SELF-ASSESSMENT

Self assessment questions

Questions 1. Over-abundance of nucleated fetal erythrocytes in late
second to third trimester
SBA 1
2. Plasma cells within the maternal decidua
Which biomarkers are included in the quadruple test?
3. Frequent immature villi after 34 weeks’ gestation
A. AFP, hCG, uE3 and PAPP-A
4. Neutrophil infiltration of membranes
B. AFP, hCG, uE3 and Inhibin-A
C. AFP, hCG, PAPP-A and Inhibin-A
D. AFP, PAPP-A, uE3 and Inhibin-A SBA 5
E. hCG, PAPP-A, uE3 and Inhibin-A A 26-year-old woman with PCOS is undergoing ovarian stim-
ulation with GnRH antagonist protocol for in vitro fertilization.
SBA 2 Her pre-treatment tests showed AMH e 40 pmol/l, FSH 6.5 IU,
From which point is cell-free fetal DNA detectable in maternal LH 10.4 IU, antral follicle count 40. Her scan on day 10 shows
circulation? 25 follicles >14 mm size. What is the best step to take in
A. 8 weeks reducing the risk of OHSS?
B. 9 weeks A. GnRH agonist trigger followed by elective cryopreservation
C. 10 weeks B. Recombinant HCG trigger
D. 11 weeks C. Cycle cancellation
E. 12 weeks D. HCG trigger and Cabergoline in addition
E. None of the above
EMQ 3
Select the single most likely external examination finding lis-
SBA 6
ted below, for each of the four possible groups of pathologies.
A woman presents with tense ascites, difficulty in breathing
A. Abnormal head shape
and nausea 10 days following her embryo transfer. Her blood
B. Encephalocoele
tests show Hb of 150 gm/dl and a haematocrit of 45%. She
C. Cryptophthalmos
received initial rehydration with normal saline, followed by
D. Hypertelorism
intravenous albumin. Her repeat haematocrit is 0.35, but she
E. Broad nasal bridge, low set ears, hypertelorism
complains of worsening abdominal distension and oliguria.
F. Cystic hygroma
What is the most appropriate next step?
G. Polydactyly
A. Continue monitoring of urine output, nothing else needed
H. Lower limb abnormalities
B. Diuretics
I. Ambiguous genitalia
C. Intravenous fluids 125 ml/h
1. Noonan syndrome, Opitz G syndrome
D. Paracentesis
2. Meckle Gruber syndrome, neural tube defect
E. None of the above
3. Monosomy X, Trisomy 21, Noonan syndrome
4. Ciliopathy, skeletal dysplasia, Trisomy 13
SBA 7
EMQ 4 Which of the following is an indication for ‘EX-utero Intra-
Select the single most likely pathology listed below, for each of partum Treatment’ (EXIT) procedure?
the four microscopic abnormalities. A. Removal of an occlusive tracheal device used for prenatal
A. Ascending maternal genital tract infection treatment of congenital diaphragmatic hernia
B. Fetal vascular occlusion B. Immediate transfer onto extracorporeal membrane
C. Delayed villous maturation oxygenation (ECMO)
D. Villitis of unknown aetiology C. To bridge separation of conjoined twins
E. Chronic histiocytic intervillositis D. Congenital anomalies of the head, neck and chest
F. Chronic deciduitis E. All of the above
G. Maternal vascular malperfusion/vasculopathy
H. Possible maternal sickle cell trait
SBA 8
I. Possible fetal hypoxia
Which of the following fetal abnormalities would be predicted
to seriously impact upon the airway at delivery?
A. Congenital high airway obstruction syndrome (CHAOS)
Norman Shreeve BSc BMBS is a Specialty Registrar at Adden- B. Pierre Robin sequence
brooke’s Hospital and Wellcome Trust Clinical PhD Fellow at the C. Teratoma of the neck
Centre for Trophoblast Research, and Department of Obstetrics D. Cystic hygromata
and Gynaecology, University of Cambridge, Cambridge, UK. E. All of the above

OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 30:8 266 Ó 2020 Published by Elsevier Ltd.
 SELF-ASSESSMENT

SBA 9 3. F
With regard to carboprost and the management of PPH, which 4. G
of the following is not true?
EMQ 4
A. It can be used every 15 min for a maximum of eight times
1. I
for PPH treatment
2. F
B. It should be administered as a first-line pharmacological
3. C
measure
4. A
C. The most common side effects are diarrhoea, nausea and
vomiting SBA 5
D. It is an expensive therapy requiring cold storage and A
therefore is difficult to employ in low resource settings Evidence supports the use of GnRH antagonist regimes in
E. It is an injectable prostaglandin form (PGE2) women with a high ovarian reserve. GnRH agonist trigger and
elective cryopreservation of all embryos further reduce the risk
SBA 10
of OHSS.
With regard to fibrinogen, which of the following statements is
true? SBA 6
A. A persistent fibrinogen level of <2 g/L is associated with D.
higher blood product requirements, larger blood loss and There is evidence that early drainage of ascites may shorten
increased need for surgical intervention the course of severe OHSS, but this is not standard practice in
B. Blood fibrinogen levels fall slowly during acute bleeding the UK. Most clinicians agree that paracentesis is indicated in
and are therefore not good early indicators of the severity women with tense ascites causing pain or breathing difficulty,
of blood loss and in women with a persistent low urine output despite
C. Fibrinogen levels can be replenished through the trans- adequate rehydration with colloids
fusion of whole blood SBA 7
D. Fibrinogen levels cannot be replenished through the E
transfusion of FFP All of the four indications listed in A-D are appropriate.
E. The early infusion of fibrinogen concentrate can aid man- Planning and executing the management of these deliveries
agement of bleeding necessitates complex multi-disciplinary team (MDT) working
and may require an ex-utero intrapartum treatment (EXIT)
Answers procedure.

SBA 1 SBA 8
B E
The quadruple test, which uses four biomarkers, AFP, hCG, SBA 9
unconjugated estriol (uE3) and Inhibin-A, is a screening test B
for trisomy 21, and is done when a woman presents too late Current guidance suggests that carboprost should be
for a nuchal translucency (NT) scan, or where an NT cannot administered as a final pharmacological measure in those non-
be obtained because of technical difficulties. responsive to previous therapies prior to surgical intervention
SBA 2 SBA 10
C A
The small fragments of fetal DNA circulating within the Blood fibrinogen levels fall rapidly in bleeding and are an
maternal plasma comprise up to 10% of the total cell free early indicator of the severity of blood loss. Fibrinogen levels
DNA, the remainder being maternal. It is detectable from a can be replenished through transfusion of fresh frozen plasma
very early gestational age, but testing can be offered from 10 (FFP), cryoprecipitate or freeze dried fibrinogen. Simply using
weeks. estimated blood loss as a guide can lead to an early infusion of
EMQ 3 fibrinogen concentrate, which has been found to have no
1. D benefit.
2. B

OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 30:8 267 Ó 2020 Published by Elsevier Ltd.