%O¥ |i lit Be + oer isl) Lt) A QUESTION 53 A 27 year old woman presents to the Emergency Department complaining of vaginal pain and discharge. She describes a foul smelling yellow discharge associated with vulval pain and lower abdominal pain. She has no past medical history. She reports recent unprotected sexual intercourse with a new partner. On examination you note an offensive smelling, yellow-green frothy discharge and vulvitis. What is the recommended treatment for this patient? Oral doxycycline 18% Intravaginal clotrimazole 4% (x) oral fluconazole 5% Oral erythromycin 4% Oral metronidazole 71% x 3 ays Sst BeB%OF |i i frothy discharge and vulvitis. What is the recommended treatment for this patient? Oral doxycycline 18% Intravaginal clotrimazole 4% (x) oral fluconazole 8% Oral erythromycin 4% ANSWER The patient has features of trichomoniasis. The recommended treatment is oral metronidazole 400 mg bd 5 - 7 days. SCORE 26% 14 39 Ml O >B%OY I A me tr rar UUAyLycniie mall Intravaginal clotrimazole 4% (x) Oral fluconazole 5% Oral erythromycin 4% ANSWER The patient has features of trichomoniasis. The recommended treatment is oral metronidazole 400 mg bd 5 - 7 days. SCORE 26% 4 39 re REFERENCE RANGES Something wrong? Ml O >B%OY |i IS . oR uy ANSWER Vaginal Discharge Bacterial vagin Cause Overgrowth of anaerobic bacte esp. Gardnerelle vaginalis Discharge Fishy-smelling, grey/white homogeneous discharge Associated symptoms No soreness, itc irritation On examination Thin white/grey homogeneous discharge coati the vaginal wall vulva with fishy no inflammatior Investigations Vaginal pH & hi vaginal swab Treatment Oral metronidaz 400 mg bd 5-7 Ml O >B%F Nin Ae + eR © © = @eediatemrcemsuccess.com g QUESTION 52 A 28 year old lady, who is 11 weeks pregnant, presents to the Emergency Department with vaginal bleeding including large clots which started earlier today associated with cramping lower abdominal pain. On arrival to the department, her observations are within normal limits. Whilst waiting to be seen by the ED doctor, she suddenly develops worsening abdominal pain and increased bleeding. Her observations are recorded as: * Heart rate: 54 beats per minute * Blood pressure: 86/54 mmHg « Respiratory rate: 24 breaths per minute What is the single most likely diagnosis? Sepsis 2% (v Jee nealenock a vol x i Ayal asl Be Ml O >am fy B%O¥ | * Blood pressure: 86/54 mmHg « Respiratory rate: 24 breaths per minute What is the single most likely diagnosis? Sepsis 2% (x) jorrhagic shock 17% (Vv) a 40% Ruptured ectopic pregnancy 31% Uterine rupture 4% | ANSWER The patient may be in cervical shock (parasympathetic stimulation caused by products in the cervical os leading to hypotension and bradycardia). In this situation the remaining products of conception should be removed using a sponge-holding forceps. The shock normally resolves spontaneously. Ml O >B%Y | I Ae om ir © © = @eediatemrcemsuccess.com 2 QUESTION 50 A 29 year old woman who is 8 weeks pregnant presents to the Emergency Department complaining of crampy lower abdominal pain and spotting. Speculum examination shows a small volume of blood oozing through the closed cervical os. You arrange for a transvaginal ultrasound which shows an intrauterine pregnancy estimated at 8 weeks gestation, foetal cardiac activity is seen. What is the most appropriate diagnosis in this patient? Incomplete miscarriage 4% Inevitable miscarriage 3% Vv) 89% (x) Complete miscarriage 2% Missed miscarriage 2% x i Ayal asl BeB%F Nin EA + eR © © = @eediatemrcemsuccess.com ANSWER Miscarriage is classified as complete, incomplete, missed, threatened, or inevitable on the basis of clinical history and findings on speculum and digital pelvic examination: + Complete miscarriage Is when all the products of conception have been expelled from the uterus and bleeding has stopped. + Incomplete miscarriage is a diagnosed non- Viable pregnancy in which bleeding has begun but pregnancy tissue remains in the uterus. Missed miscarriage (also known as delayed or silent miscarriage) is diagnosed when a non-viable pregnancy is identified on ultrasound scan, without associated pain and bleeding. Threatened miscarriage is diagnosed when there is vaginal bleeding in the presence of a viable pregnancy in the first 24 weeks of gestation. Inevitable miscarriage is a diagnosed non- viable pregnancy in which bleeding has begun and the cervical os is open, but pregnancy tissue remains in the uterus. The pregnancy will proceed to incomplete or complete miscarriage. x i Ayal asl Be Ml O >B%OY |i i Be + oR xy © © = @eediatemrcemsuccess.com el BQ QUESTION 51 A 31 year old woman presents to the Emergency Department concerned by a change in vaginal itch and irritation over the last 7 days. On examination you note a non-offensive thick, white discharge. What is the most likely diagnosis? Gonorrhoea 3% Bacterial vaginosis 8% richomoniasis 6% Vulvovaginal candidiasis 77% Chlamydia 6% ANSWER DOU Ayal asl BeB%Y | A the following is the most common site of an ectopic pregnancy? Ovary 1% | 78% Isthmus of the fallopian tube 18% Fimbria of the fallopian tube 1% Cervix 2% | ANSWER An ectopic pregnancy is a pregnancy outside the uterine cavity, with an ectopic pregnancy occurring in about 11 in 1000 pregnancies. Most ectopic pregnancies (93-98%) occur in the fallopian tube and may implant in the ampulla (73- 75%), isthmus (about 13%), or fimbria (about 12%). The others are non-tubal and may implant in the ovary, abdomen, cervix, caesarean section scar, or the interstitial part of the fallopian tube. Ml O >B%Y | IA aR a © © = @eediatemrcemsuccess.com 2 QUESTION 49 A 37 year old woman presents to the Emergency Department complaining of headache and blurred vision. She is 27 weeks pregnant with no significant past medical history. Her observations are recorded as: « Heart rate: 92 beats per minute * Blood pressure: 164/102 mmHg « Respiratory rate: 17 breaths per minute On examination you note her hands and feet are swollen. What investigation would be most useful in the management of this patient? (x) Full biood count 4% Blood glucose 3% | (Vv) 87% Pelvic ultrasound 2% Coagulation studies 5% x i Ayal asl Be Ml O >B%Y | IA oma k) management of this patient? (x) Full biood count 4% Blood glucose 3% Pelvic ultrasound 2% Coagulation studies 5% ANSWER + Forall pregnant women, dipstick the urine for protein and measure blood pressure at each visit. © If dipstick screening is positive [1+ or more], use albumin:creatinine ratio or protein:creatinine ratio to quantify proteinuria in pregnant women. © [fusing protein:creatinine ratio, use 30 mg/mmol as a threshold for significant proteinuria. © If using albumin:creatinine ratio, use 8 mg/mmol as a diagnostic threshold. Ml O >B%Y | IA aR a © © = @eediatemrcemsuccess.com g QUESTION 47 A 26 year old woman presents to the Emergency Department complaining of right lower quadrant abdominal pain. She tells you her last menstrual period was 8 weeks ago. Her observations are recorded as: « Heart rate: 120 beats per minute * Blood pressure: 110/68 mmHg « Respiratory rate: 20 breaths per minute Her urinalysis is normal and a urinary pregnancy test is positive. What is the most appropriate next management step? CT abdomen 2% (x) Cervical cutture 3% Full blood count and coagulation screen 5% Serum hCG levels 17% x i Ayal asl BeB%F [i EADS + eRe sc Mer Urinalysis IS NotMal ana a urinary pregnancy test is positive. What is the most appropriate next management step? CT abdomen 2% 72% Cervical culture 3% Full blood count and coagulation screen 5% Serum hCG levels 17% ANSWER The most life-threatening pathology requiring urgent or emergent intervention is haemorrhage from a ruptured ectopic pregnancy. A pelvic ultrasound scan is rapid and is the first step in an evaluation of a suspected ruptured ectopic pregnancy. SCORE 28% Ml O >%0¥ Ii lit A it al ied) A QUESTION 48 A 21 year old female presents to the Emergency Department complaining of