Chapter 9 Bleeding and/or pain in early pregnancy

17. Miscarriage:
a. Will always present with bleeding ( F )
b. Is most common before 12 weeks gestation ( T )
c. Cannot be diagnosed by vaginal examination alone ( F )
d. If affecting the first pregnancy, increases the risk of miscarriage the next time ( F )
e. Is often provoked by intercourse, heavy lifting or a fall ( F )
18. When a woman with bleeding in early pregnancy presents:
a. A speculum or vaginal examination could increase the risk of miscarriage ( F )
b. A smear test should be sent ( T )
c. A blood test is necessary even if her blood group is already known ( T )
d. An hCG level will not distinguish ectopic pregnancy from miscarriage ( T )
e. A history of tubal surgery should increase your suspicion of ectopic pregnancy ( T )

Chapter 10 Bleeding in the second and third trimesters of pregnancy

19. In the case of placental abruption:
a. The uterus is typically soft on palpation ( F )
b. Fetal parts are easily felt ( F )

c. The uterus is usually tender ( T )

d. Uterine contractions might be present ( T )
e. There might not be any visible bleeding ( T )
20. When managing a major placenta praevia:
a. Blood should be cross-matched if the patient presents with bleeding ( T )
b. Transvaginal ultrasound scan helps with diagnosis ( T )
c. Vaginal delivery is appropriate ( F )
d. Inpatient admission is advised in the third trimester ( T )
e. Consider maternal steroids in the preterm patient who presents with vaginal
bleeding ( T )

Chapter 16 Bleeding after delivery

31. Primary postpartum haemorrhage (PPH):
a. Is defined as occurring within 24 hours of delivery ( T )
b. Is defined as blood loss of more than 2000 Ml ( F )
c. Should be anticipated in a multiple pregnancy ( T )
d. Might be secondary to vaginal wall lacerations ( T )
e. A history of antepartum haemorrhage is not associated with a risk of primary PPH ( F )
32. Investigating secondary postpartum haemorrhage (PPH):
a. A high vaginal swab is indicated ( T )
b. An ultrasound scan of the pelvis might be appropriate ( T )
c. A decreased white blood cell count agrees with a diagnosis of endometritis ( F )
 d. A negative serum hCG level is found in cases of molar pregnancy ( F )
e. A chest X-ray is essential with a confirmed diagnosis of choriocarcinoma ( T )

Chapter 32 Early pregnancy failure

64. Ectopic pregnancy:
a. Cannot occur if tubal sterilisation has been performed ( F )
b. Is more common in IVF pregnancies ( T )
c. Must be managed surgically ( F )
d. If viable, ie with a fetal heartbeat, can be reimplanted within the uterus ( F )
e. If a woman has had one ectopic pregnancy her risk of another is increased ( T )
65. Molar pregnancy:
a. Never includes a fetus ( F )
b. If complete, contains only paternal genes ( T )
c. Commonly presents with bleeding in early pregnancy ( T )
d. hCG levels will be lower than expected in early pregnancy ( F )
e. May result in a need for chemotherapy ( F )

Chapter 34 Antepartum haemorrhage

68. When differentiating between placenta praevia and placental abruption:
a. An ultrasound scan is helpful ( T )
b. A tender hard uterus is typical of placenta praevia ( F )
c. There is an association between placental abruption and pre-eclampsia( T )
d. There may be an abnormal lie with placenta praevia ( T )
e. The cardiotocograph may be abnormal in either condition ( T )
69. Management of a patient with an antepartum haemorrhage:
a. Should always include checking the Rhesus status ( T )
b. Should always include a digital vaginal examination ( F )
c. Should always include a group and save sample in case cross-matched blood is needed (T)
d. Does not require a cardiotocograph ( F )
e. Requires urinalysis if the maternal blood pressure is raised ( T )

Chapter 41 Premature labour

83. Tocolysis:
a. Should always be instituted when there is evidence of infection, so that antibiotics
can be given to the mother ( F )
b. With ritodrine is contraindicated in asthmatics ( F )
c. Is always in the form of an infusion ( F )
d. Has been proven to reduce the maternal morbidity related to preterm labour ( F )
e. With non-steroidal anti-inflammatory drugs can result in fetal renal failure ( T )
84. The cervix in preterm labour:
a. Should not be examined with a speculum, as this may provoke more contractions ( F )
b. Should be swabbed for infection ( T )
c. Might dilate relatively painlessly ( T )
d. Can be sutured closed once it has started to open ( T )
e. Is likely to appear shortened on transvaginal scan ( T )
86. Postpartum haemorrhage (PPH):
a. Uterine atony is the most common cause of primary PPH ( T )
b. The incidence of PPH in the developed world is about 30% ( F )
c. History of an antepartum haemorrhage reduces the risk of a PPH ( F )
d. Syntocinon should be given instead of syntometrine in the patient with hypertension ( T )
e. Hysterectomy to treat PPH must be avoided at all costs ( F )

5. Theme: Bleeding in the Second and Third Trimesters of Pregnancy

a. Molar pregnancy
b. Vasa praevia
c. Ectopic pregnancy
d. Placenta praevia
e. Placental abruption
f. Cervical ectropion
g. Retained placenta
h. Vaginal tear
i. Uterine atony
j. Cervical tear

