 72.3% in England in 20052009. The 5-year survival rate
for advanced ovarian cancer in 20052009 was 43%. See Cancer
Research UK. Ovarian cancer survival statistics. Accessed online July
2015.
A 42-year-old para 2 woman is referred to your gynaecology clinic
complaining of regular but heavy menstrual bleeding that is affecting her
quality of life.
Which of the following investigations is most appropriate at the first clinic
visit?
Full blood count (FBC)
Gonadotrophin assay
Thyroid function tests (TFTs)
Thyroid function tests (TFTs)
Transvaginal ultrasound (TVS)
Correct
The correct answer is a full blood count (FBC). All women presenting with
heavy menstrual bleeding should have FBC performed. An ultrasound
scan is not indicated unless the uterus is palpable abdominally, an
adnexal mass is palpable or medical treatment fails. See National Institute
for Health and Clinical Excellence. Heavy menstrual bleeding. CG44.
NICE; 2007.
A 63-year-old woman with a history of postmenopausal bleeding returns to
the gynaecology clinic. Recent endometrial biopsy shows complex
hyperplasia without atypia. She wants to know what the risk is of these
39

abnormal cells progressing to cancer.


What is the risk of her complex hyperplasia progressing to endometrial
cancer over 10 years?
4%
8%
12%
16%
20%
Correct
The correct answer is 4%. It is important to be able to counsel patients
appropriately regarding their risk of malignancy and not to confuse
complex hyperplasia with complex atypical hyperplasia. SeePalmer JE,
Perunovic B, Tidy JA. Endometrial hyperplasia. The Obstetrician &
Gynaecologist2008;10:2116.
A 30-year-old multiparous woman with a suspected borderline left ovarian
tumour is awaiting laparotomy, frozen section and conservative or
complete staging surgery. She wants to know the accuracy of frozen
section.
How many cases diagnosed as borderline ovarian tumours on frozen
section would be later reclassified as invasive tumours?
One-tenth of cases
One-fifth of cases
One-quarter of cases
One-third of cases
One-half of cases
Correct
The correct answer is one-third of cases. Approximately one-third of cases
reported as borderline tumours on frozen section are later reclassified as
invasive tumours. For the older women with no fertility concerns, if frozen
section is reported as a borderline tumour then complete staging should
be undertaken. See Bagade P, Edmondson R, Nayar A. Management of
borderline ovarian tumours. The Obstetrician &
Gynaecologist 2012;14:11520.
A 25-year-old woman with a bicornuate uterus attends the emergency
gynaecology unit requesting emergency contraception (EC). She has
been on holiday and forgot to take her contraceptive pill for 3 days in the
first week of the calendar pack and had unprotected sexual intercourse
(UPSI) four days ago. She is in good health.
Which of the following is the recommended EC?
Copper IUCD
40

Mirena IUS
Levonorgestrel (LNG)
Mifepristone
Ulipristal acetate (UA)
Correct
The correct asnwer is ulipristal acetate (UA). The Mirena coil is not
licensed for EC. LNG is recommended only within 72 hours of UPSI. A
copper IUCD can be used within 5 days of first UPSI in a cycle but is not
indicated in the presence of a uterine anomaly. Mifepristone is not
licensed for EC in the UK. UA is licensed for use within 120 hours of UPSI
so is the recommended choice. SeeFaculty of Sexual and Reproductive
Health Care. Emergency contraception. London: FSRH; 2011.
A 46-year-old nulliparous woman has been referred by her GP having
been treated for heavy regular menstrual bleeding with cyclical
progestogens for a period of 6 months. The treatment has failed to
improve her symptoms.
What is the most appropriate next line of management?
Endometrial biopsy
Levonorgestrel intrauterine system
Non-steroidal anti-inflammatory drugs
Pelvic ultrasound
Tranexamic acid
Correct
The correct answer is endometrial biopsy. Endometrial biopsy should be
performed if a women over 45 years of age fails to respond to first line
treatment. See: National Institute for Health and Clinical
Excellence. Heavy menstrual bleeding. CG44. London: NICE; 2007.
A 45-year-old woman is due to have a total abdominal hysterectomy and
bilateral salpingo oopherectomy for chronic pelvic pain. You receive a
letter from her GP informing you that her recent cervical smear has shown
borderline changes in endocervical cells.
What arrangement will you make, if any, prior to her admission?
Endometrial sampling
HPV testing
No change in her management
Referral to colposcopy
Repeat cervical cytology
Correct
The correct answer is referral to colposcopy. All women being considered
41