acute severe pelvic pain. She reports she has not had a period for 6 weeks - her menstrual cycle is usually 28 days. A urine pregnancy test is positive and you suspect an ectopic pregnancy. Which of the following is the most common site of an ectopic pregnancy? Ovary 1% Ampulla of the fallopian tube. 78% Isthmus of the fallopian tube 18% Fimbria of the fallopian tube 1% Cervix 2% ANSWER Anectanie nreananevis.a.nreananey outside the. x i ays Sst Be Ml O >B%% | IA 2m Pelvic inflammatory disease 4% Threatened abortion 3% Ovarian cyst rupture 5% Urinary tract infection 2% ANSWER Suspect ectopic pregnancy in a woman who presents with any of the following: * Common symptoms © Abdominal or pelvic pain © Amenorrhoea or missed period © Vaginal bleeding * Common signs © Pelvic tenderness © Adnexal tenderness © Abdominal tenderness srope 20% Ml O >%0¥ Ii lit Be eet al na Ee A QUESTION 46 A 28 year old woman who is 32 weeks pregnant, presents to the Emergency Department with vaginal bleeding for the last few hours associated with abdominal pain. Her observations are: * Heart rate: 110 beats per minute * Blood pressure: 95/54 mmHg « Respiratory rate: 20 breaths per minute On examination, her uterus is tender and feels tense and ‘woody’ on palpation. What is the single most likely diagnosis? (x) Cervical ectropium 4% Placenta praevia 4% Placental abruption 88% Vasa praevia 1% Pelvic inflammatory disease 3% a: ayall assy BeB%O¥ i EA had md) a% Placenta praevia 88% Vasa praevia 1% Pelvic inflammatory disease 3% ANSWER Placental abruption is the premature separation of a normally placed placenta before delivery of the foetus with blood collecting between the placenta and the uterus. It may be classified as concealed (20% of cases) where the haemorrhage is confined within the uterine cavity or revealed (80% of cases) where blood drains through the cervix. Patients may present with vaginal bleeding, continuous abdominal pain, uterine contractions, shock or foetal distress. A tense, tender uterus with a ‘woody’ feel may be palpated on abdominal examination. Patients may be haemodynamically compromised, out of proportion to the degree of visible blood loss. Platelet count may be low, and coagulopathy is common. Ultrasound is not reliable at identifying abruption. Ml O >B%% | IEA ama © © = @eediatemrcemsuccess.com A QUESTION 44 You have been asked to give a teaching session to a group of junior colleagues, the topic of the session is “Complications of Early Pregnancy”. Which of the following is NOT a key feature of hyperemesis gravidarum? Severe protracted nausea and vomiting 5% Weight loss 16% Dehydration 5% Hypoglycaemia 64% ‘Osis 11% ANSWER Hyperemesis gravidarum is a diagnosis of exclusion characterised by: x i ays Sst Be Ml O >6% | A + om Severe protracted nausea and vomiting 5% Weight loss 16% Dehydration 5% ~) ANSWER Hyperemesis gravidarum is a diagnosis of exclusion characterised by: + Severe, protracted nausea and vomiting * Weight loss of more than 5% of prepregnancy weight * Dehydration + Electrolyte imbalances + Ketosis SCORE 30% 3 ay Ml O >B%0 in if @ QUESTION 45 + ma A 28 year old lady is brought to the Emergency Department after fainting at work following severe worsening pelvic pain for the last few hours. On further questioning, she tells you her last period was 6 weeks ago and she has been trying to get pregnant with her partner. She denies any vaginal bleeding or discharge. On examination, she is tender in the left iliac fossa with rebound tenderness. She is apyrexial, her blood pressure is 95/50 mmHg and her heart rate is 105 beats per minute. What is the most likely diagnosis? (x) Pelvic inflammatory disease 4% Threatened abortion 3% Ovarian cyst rupture 5% Urinary tract infection 2% ANQWED. x i Ayal asl Be6% Ih 28a Metoclopramide 2% (x) Pomperidone 6% Ondansetron 12% Prednisolone 2% ANSWER + If an antiemetic is required in pregnancy, prescribe an antihistamine (oral cyclizine or oral promethazine), or a phenothiazine (oral prochlorperazine). * Oral metoclopramide or oral ondansetron are second-line options. * Corticosteroids should be reserved for cases of HG where standard therapies have failed. SCORE 31% 3 29 Ml O >B%% | EA + ed © © = @eediatemrcemsuccess.com QUESTION 43 3° You have been asked to give a teaching session to a group of junior colleagues, the topic of the session is "Complications of Early Pregnancy”. Which of the following is NOT a risk factor for ectopic pregnancy? Smoking 18% Maternal age < 25 years 70% Assisted reproductive techniques 7% Previous ectopic pregnancy 2% History of pelvic inflammatory disease 4% ANSWER Risk factors for ectopic pregnancy include: x i ays Sst Be Ml O >B%% | EA oma © © = @eediatemrcemsuccess.com A) Pieviwus cewupre prey! Ly ~~ History of pelvic inflammatory disease 4% | ANSWER Risk factors for ectopic pregnancy include: + Previous ectopic pregnancy + History of pelvic inflammatory disease + History of tubal or other pelvic surgery + History of sterilisation or reversal of sterilisation + History of infertility + Assisted reproductive techniques * Cigarette smoking + Maternal age over 35 years + Having multiple sexual partners SCORE 30% 13 30 a x i Ayal asl BeB%% Ih EAs . amar © © = @eediatemrcemsuccess.com A QUESTION 41 A 34 year old woman presents to the Emergency Department concerned by a strong smelling and offensive vaginal discharge for the last 5 days. She describes the smell as "fishy". She denies any itch or soreness. On examination you note a thin, grey discharge. How should this patient be managed? Oral doxycycline 9% Intravaginal clotrimazole 8% ral fluconazole 7% Oral erythromycin 3% Oral metronidazole 73% ANSWER x i ays Sst Be Ml O >6% Ih oma Oral doxycycline 9% | Intravaginal clotrimazole 8% 9 Oral erythromycin 3% ANSWER The patient has features of bacterial vaginosis. The recommended treatment is oral metronidazole 400 mg bd 5 - 7 days. SCORE 32% 13 28 REFERENCE RANGES Something wrong? Ml O >B%% Ih EAs oR a © © = @eediatemrcemsuccess.com g QUESTION 42 A 34 year old woman presents to the Emergency Department complaining of severe and persistent nausea and vomiting for the past 2 weeks. She has no past medical history. Her last menstrual period was 12 weeks ago and a urinary pregnancy test is positive. You diagnose hyperemesis gravidarum. Which of the following is a first line drug in the management of hyperemesis gravidarum? Metoclopramide 2% (x) Pomperidone 6% Ondansetron 12% Prednisolone 2% ANSWER x i Ayal asl BeB%% Ih Ae . amas g QUESTION 40 A 23 year old woman presents to the Emergency Department with a 2 week history of lower abdominal pain and "severe pain after sex”. In the last 2 days she has noted some spots of blood in her underwear, her last menstrual period was 2 weeks ago. On examination you note bilateral lower abdominal tenderness. Her observations are: HR 89 beats per minute, blood pressure 134/59 mmubg, respiratory rate 18 breaths per minute and temperature 37.6°C. What is the most likely diagnosis? (x) ictopic pregnancy 8% Appendicitis % Ruptured ovarian cyst 4% Urinary tract infection 2% ANSWER Clinical features of pelvic inflammatory disease: Ml O >B%1 Ih, IIA oR a ANSWER Clinical features of pelvic inflammatory disease: + Symptoms: © Pelvic or lower abdominal pain (usually bilateral but can be unilateral). © Deep dyspareunia particularly of recent onset. © Abnormal vaginal bleeding (intermenstrual, postcoital, or ‘breakthrough’) which may be secondary to associated cervicitis and endometritis. © Abnormal vaginal or cervical discharge as a result of associated cervicitis, endometritis, or bacterial vaginosis. This is often very slight and may be transient, especially with chlamydial infection. © Right upper quadrant pain due to perihepatitis (Fitz~Hugh-Curtis syndrome). © Secondary dysmenorrhoea. + Signs: © Lower abdominal tenderness (usually bilateral). © Adnexal tenderness (with or without a palpable mass), cervical motion tenderness, or uterine