1. A 35-year-old woman, who has had two previous caesarean sections, presents with
vaginal spotting and a transverse lie at 35 weeks. d
2. A 22-year-old woman has artificial rupture of membranes during labour and there is
heavy vaginal bleeding in association with an abnormal CTG. The uterus is soft and
non-tender. b
3. A 28-year-old woman has a history of 16 weeks amenorrhoea. She has severe nausea
and vomiting. On abdominal palpation the uterus is 24 weeks size. No intrauterine sac can
be seen on ultrasound scan. a
4. A 32-year-old woman is 28 weeks pregnant. She has a 2 hour history of vaginal
bleeding. She also complains of a headache and constant abdominal pain. On
examination, the uterus is firm and tender. e
5. A 30-year-old presents with a post-coital bleed at 22 weeks gestation. f

6. Theme: Abdominal Pain in the Second and Third Trimesters of Pregnancy

a. Fibroid degeneration
b. Gastroenteritis
c. Symphysis pubis dysfunction
d. Placental abruption
e. Acute appendicitis
f. Ovarian torsion
g. Pre-eclampsia
h. Urinary tract infection
i. Gallstones
j. Labour

1. On abdominal palpation, hard tender uterus, difficulty defining the fetal parts. d
2. Leucocytosis on urinalysis. h
3. Regular contractions palpated on abdominal examination, cervical change on vaginal
examination. j
4. The uterus palpates large-for-dates, with tenderness elicited over a specific site. a
5.The patient is hypertensive and hyperreflexic, with tenderness over the right hypochondrium. g

20. Theme: Maternal Collapse

a. Placental abruption
b. Post-partum haemorrhage
c. Uterine rupture
d. Amniotic fluid embolism
e. Eclampsia
f. Epileptiform seizure
g. Diabetic ketoacidosis
h. Puerperal septic shock
i. Pulmonary embolism
j. Myocardial infarction

1. A 25-year-old woman was found collapsed at home at 8 weeks’ gestation. Her past
history includes a deep vein thrombosis at the age of 18 years following which she was
found to carry the Factor V Leiden mutation. i
2. A 26-year-old woman underwent a caesarean section in her first pregnancy for fetal
distress. This current pregnancy was uneventful and she went into spontaneous labour. She
requested an epidural for analgesia. At 7 cm dilatation she felt unwell and collapsed at
the same time that the fetal heart rate pattern became bradycardic. c
3. A 34-year-old grand multiparous woman presented to the labour ward at 34 weeks’
gestation having experienced a small APH at home. By the time she arrived she was
experiencing severe abdominal pain. Abdominal examination revealed a tender, hard uterus
and the fetal heart could not be heard with the sonicaid. During the examination she
collapsed and was unresponsive. a
4. An unbooked woman was admitted via ambulance unconscious. The only history
available is that she was feeling unwell for the previous few days with headaches and
had collapsed at home ‘shaking’. On examination, she was unconscious, her BP was
180/110 mmHg and urinalysis revealed proteinuria. e
5. A 35-year-old multiparous woman spontaneously ruptured her membranes at term
in her third pregnancy. 48 hours later she went into labour and had a normal delivery.
She went home after 6 hours. 72 hours later she started feeling unwell and feverish. She
collapsed at home and was brought into hospital by ambulance. On examination she was
unconscious with central cyanosis. Her temperature was 39°C, pulse 120 beats per
minute and she was profoundly hypotensive. h
23. Theme: Complications of Labour
a. Failure to progress
b. Meconium-stained liquor
c. Placental abruption
d. Post-partum haemorrhage
e. Cord prolapse
f. Ruptured uterus
g. Uterine hyperstimulation
h. Shoulder dystocia
i. Face presentation
j. Fetal bradycardia

1. A patient who has previously had a caesarean section is having a vaginal delivery in
this pregnancy. At 8 cm dilatation, the CTG suddenly shows a prolonged fetal
bradycardia. f
2. After a long labour, a primiparous patient with a BMI of 35 has a ventouse delivery
for a prolonged second stage. The fetal head shows the turtle-neck sign as it delivers
and there is difficulty delivering the baby. h
3. In established labour with a breech presentation, the CTG suddenly shows a
prolonged fetal bradycardia. e
4. A patient who has been diagnosed with severe pre-eclampsia is having labour induced
at 37 weeks. She starts to complain of constant sharp abdominal pain. The uterus is
tender and hard on palpation. The CTG has become suspicious. c
5. A patient on intravenous syntocinon is contracting 6 in 10. The CTG shows variable
decelerations with a rise in the baseline heart rate. g

Theme: Postpartum Haemorrhage PPH

a. Primary PPH
b. Secondary PPH
c. Second degree tear
d. Third degree tear
e. Uterine atony
f. Uterine rupture
g. Retained products of conception
h. Endometritis
i. Placenta accreta
j. Uterine inversion
1. The patient has had a forceps delivery with an episiotomy after a prolonged labour.
On examination, the episiotomy has extended into the external anal sphincter and the
patient is bleeding heavily from the area. d
2. The patient has just had a normal vaginal delivery of a twin pregnancy. She is
bleeding heavily. On examination, the uterine fundus is above the umbilicus and poorly
contracted. e
3. A woman has previously had two caesarean sections. At the time of caesarean section
in this pregnancy, the placenta was morbidly adherent to the uterine wall. i
4. Bleeding more than 500mL within the first 24 hours of delivery of the baby. a
5. At the time of controlled cord traction in the 3rd stage of labour, the patient
suddenly complains of severe abdominal pain and bleeding. The uterine fundus cannot be
palpated on abdominal examination. j