for hysterectomy who have an uninvestigated abnormal test result or


symptoms attributable to cervical cancer should have diagnostic
colposcopy and an appropriate biopsy. See: NHS Cancer Screening
Programmes.Colposcopy and Programme Management. Guidelines for
the NHS Cervical Screening Programme. Second edition. Sheffield: NHS
Cancer Screening Programmes; 2010.
A 55-year-old woman is seen in the pre-assessment clinic. She is due to
undergo full staging surgery for ovarian cancer as recommended by the
MDT. Her only current medications are clopidogrel and thyroxine.
If the benefits of stopping clopidogrel outweigh the risks, how long should
clopidogrel be stopped prior to surgery?
1 day
3 days
5 days
7 days
14 days
Correct
The correct answer is 7 days. You should assess the risks and benefits of
stopping pre-existing antiplatelet therapy 1 week before surgery. Consider
involving the multidisciplinary team in the assessment. See: National
Institute for Health and Clinical Excellence. Venous thromboembolism:
reducing the risk. CG92. London: NICE; 2010.
You see a 38-year-old woman with a 2.5 cm malignant tumour on her
cervix and no extracervical disease on imaging. She is fit and healthy.
What is her best treatment option?
Radical hysterectomy
Radical hysterectomy and bilateral pelvic lymphadenectomy
Radical trachelectomy
Radical trachelectomy and bilateral pelvic lymphadenectomy
Radiotherapy
Correct
The correct answer is radical hysterectomy and bilateral pelvic
lymphadenectomy. Radical surgery is recommended in stage 1B1 disease
if there is no contraindication to surgery. Radical trachelectomy can only
be offered for fertility sparing in tumours less than 2 cm. See Scottish
Intercollegiate Guidelines Network. Management of cervical cancer.
Guideline 99. Edinburgh: SIGN; 2008.
A 23-year-woman had an ultrasound scan that was suggestive of a
missed miscarriage. She underwent evacuation of the uterus and products
of conception were sent for histology. The histology report confirmed that
this had been a partial molar pregnancy.
42

What are the most likely genetic features of the partial molar pregnancy?
46 XY
46 YY
46 YYY
69 XYY
69 YYY
Correct
The correct answer is 69 XYY. Complete moles are usually diploid and all
chromosomes are of paternal origin. Partial molar pregnancies are usually
triploid, with the additional set of chromosomes of maternal origin.
Incidence varies worldwide, ranging from 2 in 1000 pregnancies in Japan
to 0.61.1 per 1000 in Europe and North America. See Royal College of
Obstetricians and Gynaecologists. Gestational trophoblastic disease.
Green-top Guideline 38. London: RCOG; 2010.
A 40-year-old woman has regular heavy menstrual bleeding. The history
and investigations indicate that pharmacological treatment is appropriate.
Her GP has tried tranexamic acid without success.
What is the most appropriate next pharmaceutical treatment?
Etamsylate
Gonadotrophin-releasing hormone analogues
Injected long acting progestogens
Levonorgestrel-releasing intrauterine system (LNG-IUS)
Norethisterone 15 mg daily from day 5 to day 26 of cycle
Correct
The correct answer is levonorgestrel-releasing intrauterine system (LNGIUS). The LNG-IUS is first line treatment in women complaining of heavy
menstrual bleeding and NICE recommends it's use before tranexamic
acid. See National Institute for Health and Clinical Excellence. Heavy
menstrual bleeding. CG44. NICE; 2007.
A 67-year-old woman is referred to the rapid access clinic with a 2 day
history of postmenopausal bleeding, which has since resolved. She is
otherwise fit and well. The endometrial thickness is 7 mm on transvaginal
ultrasound scan, the endometrium appears polypoidal at hysteroscopy
and histology on an endometrial sample is reported as showing irregular
and tightly packed glands with large and vesicular nuclei containing
prominent nucleoli.
What is the most appropriate management for this woman?
Bilateral oophorectomy
Combined estrogen and progestogen hormone replacement therapy
Expectant management
43