tenderness (on bimanual vaginal examination). © Abnormal cervical or vaginal mucopurulent discharge (on speculum examination). Ml O >B%) Ih, int amar endometritis. Abnormal vaginal or cervical discharge as a result of associated cervicitis, endometritis, or bacterial vaginosis. This is often very slight and may be transient, especially with chlamydial infection. Right upper quadrant pain due to perihepatitis (Fitz-Hugh-Curtis syndrome). Secondary dysmenorthoea. * Signs: © Lower abdominal tenderness (usually bilateral). Adnexal tenderness (with or without a palpable mass), cervical motion tenderness, or uterine tenderness (on bimanual vaginal examination). Abnormal cervical or vaginal mucopurulent discharge (on speculum examination). © A fever of greater than 38°C, although the temperature is often normal. SCORE 33% Ml O >6% Ih, IS .aRaur © © = @eediatemrcemsuccess.com ANSWER Chromosomal abnormalities are the most common cause of first trimester miscarriage. SCORE 34% 13 25 TT , REFERENCE RANGES Something wrong? Miscarriage OBSTETRICS & GYNAECOLOGY Bookmark Micrarriana ic the cnantananuc lace ofa. nresnanct Ml O >6% Ih I ome TA Eh) il A QUESTION 39 A 21 year old woman presents to the Emergency Department with a 1 week history of pelvic pain and fever. She notes that she has been experiencing pain during sex. She has also had some breakthrough bleeding despite being on the combined oral contraceptive pill. What is the most likely causative organism for this patient's condition? (x) Garaneretia vaginalis 8% Neisseria gonorrhoeae 24% (/) chiamyaiia trachomatis 63% Mycoplasma genitalium 3% | Streptococcus agalactiae 3% | ANSWER The patient has features of pelvic inflammatory Al eecececeemhEaennt eet bith ete tei TC PCCC RADA x i ays Sst Be Ml O >5% Ih, lh a : maar the combined oral contraceptive pill. What is the most likely causative organism for this patient's condition? (x) Garaneretia vaginalis 8% Neisseria gonorrhoeae 24% Mycoplasma genitalium 3% Streptococcus agalactiae 3% ANSWER The patient has features of pelvic inflammatory disease. Many types of bacteria can cause PID, but gonorrhea (2-3% of cases) or chlamydia infections (14-35% of cases) are the most common. SCORE 33% 3 26 Ml O >B% Ih II + 28a © © = @eediatemrcemsuccess.com @ QUESTION 37 A19 year old woman presents to the Emergency Department with a 4 hour history of cramping lower abdominal pain and spotting. She tells you a home pregnancy test was positive 2 weeks ago. She has no past medical or obstetric history. On examination you find her abdomen is soft and non- tender. Her observations are recorded as: ° Heart rate: 87 beats per minute * Blood pressure: 134/89 mmHg « Respiratory rate: 18 breaths per minute » Temperature: 37.1°C What is the single most likely diagnosis? Molar pregnancy 4% Cervicitis 6% | Placenta praevia 6% x i Ayal asl Be Ml O >B% Ih MI . amar; * Blood pressure: 134/89 mmHg * Respiratory rate: 18 breaths per minute * Temperature: 371°C What is the single most likely diagnosis? Molar pregnancy 4% | Cervicitis 6% Placenta praevia 6% Ectopic pregnancy 20% ANSWER Suspect a miscarriage in women who are pregnant, or with symptoms of pregnancy (amenorrhoea, missed period, breast tenderness), presenting with vaginal bleeding in the first 24 weeks of pregnancy. Bleeding is typically scanty, varying from a brownish discharge to bright red bleeding, and may recur over several days. Lower abdominal cramping pain or lower backache, when it occurs, usually develops after the onset of bleeding. Ml O >%0- Ih I . aR A QUESTION 38 A19 year old woman presents to the Emergency Department with a 4 hour history of cramping lower abdominal pain and vaginal bleeding. She tells you a home pregnancy test was positive 2 weeks ago and a private early pregnancy scan has confirmed an intrauterine pregnancy. Whilst in the department she passes a larger volume of blood with clot. You suspect this is a miscarriage. What is the most common cause of first trimester miscarriage? Thrombophilic abnormalities 5% Chromosomal abnormalities 69% fection 9% Uterine abnormalities 7% Cervical incompetence 1% x / 3 - ays Sst BeB%0 Ih A + 28a J Targeted temperature management 8% should be avoided in the pregnant patient There is a decreased risk of pulmonary 3% aspiration of gastric contents ANSWER After approximately 20 weeks gestation, the pregnant woman's uterus can press down against the inferior vena cava (IVC) and the aorta, impeding venous return, cardiac output and uterine perfusion; IVC compression limits the effectiveness of chest compressions. The potential for IVC compression suggests that IV or 10 access should ideally be established above the diaphragm. SCORE 34% 12 23 Ml O >B% Ih I + 28a © © = @eediatemrcemsuccess.com q QUESTION 36 A 28 year old lady is brought to the Emergency Department after fainting at work following severe worsening pelvic pain for the last few hours. On examination she is tender in the left iliac fossa with rebound tenderness. She is apyrexial, her blood pressure is 95/50 mmHg and her heart rate is 105 beats per minute. What investigation should be performed first in the management of this patient? (Vv) : 88% (x) Urinalysis 5% Cervical cultures 2% Full blood count 2% Abdominal x-ray 3% x i Ayal asl BeB% Mh IEA . amar Abdominal x-ray 3% ANSWER In patients with a suspected ectopic pregnancy, arrange a urine pregnancy test. Refer immediately to an early pregnancy assessment service (or out-of-hours gynaecology service if the early pregnancy assessment service is not available) for further assessment of women with a positive pregnancy test and the following on examination: + pain and abdominal tenderness or + pelvic tenderness or + cervical motion tenderness. SCORE 33% 12 24 REFERENCE RANGES Something wrong? Ml O >B% Ih II + 28a © © = @eediatemrcemsuccess.com a QUESTION 34 A 34 year old woman is brought to the Emergency Department with postpartum bleeding 48 hours following a home delivery. She has no past medical history. You suspect a secondary postpartum haemorrhage. What is the most common cause of secondary postpartum haemorrhage? Abnormal involution of the placental 6% site Retained products of conception 83% Trophoblastic disease 2% coagulopathy 6% Dehiscence of a cesarean scar 3% x i ays Sst Be4% Ih I . 28a Abnormal involution of the placental 6% site Trophoblastic disease 2% (x) coagulopathy 6% Dehiscence of a cesarean scar 3% ANSWER The two most common causes are endometritis and retained products of conception. SCORE 32% n 23 REFERENCE RANGES Something wrong? Ml O >B% Ih A + ama 9 QUESTION 35 A 23 year old woman is brought to the Emergency Department after collapsing at home. She is 30 weeks pregnant with her second pregnancy. Whilst you are assessing the patient she becomes unresponsive and you cannot feel a central pulse. Which of the following statements regarding cardiac arrest management in the pregnant patient is TRUE? Left lateral tilt should only be applied in 28% the third trimester Higher energy doses should be used for 5% defibrillation Targeted temperature management 8% should be avoided in the pregnant patient There is a decreased risk of pulmonary 3% aspiration of gastric contents ANSWER Ml O >B% Ih IAs -eRaan switch to group-specific blood as soon as feasible. If clinically required; until blood is available, infuse up to 3.5 | of warmed clear fluids, initially 2 | of warmed isotonic crystalloid. Further fluid resuscitation can continue with additional isotonic crystalloid or colloid (succinylated gelatin). * To stop the bleeding, the following measures are taken in turn: © Bimanual uterine compression © Ensure bladder is empty (urinary catheter) © Drugs = Oxytocin 5 units slow IV = Ergometrine 500 micrograms slow IV or IM * Tranexamic acid 1 g slow IV (give early) * Oxytocin infusion 40 units in 500 ml isotonic crystalloids at 125 ml/hour = Carboprost 250 micrograms IM every 15 minutes, up to 8 doses « Misoprostol 800 micrograms SL © Repair