Hysterectomy
Insertion of a levonorgestrel-releasing intrauterine system
Correct
The correct answer is hysterectomy. The endometrial sample has features
that are diagnostic of complex atypical hyperplasia. Atypical hyperplasia is
a premalignant condition and will progress to malignancy in 29% of cases.
It can co-exist with an invasive carcinoma. Less aggressive abnormalities
are complex hyperplasia which will progress to malignancy in only 4% of
women, but will persist in 22%. The majority of simple hyperplasias will
regress spontaneously although 3% progress to complex atypical
hyperplasia. Current advice is that these women should be offered a
hysterectomy, especially with the risk of co-existing carcinoma. In younger
women high doses of progestagens have been used with success, and
there have been reported pregnancies following treatment. See Palmer
JE, Perunovic B, Tidy JA. Endometrial hyperplasia. The Obstetrician &
Gynaecologist 2008;10:2116.
A 37-year-old woman is undergoing a diagnostic laparoscopy for
investigation of pelvic pain. Following insertion of the laparoscope through
the umbilical port you find bowel adherent to the anterior abdominal wall in
the midline. You are worried that bowel may be adherent under the
umbilicus.
What is the recommended course of action?
Continue with procedure as Palmers test was normal
Convert to laparotomy
Remove port and reinsert at Palmers point
Seek surgical advice
Visualise the primary trocar site from a secondary port site
Correct
The correct answer is visualise the primary trocar site from a secondary
port site. If there are adhesions within the abdomen it is advisable to
check the umbilical port by inspecting it through a preferably 5 mm scope
via a secondary port. If damage has occurred seek surgical advice.
SeeRoyal College of Obstetricians and Gynaecologists. Preventing entryrelated gynaecological laparoscopic injuries. Green-top Guideline 49.
London: RCOG; 2008.
A 25-year-old woman develops a wound infection after a straight forward
elective subtotal hysterectomy.
What is the single most likely causative organism?
Escherichia coli
Haemophilus influenzae
Methicillin resistant Staphylococcal aureus
44

Staphylococcal aureus
Streptococcus milleri
Correct
The correct answer is Staphylococcal aureus. All wounds are colonised
with bacteria. This does not mean all wounds will become infected. If there
is an infection it is likely to be from skin flora which have colonised the
wound and thus Staphylococcal aureus is the most likely bacteria.
A 15-year-old girl attends sexual health clinic requesting termination of
pregnancy. She is 7 weeks pregnant. Her boyfriend is also 15-years-old
and studies in the same school. She has not informed anyone of this
pregnancy.
What is your most likely immediate action?
Encourage her to inform her parents
Inform specialist youth worker
Inform the GP
Inform the school head teacher
Reject the request without parental consent

1.
2.
3.
4.
5.

Correct
The correct answer is encourage her to inform her parents. Fraser
guidelines relate to a case in 1984 Gillick v West Norfolk and provide a
framework for dealing with children under the age of 16. It revolves around
whether a child is capable of making a reasonable assessment of the
advantages and disadvantages of treatment and thus their ability to
consent to treatment. In his guidance Fraser stated that a doctor could
prescribe contraceptives "provided he is satisfied in the following criteria:
That the girl (although under the age of 16 years of age) will
understand his advice
That he cannot persuade her to inform her parents or to allow him
to inform the parents that she is seeking contraceptive advice
That she is very likely to continue having sexual intercourse with or
without contraceptive treatment
That unless she receives contraceptive advice or treatment her
physical or mental health, or both, are likely to suffer
That her best interests require him to give her contraceptive advice,
treatment, or both, without the parental consent."
The same guidelines relate to termination of pregnancy. See Royal
College of Obstetricians and Gynaecologists. The care of women
requesting induced abortion. Evidence-based Clinical Guideline 7.
London: RCOG; 2011.
Your consultant asks you to prescribe a 3 month course of ulipristal
acetate to a patient with fibroids prior to having a hysterectomy.
To which class of drugs does ulipristal acetate belong?
Aromatase inhibitor
45

Gonadotrophin releasing hormone (GnRH) antagonist


Progestogen antagonist
Prostaglandin
Selective estrogen receptor modulator (SERM)
Correct
The correct answer is progestogen antagonist. Ulipristal acetate has been
used as a drug for emergency contraception. It has recently been licensed
for use in reducing the size of fibroids prior to surgery and it does this by
inducing apoptosis in the cells. See the British National Formulary for
more details.
A 24-year-old woman in her first pregnancy attends the antenatal clinic.
Her community midwife has referred her to a Consultant clinic as she
disclosed having had female genital mutilation (FGM) at 8 years of age.
Which one of the following countries is this woman LEAST likely to
originate from?
Egypt
Eritrea
Nigeria
Somalia
Sudan
Correct
The correct answer is Nigeria. The prevalence of FGM varies by country.
The type of FGM also varies and the more severe types are commonest in
Somalia. Somalia has the highest incidence at 98100% of girls and this
is usually type III. Royal College of Obstetricians and
Gynaecologists.Female genital mutilation and its management. Green-top
Guideline 53. London: RCOG; 2009.
A 23-year-old woman undergoes laparoscopic cystectomy of a right
endometrioma, densely adherent to the pelvic side wall. She is discharged
home soon after the surgery but presents 36 hours later with right flank
pain.
Which investigation would you arrange to confirm and locate any ureteric
injury?
Computerised tomography intravenous urogram
Magnetic resonance imaging
Renogram
Transurethral cystoscopy and stenting
Ultrasonography
Correct
46

The correct answer is computerised tomography intravenous urogram.


Endometriosis increases the risk of injury to the urinary tract. An acute
injury usually presents within 48 hours with diffuse abdominal pain,
distension and ileus. The chemical peritonitis has more subtle symptoms
compared with peritonitis secondary to faeces or infection. A CT scan with
contrast will usually demonstrate a uroperitoneum and may show direct
evidence of the injury. MRI is useful in late presentations where a fistula is
suspected. See Minas V, Gul N, Aust T, Doyle M, Rowlands D. Urinary
tract injuries in laparoscopic gynaecological surgery; prevention,
recognition and management. The Obstetrician &
Gynaecologist 2014;16:1928.
A 48-year-old woman undergoes a total abdominal hysterectomy and
bilateral salpingo-oophrectomy and omental biopsy for an ovarian tumour.
Pathology confirms a serous borderline ovarian tumour.
Which of the following is a feature of borderline ovarian tumours?
Absence of stromal invasion
Complex histological architecture
Mitotic figures
Peritoneal implants
Raised serum CA125
Correct
The correct asnwer is absence of stromal invasion. Borderline tumours
are often found following primary surgery in younger women. They show
higher proliferative activity than benign tumours, but do not show stromal
invasion. They constitute 1015% of ovarian neoplasms. Serous
borderline tumours are the most common and are often (30%) bilateral.
See Bagade P, Edmondson R, Nayar A. Management of borderline
ovarian tumours. The Obstetrician & Gynaecologist 2012;14:11520.
A 26-year-old woman has been admitted with late onset severe ovarian
hyperstimulation syndrome (OHSS) 10 days after embryo transfer in an
IVF cycle. She reports generalised abdominal pain and sickness for 2
days. Abdominal examination revealed significant ascites, whilst
abdominal ultrasound showed bilateral enlarged ovaries with a maximal
diameter of 10 cm.
Which of the following combination of blood results is commonly observed
on admission?
Haematocrit decreased, fibrinogen increased, albumin increased
Haematocrit increased, fibrinogen decreased, albumin decreased
Haematocrit increased, fibrinogen decreased, albumin increased
Haematocrit increased, fibrinogen increased, albumin decreased
Haematocrit increased, fibrinogen increased, albumin increased
Correct
47

The correct answer is haematocrit increased, fibrinogen increased,


albumin decreased. Severe OHSS is usually associated with an increased
capillary permeability resulting in a reduction of intravascular volume and
haemoconcentration (increase haematocrit), and a shift of fluid into the
third compartment (a reduction of serum albumin concentrations). The
woman is at risk of developing thrombosis (increase fibrinogen levels).
See Prakash A, Mathur R. Ovarian hyperstimulation syndrome. The
Obstetrician & Gynaecologist 2013;15:315.
A 51-year-old woman attends your clinic with history of severe vasomotor
symptoms (hot flushes, night sweats). She has a family history of breast
cancer and would like to avoid hormone replacement therapy (HRT).
Which non-hormonal medication is most likely to control her symptoms?
Citalopram
Metaprolol
Nifedipine
Phentolamine
Venlafaxine
Correct
The correct answer is Venlafaxine. Selective serotonin and noradrenaline
reuptake inhibitors are the drugs used most commonly to alleviate
vasomotor symptoms. The most convincing data relates to venlafaxine,
although this was a short study. See Royal College of Obstetricians and
Gynaecologists. Alternatives to HRT for the management of symptoms of
the menopause. Scientific Impact Paper 6. London: RCOG; 2010.
A 36-year-old parous woman was diagnosed with stage 3 endometriosis.
She was on GnRH (gonadotrophin releasing hormone) analogue for 12
months. Subsequently she had laparoscopic excision of recto-vaginal
endometriosis. She continues to be in pain despite medical and surgical
management.
What is the next most appropriate management option for her?
Aromatase inhibitors
Danazol
Long term GnRH
Progesterone only pills
Tibolone
Correct
The correct answer is aromatase inhibitors. Aromatase inhibitors are
recommended in women with rectovaginal endometriosis which is
refractory to medical or surgical treatment. It can be prescribed in
combination with hormones or GnRH analogues. See Dunselman GAJ,
Vermeulen N, Becker C, Calhaz-Jorge C, DHooghe T, De Bie B. ESHRE
guideline: management of women with endometriosis. Hum
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