perineal/vaginal/cervical tears Ml O >5% Ih II eR A QUESTION 33 A 30 year old woman presents to the Emergency Department complaining of lower abdominal pain. On examination you note lower abdominal tenderness. A gynaecology registrar performs a bimanual pelvic examination and finds bilateral adnexal, uterine and cervical motion tenderness. Her urinary pregnancy test is negative and urinalysis is normal. What is the most appropriate next step in the patient’s management? Await cervical culture results 3% | Obtain a full blood count 4% | (x) obtain a cT abdomen 5% Perform a pelvic ultrasound 33% | (V) Start treatment with antibiotics 56% x ays Sst Be Ml O >B%O Ih II + ama Await cervical culture results 3% Obtain a full blood count 4% Obtain a CT abdomen 5% Perform a pelvic ultrasound 33% iotics 56% ANSWER The constellation of uterine tenderness, bilateral adnexal tenderness, and cervical motion tenderness is classically associated with pelvic inflammatory disease (PID), particularly when the pain onset is during or just after menstruation. A diagnosis of pelvic inflammatory disease (PID) should be made on clinical grounds. Do not delay making a diagnosis and initiating treatment whilst waiting for the results of laboratory tests. Negative swab results do not rule out a diagnosis of PID. SCORE 33% Ml O >B%E |i Mh aman Nausea and vomiting of pregnancy 4% Gastroenteritis 2% Urinary tract infection 5% Uraemia 2% ANSWER Hyperemesis gravidarum is a diagnosis of exclusion characterised by: + Severe, protracted nausea and vomiting * Weight loss of more than 5% of prepregnancy weight * Dehydration + Electrolyte imbalances + Ketosis Save SCORE 35% Ml O >B% Ih Ae oR © © = @eediatemrcemsuccess.com a QUESTION 32 A 23 year old woman presents to the Emergency Department in labour. There is no maternity service on site. She tells you she has been hiding the pregnancy from her family but she is now in her 39th week of pregnancy and has been having contractions for several hours. On examination she is crowning and delivery is imminent. You prepare a team and deliver a baby boy. You hand him to the waiting paediatric team. There was no perineal tear. She is now bleeding heavily. What is the next management step? Intrauterine balloon tamponade ™% Place woman in eft lateral tilt position 6% Urgent pelvic ultrasound 2% (x) urgent laparotomy 5% x i Ayal asl Be6% Mh IE eRe © © = @eediatemrcemsuccess.com ANSWER + The cause is most likely uterine atony + First ensure initial resuscitation and supportive care: © Transfuse blood as soon as possible; major obstetric haemorrhage protocols must include the provision of emergency blood with immediate issue of group O, rhesus D (RhD)- negative and K-negative units, with a switch to group-specific blood as soon as feasible. If clinically required; until blood is available, infuse up to 3.5 | of warmed clear fiuids, initially 2 | of warmed isotonic crystalloid, Further fluid resuscitation can continue with additional isotonic crystalloid or colloid (succinylated gelatin). + To stop the bleeding, the following measures are taken in turn: © Bimanual uterine compression © Ensure bladder is empty (urinary catheter) © Drugs * Oxytocin 5 units slow IV * Ergometrine 500 micrograms slow IV or IM * Tranexamic acid 1 g slow IV (give early) Ml O >B%E | MEAs + =i mare © © = @eediatemrcemsuccess.com QUESTION 30 =3- You are discussing bleeding in pregnancy with some junior colleagues. The topic of rhesus status comes up and one of the junior doctors asks about rhesus sensitising events. Which of the following is a rhesus sensitising event requiring anti-D immunoglobulin? Threatened miscarriage 4% Ectopic pregnancy 4% Blunt abdominal trauma 4% Antepartum haemorrhage 5% All of the above 84% ANSWER x i ays Sst BeB%E | MEAs + 2 ste ANSWER + Following potentially sensitising events, anti- D Ig should be administered as soon as possible and always within 72 h of the event. If, exceptionally, this deadline has not been met some protection may be offered if anti-D Ig is given up to 10 days after the sensitising event. Potentially sensitising events in pregnancy include: © Amniocentesis, chorionic villus biopsy and cordocentesis © Antepartum haemorrhage/Uterine (PV) bleeding in pregnancy © External cephalic version © Abdominal trauma (sharp/blunt, open/closed) © Ectopic pregnancy © Evacuation of molar pregnancy ° Intrauterine death and stillbirth © In-utero therapeutic interventions (transfusion, surgery, insertion of shunts, laser) © Miscarriage, threatened miscarriage © Therapeutic termination of pregnancy © Delivery - normal, instrumental or Caesarean section © Intra-operative cell salvage End Saccinn Ml O >B% Ih, eRe © © = @eediatemrcemsuccess.com g QUESTION 31 A 27 year old woman who is 8 weeks pregnant presents to the Emergency Department complaining of nausea and vomiting. She is unable to keep any food down. Her pre-pregnancy weight was 60 kg, today she weighs 56 kg. Her observations are recorded as: « Heart rate: 105 beats per minute * Blood pressure: 105/87 mmHg Urinalysis shows leucocytes and ketones. What is the single most likely diagnosis? Nausea and vomiting of pregnancy 4% Gastroenteritis 2% Urinary tract infection 5% Uraemia 2% x i Ayal asl BeBE In MA + Oma aro * Alanine aminotransferase : 678 U/L * Gamma GT: 67 U/L * Alkaline phosphatase: 53 U/L. * AST: 287 U/L A blood smear shows schistocytes. What is the single most likely diagnosis? Aplastic anaemia 3% (x) Disseminated intravascular coagulation 4% Hepatic necrosis 3% ANSWER HELLP syndrome (Haemolysis, Elevated Liver enzymes, and Low Platelets syndrome) is a severe form of pre-eclampsia that is associated with high maternal and perinatal morbidity and mortality. Ml O >B%E | MEAs + Oam ito © © © @ cediate.mrcemsuccess.com @ QUESTION 29 A 32 year old woman is brought to the Emergency Department complaining of a headache and blurred vision. She is 34 weeks pregnant. This is her first pregnancy. She has no past medical history. On examination you note significant swelling of her hands and feet. Her observations are recorded as: « Heart rate: 79 beats per minute * Blood pressure: 176/109 mmHg « Respiratory rate: 18 breaths per minute Whilst assessing the patient she has a seizure. What immediate treatment does this patient require? Intravenous diazepam 4% Intravenous phenytoin % 89% Intravenous lorazepam 5% | Ayal ajay a &+ Oagire neem Intravenous phenytoin % Intravenous lorazepam 5% Intravenous phenobarbital 2% ANSWER A loading dose of magnesium sulfate 4 g should be given intravenously over 5 to 15 minutes, followed by an infusion of 1 g/hour maintained for 24 hours. If the woman has had an eclamptic fit, the infusion should be continued for 24 hours after the last fit. Do not use diazepam, phenytoin or other anticonvulsants as an alternative to magnesium sulfate in women with eclampsia. SCORE 34% 10 19 Ml O >Oamaru B% Ih, © © = @eediatemrcemsuccess.com g QUESTION 27 A 23 year old woman, who is 11 weeks pregnant, presents to the Emergency Department with persistent and severe nausea and vomiting. This is her first pregnancy. She has been having morning sickness since around 6 weeks into the pregnancy but the symptoms seem to be getting worse. She has tried oral cyclizine and oral promethazine from her GP but she isn't able to keep the medication or food down. She is now starting to feel weak and lightheaded. Her observations are: * Heart rate: 104 beats per minute * Blood pressure: 105/65 mmHg « Respiratory rate: 20 breaths per minute « Temperature: 37.1°C Which of the following investigations is most useful for further assessment of this patient? (x) I blood gas 18% x i Ayal asl BeBE MMA, /Oamir Which of the following investigations is most useful for further assessment of this patient? (x) I blood gas 18% Blood glucose 16% Full blood count 3% Pelvic ultrasound 1% ANSWER If awoman has nausea or vomiting of sufficient severity to affect fluid and food intake: * Monitor her weight. + Examine for signs of dehydration (for example dry mucous membranes, tachycardia, postural hypotension). + Look for signs of muscle wasting. + Test the urine for ketones. + Consider assessing for signs of hypokalaemia or thyrotoxicosis. + Consider referring for ultrasonography to identify predisposing factors (for example multiple or molar pregnancy). Ml O >B%E I ES + Oa xro Ee A QUESTION 28 A39 year old woman presents to the Emergency Department complaining of headache and blurred vision. She is 26 weeks pregnant with no significant past medical history. Her observations are recorded as: « Heart rate: 91 beats per minute * Blood pressure: 165/102 mmHg * Respiratory rate: 18 breaths per minute Her blood results show: * Haemoglobin: 85 g/L * White cell count: 5.9 x 10/L * Platelets: 97 x 109/L * Sodium: 139 mmol/L * Potassium: 4.5 mmol/L * Urea: 5.6 mmol/L * Creatinine: 79 ymol/L * Alanine aminotransferase : 678 U/L * Gamma GT: 67 U/L * Alkaline phosphatase: 53 U/L © AST: 287 U/L A blood smear shows schistocytes. What x i ays Sst Be Ml O >BEA | MEAs Oamaru ANSWER + Pre-eclampsia is new hypertension presenting after 20 weeks gestation and the coexistence of 1 or more of the following new-onset conditions: © Proteinuria © Other maternal organ dysfunction: « Renal insufficiency (creatinine 90 micromol/litre or more, 1.02 mg/100 ml or more). Liver involvement (elevated transaminases [alanine aminotransferase or aspartate aminotransferase over 40 lU/litre] with or without right upper quadrant or epigastric abdominal pain). Neurological complications such as eclampsia, altered mental status, blindness, stroke, clonus, severe headaches or persistent visual scotomata. Haematological complications such as thrombocytopenia (platelet count below 150,000/microlitre), disseminated intravascular coagulation or haemolysis Uteroplacental dysfunction such as fetal growth restriction, abnormal umbilical artery doppler waveform analysis, or stillbirth. Ml O >Oamaru © © = @eediatemrcemsuccess.com g QUESTION 26 A19 year old woman presents to the Emergency Department complaining of a 2 year history of heavy, painful periods. She has seen her GP but feels they are not addressing her concerns. She denies intermenstrual bleeding or postcoital bleeding. Her cycle is regular and she has no past medical history. A pelvic ultrasound has been reported as normal. Which of the following treatments would be most appropriate to prescribe from the ED? Paracetamol 1% Vv) 70% Phytonadione 15% | (x) Ethamsylate 5% Codeine 3% i aMewen. a dyal aval Be Ml O >BEA In IE + Oamaru Ethamsylate 5% Codeine 3% | ANSWER * For women with no identified pathology, fibroids less than 3. cm in diameter, or suspected or diagnosed adenomyosis: © Consider a levonorgestrel intrauterine system (LNG-IUS) as the first-line treatment. © If an LNG-IUS is declined or unsuitable, consider the following pharmacological treatments: * Non-hormonal: tranexamic acid or anon steroidal anti- inflammatory drug (NSAID). + Hormonal: combined hormonal contraception (CHC) or a cyclical oral progestogen (such as oral norethisterone). SCORE 35% Ml O >BM Ih Ae : _° Gamer a headache and blurred vision. She is 34 weeks pregnant and this is her first pregnancy. She has no past medical history. On examination you note significant swelling of her hands and feet. Her observations are recorded as: * Heart rate: 79 beats per minute * Blood pressure: 170/110 mmHg « Respiratory rate: 18 breaths per minute How should this patient be managed in the first instance? Admit and observe 10% 61% Treat with methyldopa 13% at with hydralazine 10% Treat with nifedipine 7% ANSWER Offer labetalol to treat hypertension in pregnant women with pre-eclampsia. Offer nifedipine for women in whom labetalol is not suitable, and methyldopa if labetalol or nifedipine are not suitable. BP should be measured every 15-30 minutes until BP is less than 160/110 mmHg, then Ml O >BEA | MEAs -Oamir Admit and observe 10% Treat with methyldopa 13% (x) eat with hydralazine 10% Treat with nifedipine 1% | ANSWER Offer labetalol to treat hypertension in pregnant women with pre-eclampsia. Offer nifedipine for women in whom labetalol is not suitable, and methyldopa if labetalol or nifedipine are not suitable. BP should be measured every 15-30 minutes until BP is less than 160/110 mmHg, then at least 4 times daily while the woman is an inpatient, depending on clinical circumstances. Aim for BP of 135/85 mmHg or less. SCORE 38% Ml O >BEA | MEAs -Oamasrr © © = @eediatemrcemsuccess.com A QUESTION 25 A 36 year old woman who is 31 weeks pregnant presents to the Emergency Department concerned she may have pre-eclampsia. She has no significant past medical history. What features are most consistent with a diagnosis of pre- eclampsia? Liver dysfunction and hypoglycaemia 1% Hypertension and proteinuria 91% Ketonuria and weight loss 3% Acute kidney injury and haematuria 2% Thiamine deficiency and psychosis 3% ANSWER x i ays Sst Be+ Oar B%A Ih, © © = @eediatemrcemsuccess.com ta a i A QUESTION 23 " A 32 year old woman presents to the Emergency Department complaining of right upper quadrant abdominal pain. She was recently diagnosed with pelvic inflammatory disease at the GUM clinic for which she is receiving treatment. What is the most likely cause of this patient's right upper quadrant pain? Referred pain 1% Fitz-Hugh-Curtis syndrome 78% Pneumoperitoneum 3% Ruptured ovarian cyst 4% Pancreatitis 4% ANSWER x i ays Sst Be Ml O >B%EA Ih Ae + Oagaur intammatory disease at the GUM clinic for which she is receiving treatment. What is the most likely cause of this patient's right upper quadrant pain? Referred pain 1% 78% Pneumoperitoneum 3% Ruptured ovarian cyst 4% Pancreatitis 4% ANSWER Fitz-Hugh-Curtis syndrome is a rare complication characterised by right upper quadrant pain associated with peri-hepatitis which occurs in some women with PID, especially by Chlamydia trachomatis. SCORE 39% Ml O >BEA | MEA *Oamir © © = @eediatemrcemsuccess.com —_—_—————> A QUESTION 24 A 32 year old woman is brought to the Emergency Department complaining of a headache and blurred vision. She is 34 weeks pregnant and this is her first pregnancy. She has no past medical history. On examination you note significant swelling of her hands and feet. Her observations are recorded as: « Heart rate: 79 beats per minute * Blood pressure: 170/110 mmHg « Respiratory rate: 18 breaths per minute How should this patient be managed in the first instance? Admit and observe 10% Treat with labetalol om Treat with methyldopa 13% at with hydralazine 10% x 3 aysll dist BeB%EA I EA, Oem © © = @eediatemrcemsuccess.com g QUESTION 22 A 25 year old woman who is 34 weeks pregnant, presents to the Emergency Department with a severe frontal headache and visual blurring. She has only moved to the UK recently and has not attended any antenatal clinics since her booking scan at 11 weeks. This is her first pregnancy, and she is otherwise fit and well. She has been experiencing headaches more and more frequently over the last week. Her observations are: * Heart rate: 90 beats per minute * Blood pressure: 160/100 mmHg « Respiratory rate: 17 breaths per minute * Temperature: 36.5°C What is the single most likely diagnosis? Migraine 2% Hypertension in pregnancy Hyperthyroidism x i Ayyall Ml O >B%EA Wn MIE Ae + Oaemurr Department with a severe frontal headache and visual blurring. She has only moved to the UK recently and has not attended any antenatal clinics since her booking scan at 11 weeks. This is her first pregnancy, and she is otherwise fit and well. She has been experiencing headaches more and more frequently over the last week. Her observations are: * Heart rate: 90 beats per minute * Blood pressure: 160/100 mmHg « Respiratory rate: 17 breaths per minute * Temperature: 36.5°C What is the single most likely diagnosis? Migraine 2% Hypertension in pregnancy Hyperthyroidism 1% Tension headache 2% ANSWER Symptoms of pre-eclampsia + Severe headaches (increasing frequency unrelieved by regular analgesics). Ml O >B%EA Ih Mh Oem ur Migraine 2% Hypertension in pregnancy 15% Hyperthyroidism % Tension headache 2% ANSWER Symptoms of pre-eclampsia + Severe headaches (increasing frequency unrelieved by regular analgesics). * Visual problems, such as blurred vision, flashing lights, double vision, or floating spots. + Persistent new epigastric pain or pain in the right upper quadrant. + Vomiting. + Breathlessness. * Sudden swelling of the face, hands, or feet. Ml O >BEA |i MEAs + Oamaur Blurred vision 2% Pain in right upper quadrant 18% Sudden swelling of hands or feet 12% ANSWER Symptoms of pre-eclampsia + Severe headaches (increasing frequency unrelieved by regular analgesics). * Visual problems, such as blurred vision, flashing lights, double vision, or floating spots. + Persistent new epigastric pain or pain in the right upper quadrant. + Vomiting. + Breathlessness. * Sudden swelling of the face, hands, or feet. SCORE 40% Ml O >BEA | MEAs Oem © © = @eediatemrcemsuccess.com 8 Ee A QUESTION 21 You have been asked to give a teaching session to a group of junior colleagues, the topic of the session is "Complications of Early Pregnancy”. You are discussing hyperemesis gravidarum. Which of the following is a risk factor for hyperemesis gravidarum? Male foetus 4% Molar gestation 76% ‘Smoking 9% ‘Second pregnancy 4% Being underweight pre-pregnancy, 7% ANSWER Risk factors include: x i ays Sst Be Ml O >BEA Ih MEA /Oamaury SITUKING yn Second pregnancy 4% Being underweight pre-pregnancy 1% | ANSWER Risk factors include: * Increased placental mass (for example advanced molar gestation, multiple gestation) + History of hyperemesis gravidarum in previous pregnancies * History of motion sickness + History of migraines + Family history (first-degree relatives) of nausea and vomiting in pregnancy + History of nausea with oestrogen-containing oral contraceptives + First pregnancy. + Obesity * Stress + Being seropositive for Helicobacter pylori SCORE 38% Ml O >Oem BQ QUESTION 19 A 49 year old woman presents to the Emergency Department with vaginal bleeding. Her last menstrual period was 8 weeks ago and a home pregnancy test was positive 2 weeks ago. The bleeding is heavy and has been ongoing for 24 hours. She has noticed some larger clots in the bleeding which she describes as looking like 'frogspawn’. A serum beta- hCG is taken which shows levels of 150,000 IU/L. What is the single most likely diagnosis? Miscarriage 14% Molar pregnancy 75% topic pregnancy 8% Cervicitis 0% Placenta praevia 3% ciate Ayal Silest BeB%LV | MEAs *OOm uy © © = @eediatemrcemsuccess.com Cervicitis 0% Placenta praevia 3% | ANSWER Hydatidiform moles are abnormal conceptions with excessive placental, and little or no fetal, development. The two major types—complete and partial—have distinctive histological and genetic features. The most common presentation is irregular vaginal bleeding, a positive pregnancy test and supporting ultrasonographic evidence. Less common presentations of molar pregnancies include hyperemesis, excessive uterine enlargement, hyperthyroidism, early-onset pre- eclampsia and abdominal distension due to theca lutein cysts. SCORE 42% 8 n x i Ayal asl BeBEA | MEAs -OMaaryr © © = @eediatemrcemsuccess.com A QUESTION 20 A 34 year old woman who is 32 weeks pregnant presents to the Emergency Department concerned she may have pre-eclampsia. She has no significant past medical history. Which of the following is NOT a typical symptom of pre-eclampsia? [seereneaecre = Blurred vision 2% Pain in right upper quadrant 18% Chest pain 67% Sudden swelling of hands or feet 12% ANSWER x i ays Sst BeB%LV | A -9eawn 73% Bleeding associated with uterine 5% contractions ANSWER Placenta praevia Placental abru Painless Painful Soft non-tender Tender ‘woody’ uterus on palpation No signs of foetal Foetal distress distress Clinical shock in Clinical shock o proportion to visible proportion to vi: PV bleed PV bleed SCORE 47% Ml O >B%LY Ih -9emawn © © = @eediatemrcemsuccess.com g QUESTION 18 A 23 year old woman presents to the Emergency Department complaining of a 2 year history of heavy, painful periods. She has seen her GP but feels they are not addressing her concerns. She denies intermenstrual bleeding or postcoital bleeding. Her cycle is regular and she has no past medical history. A pelvic ultrasound has been reported as normal. You are able to arrange outpatient gynaecology follow up for her, what treatment are they likely to recommend in the first instance? (Vv) iorgestrel intrauterine system 40% (x) amic acid 20% Mefenamic acid 22% Combined hormonal contraception 14% | Cyclical oral progestogen 5% x i Ayal asl Be Ml O >BN IMA -Comrw © © = @eediatemrcemsuccess.com ANSWER * For women with no identified pathology, fibroids less than 3. cm in diameter, or suspected or diagnosed adenomyosis: © Consider a levonorgestrel intrauterine system (LNG-IUS) as the first-line treatment. © Ifan LNG-IUS Is declined or unsuitable, consider the following pharmacological treatments: * Non-hormonal: tranexamic acid or anon steroidal anti- inflammatory drug (NSAID). + Hormonal: combined hormonal contraception (CHC) or a cyclical oral progestogen (such as oral norethisterone). SCORE 44% Ml O >B%LV | MEAs Om tay © © = @eediatemrcemsuccess.com A QUESTION 16 A 23 year old woman presents to the Emergency Department complaining of headache and blurred vision. She is 31 weeks pregnant. You suspect she is suffering from pre-eclampsia. Which of the following is NOT a risk factor for pre- eclampsia? Chronic kidney disease 1% jabetes mellitus 9% First pregnancy 12% Multiple pregnancy 8% Maternal age < 25 64% ANSWER x i ays Sst BeANSWER Women are at high-risk of pre-eclampsia if they have: + One of the following high risk factors © Ahistory of hypertensive disease during a previous pregnancy © Chronic kidney disease © Autoimmune disease, such as systemic lupus erythematosus or antiphospholipid syndrome © Type 1 or type 2 diabetes © Chronic hypertension + Two or more of the following moderate risk factors: © First pregnancy © Aged 40 years or older © Pregnancy interval of more than 10 years © Body mass index (BMI) of 35 kg/m2 or greater at the first visit © Family history of pre-eclampsia © Multiple pregnancy Ml O >B%LV | MEAs - Omar © © = @eediatemrcemsuccess.com A QUESTION 17 # A17 year old girl presents to the Emergency Department with a 1 hour history of vaginal bleeding. She tells you she is 28 weeks pregnant. You are considering the potential causes. Which of the following clinical findings is most consistent with placenta praevia? Bleeding associated with abdominal 5% pain Bleeding associated 5% Clinical shock out of proportion to 12% visible bleeding @ Bleeding associated with soft non- 73% tender uterus Bleeding associated with uterine 5% contractions Oot dwell adel BeA QUESTION 15 A 29 year old woman presents to the Emergency Department complaining of vaginal pain and discharge. She describes a white discharge associated with vulval itching. She has no past medical history. She reports recent unprotected sexual intercourse with a new partner. On examination you note a white, curdy discharge and vulval excoriations. What is the recommended treatment for this patient? Oral doxycycline 6% (x) Topical fusidic acid 4% Vv) Oral fluconazole 72% Oral erythromycin 3% Oral metronidazole 15% ayyall — ayjubesyl Ml O >Oral erythromycin 3% | Oral metronidazole 15% ANSWER The patient has features of vulvovaginal candidiasis. For most women, prescribe an initial course of an intravaginal antifungal cream or pessary (clotrimazole, econazole, miconazole, or fenticonazole) or an oral antifungal (fluconazole or itraconazole). If there are vulval symptoms, consider prescribing a topical imidazole in addition to an oral or intravaginal antifungal. Options include clotrimazole or ketoconazole. Give advice on self-care, SCORE 53% 8 7 REFERENCE RANGES Ml O >B%LV Ih IIe Osu © © = @eediatemrcemsuccess.com A QUESTION 16 A 23 year old woman presents to the Emergency Department complaining of headache and blurred vision. She is 31 weeks pregnant. You suspect she is suffering from pre-eclampsia. Which of the following is NOT a risk factor for pre- eclampsia? Chronic kidney disease 1% jabetes mellitus 9% First pregnancy 12% Multiple pregnancy 8% Maternal age < 25 64% ANSWER x i ays Sst BeB% In IEA *Osmaan ANSWER Primary postpartum haemorrhage (PPH) is the most common form of major obstetric haemorrhage. The traditional definition of primary PPH is the loss of 500 ml or more of blood from the genital tract within 24 hours of the birth of a baby. PPH can be minor (500-1000 mi) or major (more than 1000 mi). SCORE 62% REFERENCE RANGES Something wrong? Postpartum Haemorrhage OBSTETRICS & GYNAECOLOGY Ml O >BN Nh LIA Osun © © = @eediatemrcemsuccess.com ry QUESTION 14 tt A311 year old lady presents to the Emergency Department with heavy vaginal bleeding with clots. Her last menstrual period was 8 weeks ago, and she had a positive home pregnancy test 1 week ago. She has previously had 2 miscarriages. You suspect she is having a further spontaneous miscarriage. Her cervical os is open. What is the diagnosis? Missed miscarriage 3% (x) Threatened miscarriage % Inevitable miscarriage 63% Complete miscarriage 1% Incomplete miscarriage 16% ANSWER x ¢ Ayal dest Bg Ml O >B%LV Ih IIe “Olmuwi ANSWER Miscarriage is classified as complete, incomplete, missed, threatened, or inevitable on the basis of clinical history and findings on speculum and digital pelvic examination: + Complete miscarriage Is when all the products of conception have been expelled from the uterus and bleeding has stopped. + Incomplete miscarriage is a diagnosed non- viable pregnancy in which bleeding has begun but pregnancy tissue remains in the uterus. + Missed miscarriage (also known as delayed or silent miscarriage) is diagnosed when a non-viable pregnancy is identified on ultrasound scan, without associated pain and bleeding. + Threatened miscarriage is diagnosed when there is vaginal bleeding in the presence of a viable pregnancy in the first 24 weeks of gestation. * Inevitable miscarriage is a diagnosed non- viable pregnancy in which bleeding has begun and the cervical os is open, but pregnancy tissue remains in the uterus. The pregnancy will proceed to incomplete or complete miscarriage. x i Ayal asl BeBN Nh LIA Osun © © = @eediatemrcemsuccess.com EE Sener a QUESTION 12 i A 56 year old woman presents to the Emergency Department with a 3 day history of vaginal bleeding. She has had 2 previous vaginal deliveries and tells you she experienced the menopause 4 years ago. Her observations are all within normal limits and her haemoglobin is normal. Which of the following management plans is most appropriate for this patient? Pelvic ultrasound 37% Reassure that it is likely due to atrophic 10% changes YY Refer for 2 week wait gynaecology 48% appointment Coagulation screen % CT abdomen 4% x 3 aysll dist BeCoagulation screen 1% | CT abdomen 4% | ANSWER Postmenopausal bleeding is always abnormal. Refer women using a suspected cancer pathway referral (for an appointment within 2 weeks) for endometrial cancer if they are aged 55 years and over with post-menopausal bleeding (unexplained vaginal bleeding more than 12 months after menstruation has stopped because of the menopause). Consider a suspected cancer pathway referral (for an appointment within 2 weeks) for endometrial cancer in women aged under 55 years with post-menopausal bleeding. SCORE 67% 8 4 OO TT REFERENCE RANGES Ml O >BH Mh IE Ae Oia @ QUESTION 13 You have been asked to give a teaching session to a group of junior colleagues. The title of the session is "Managing Obstetric Complications in the Emergency Department”. You are discussing postpartum haemorrhage. What is the definition of primary postpartum haemorrhage? Any bleeding occurring in the first 4 5% hours after delivery > 1000 mis occurring in the first rs after delivery Loss of > 1000 mls occurring in the first 7% 48 hours after delivery g in the first Bleeding occurring in the first 28 days 1% after delivery ANSWER Primary postpartum haemorrhage (PPH) is the most common form of maior obstetric Ml O >BT Nh IAs » Od 1 arr ml Vaginal bleeding with signs of clinical 3% shock ANSWER Antepartum haemorrhage (APH) is defined as. bleeding from or in to the genital tract, occurring from 24+0 weeks of pregnancy and prior to the birth of the baby. The most important causes of APH are placenta praevia and placental abruption, although these are not the most common. * Minor haemorrhage - blood loss less than 50 mil that has settled + Major haemorrhage - blood loss of 50-1000 ml, with no signs of clinical shock * Massive haemorrhage - blood loss greater than 1000 ml and/or signs of clinical shock SCORE 60% 6 4 OO Ml O >BN Nh LIA * Od 1 arn © © = @eediatemrcemsuccess.com Q QUESTION 11 A 39 year old woman who is 30 weeks pregnant presents to the Emergency Department with a 1 hour history of severe vaginal bleeding. She denies abdominal pain and on examination her abdomen is soft. She describes normal foetal movements and cardiotocography shows no sign of foetal distress. What is the single most likely diagnosis? Placental abruption 8% Uterine rupture 2% Placenta praevia 82% Cervical ectropion 5% Pelvic inflammatory disease 3% x i ays Sst BeBN Nh LIA + © Lad un Cervical ectropion 5% Pelvic inflammatory disease 3% ANSWER Placenta praevia occurs when the placenta is inserted wholly or in part into the lower segment of the uterus. It is classified as major if the placenta is covering the internal os of the cervix, or minor if the leading edge is in the lower segment but not covering the os. It may be an incidental finding on a routine anomaly ultrasound or it may present with painless bleeding usually after the 28" week. Typically it is sudden and profuse, but does not last long and is rarely life-threatening. There may bea high presenting part or abnormal lie of the foetus. There is a high risk of preterm delivery. It is considered good practice to avoid vaginal and rectal examinations in women with placenta praevia, and to advise these women to avoid penetrative sexual intercourse. Ml O >BN Nh LIA + Old ayn © © = @eediatemrcemsuccess.com A QUESTION 9 i A 23 year old woman is brought to the Emergency Department after collapsing at home. She is 30 weeks pregnant with her second pregnancy. You are supervising a medical student as they assess the patient. Which of the following is a physiological change that occurs during pregnancy? Decreased oxygen consumption 1% Increased circulatory volume 74% Decreased tidal volume 19% Peripheral vasoconstriction 4% Decreased heart rate 2% ANSWER Significant physiological changes occur during a: aysll dist Be Ml O >BT Ih IEA + OM@tarn Decreased heart rate 2% ANSWER Significant physiological changes occur during pregnancy including: + Cardiovascular system © Peripheral vasodilation © Increased cardiac output (increased stroke volume and increased heart rate) © Increased circulatory volume (increased plasma volume) + Respiratory system © Increased minute ventilation (increased tidal volume) © Increased oxygen consumption SCORE 56% REFERENCE RANGES Ml O >BN Nh LIA * Od sur © © = @eediatemrcemsuccess.com QUESTION 10 =3- You have been asked to give a teaching session to a group of medical students on bleeding in pregnancy. You are discussing antepartum haemorrhage. What is the definition of antepartum haemorrhage? Vaginal bleeding occurring after the first 7% trimester Vaginal bleeding occurring in pregnancy 12% Vaginal bleeding occurring from 24 weeks of pregnancy Vaginal bleeding of greater than 1000 3% mi Vaginal bleeding with signs of clinical 3%6 shock x i ays Sst BeB%7 Ih IAs * Od 1 uw Give intravenous fluid bolus 2% immediately Give intravenous adrenaline 9% immediately ANSWER * All the principles of basic and advanced life support apply Summon help immediately; obtain expert help including an obstetrician, anaesthetist and neonatologist Start CPR according to ALS guidelines; ensure high quality chest compressions with minimal interruptions; the hand position may have to be slightly higher on the sternum in advanced pregnancy Manually displace the uterus to the left to minimise IVC compression Add left lateral tilt only if this is feasible; the patient's body will need to be supported on a firm surface to allow effective chest compressions (the use of soft pillows or wedges is ineffective) Ml O >BN Nh LIA Os uv © © = @eediatemrcemsuccess.com A QUESTION 8 A 36 year old woman presents to the Emergency Department with a 4 hour history of vaginal bleeding. She tells you a home pregnancy test was positive. She describes the bleeding like "bunch of grapes”. You suspect a molar pregnancy. Which of the following features is NOT consistent with molar pregnancy? Hyperemesis gravidarum 4% Maternal age > 45 years 4% Irregular vaginal bleeding 4% Snowstorm pattern on pelvic 3% ultrasound Lowerthan normal serum B-hCG levels 85% x i ays Sst BeBN Nh LIA -Otmuy Hyperemesis gravidarum 4% (x) Maternal age > 45 years 4% Irregular vaginal bleeding 4% Snowstorm pattern on pelvic 3% ultrasound ANSWER Beta-hCG levels are higher than normal in a molar pregnancy. Classically, a ‘snowstorm pattern’ has been described on ultrasound, resulting from the presence of a complex vesicular intrauterine mass. containing many ‘grape-like' cysts. SCORE 50% Ml O >B%L hI Ae * Od lu © © = @eediatemrcemsuccess.com A QUESTION 6 A19 year old woman presents to ED complaining of very heavy menstrual flow. She has been having heavy painful periods for the last year. She has no other past medical history. Which of the following investigations is most useful in the initial management of this patient? Cervical swab 3% Full blood count 36% Pelvic ultrasound 42% Coagulation screen 6% Thyroid function test 12% ANSWER + Arrange a full blood count in all women — to a: aysll dist Be Ml O >B%EO |, Ae “Olu J ANSWER + Arrange a full blood count in all women — to rule out iron deficiency anaemia. * For women with suspected submucosal fibroids, polyps, or endometrial pathology — offer a hysteroscopy or ultrasound to assess for a cause of menorrhagia + Arrange other investigations as suggested by history and clinical findings, for example: © A vaginal or cervical swab ~ if an infection is suspected. © Thyroid function tests — if there are features of hypothyroidism. © Tests for coagulation disorders (for example von Willebrand disease) — in women who have had heavy menstrual bleeding since menarche, and a personal or a family history of a coagulation disorder SCORE 50% Ml O >BN Nh LIA Otay © © = @eediatemrcemsuccess.com g QUESTION 7 You are called urgently to the waiting room by a receptionist. A 23 year old woman who presented with chest pain has collapsed. She is 32 weeks pregnant. You find no signs of life and a nurse has started chest compressions. A maternal cardiac arrest call is made. What action should you take first? Continue chest compressions and 10% ventilations in a ratio of 15:2 until rhythm is assessed Give intravenous magnesium sulfate 4% immediately Give intravenous fluid bolus 2% immediately Give intravenous adrenaline 9% immediately x i Ayal asl BeB%L9 Ih, IE Ae Uterine abnormalities % Obesity 4% Thrombophilic abnormalities % ANSWER Hydatidiform moles affect women throughout the reproductive age range but are more common at the extremes of the range. Women under 16 have a six times higher risk of developing the disease than those aged 16-40, and women who conceive aged 50 or more have a one in three chance of having a molar pregnancy. SCORE 25% 1 3 — REFERENCE RANGES Ml O >B%L hI Ae -Om@ lawn © © = @eediatemrcemsuccess.com Fie A QUESTION 5 A 34 year old woman presents to the Emergency Department concerned by a strong smelling and offensive vaginal discharge for the last 5 days. She describes the smell as “fishy”. She denies any itch or soreness. On examination you note a thin, grey discharge. What is the diagnosis? Physiological vaginal discharge % Bacterial vaginosis 77% Trichomoniasis 14% Vulvovaginal candidiasis 3% Chlamydia 5% ANSWER ciate Ayal Silest BeB%L hI Ae “Ol@awn ANSWER Vaginal Discharge Bacterial vagin Cause Overgrowth of anaerobic bacte esp. Gardnerellz vaginalis Discharge Fishy-smelling, grey/white homogeneous discharge Associated symptoms _No soreness, itc irritation On examination Thin white/grey homogeneous discharge coati the vaginal wall vulva with fishy no inflammatior Investigations Vaginal pH & hi vaginal swab Treatment Oral metronidaz 400 mg bd 5-7 Ml O >B%L hI Ae -Om@ lawn © © = @eediatemrcemsuccess.com A QUESTION 3 A 34 year old woman presents to the Emergency Department with a 3 year history of menorrhagia. She is otherwise well with no past medical history. She has no intermenstrual or postcoital bleeding. What is the most common cause of menorrhagia? Is 33% Endometriosis 8% Dysfunctional uterine bleeding 55% Polycystic ovary syndrome 2% Hypothyroidism 3% ANSWER x i ays Sst BeB%EO |, I Ae *Om@ian Endometriosis 8% eding 55% Polycystic ovary syndrome 2% Hypothyroidism 3% ANSWER In almost 50% of women with menorrhagia, no cause is identified — this is classified as dysfunctional uterine bleeding. SCORE 0% 0 5 eee REFERENCE RANGES Something wrong? Ml O >B%L hI Ae -Om@ lawn © © = @eediatemrcemsuccess.com Ene A QUESTION 4 You have been asked to give a teaching session to a group of junior colleagues. The title of the session is "Early Pregnancy Complications in the Emergency Department”. You are discussing molar pregnancy. Which of the following is a risk factor for molar pregnancy? Smoking 15% Maternal age > 45 years 67% Uterine abnormalities 7% Obesity 4% Thrombophilic abnormalities 1% ANSWER x i ays Sst BeB%E0 In _. *Otmxe after delivering a concealed pregnancy at home. She is bleeding heavily. What is the most common cause of primary postpartum haemorrhage? (x) Uterine rupture 3% Retained placenta 15% Vaginal laceration 4% Coagulopathy 2% ANSWER The most common cause of postpartum haemorrhage is uterine atony. SCORE 0% Ml O >B%E | Ae Saag & a Ly + Ol@ 4 a¥0 QUESTION 2 A 28 year old woman presents to the Emergency Department concerned by a change in vaginal discharge over the last 3 days. She describes feeling "sore down below" and "itchy". On examination you note a frothy, yellow discharge. On speculum examination you see a strawberry like cervix. What is the diagnosis? Gonorrhoea (x) Bacterial vaginosis Trichomoniasis Vulvovaginal candidiasis Chlamydia ANSWER Sees iuyall 6% 69% 5% 1% Ajdesyll &B%E0 |b A uniainyara *Oi rr ANSWER Vaginal Discharge Bacterial vagin Cause Overgrowth of anaerobic bacte esp. Gardnerelle vaginalis Discharge Fishy-smelling, grey/white homogeneous discharge Associated symptoms No soreness, itc irritation On examination Thin white/grey homogeneous discharge coati the vaginal wall vulva with fishy no inflammatior Investigations Vaginal pH & hi vaginal swab Treatment Oral metronidaz 400 mg bd 5 -7 Ml O >BONS |n 20 id ac 2% Acromegaly Cushing's syndrome 3% Addison's disease 1% Pheochromocytoma 3% ANSWER Suspect a diagnosis of hyperthyroidism if there are one or more symptoms of: + Rapid-onset malaise, fever, and thyroid pain + Compression symptoms of breathlessness, hoarse voice, dysphagia, neck pressure * Agitation, emotional lability, insomnia, irritability, anxiety, palpitations + Exercise intolerance, fatigue, muscle weakness * Heat intolerance, increased sweating * Increased appetite with unintentional weight loss, diarrhoea + Subfertility, oligomenorrhoea, amenorrhoea * Polyuria, thirst, generalised itch + Reduced libido, gynaecomastia in men. * Deterioration in blood glucose control and hyperglycaemia in people with diabetes mellitus * Deterioration of comorbid heart disease, for example in the elderly Ul oO >