Obstetrics 1

1. A 29-year-old woman comes to the office for confirmation of pregnancy

after a recent positive home pregnancy test. The patient has mild fatigue and
nausea but no vomiting, vaginal bleeding, or pelvic pain. She has no chronic
medical conditions, and her only medications are a daily probiotic and
prenatal vitamin. The patient does not use tobacco, alcohol, or illicit drugs.
She exercises daily, alternating between running and weight training. The
patient avoids processed foods and red meat, preferring a diet rich in
vegetables and fish. She drinks decaffeinated coffee with breakfast and has
ginger tea throughout the day to help relieve nausea. BMI is 21 kg/m². Vital
signs are normal. Physical examination is unremarkable. Ultrasound shows a
7- week intrauterine fetal pole with cardiac motion. Which of the following
part of this patient's history requires further evaluation?
A. Ginger consumption
B. Caffeine intake
C. Exercise routine
D. Fish intake
E. Probiotic regime
Caffeine is not recommended in excessive amounts during pregnancy
• generally advised to consume no more
than 200-300 milligrams of caffeine per
day during pregnancy
• caffeine is found not only in coffee but
also in tea, soft drinks, energy drinks, and
some medications
• Risk of Miscarriage
• Fetal Development: High caffeine intake
can potentially affect fetal development,
particularly in the early stages of
pregnancy.
• Increased Heart Rate: it can affect blood
flow to the fetus.
• Sleep Disruption: Caffeine is known to
disrupt sleep patterns.
• Potential for Preterm Birth
2. A 34-year-old woman has been using oral contraceptive pills for past
3 years. She is planning to conceive this year. She drinks regular
alcohol. What is the most appropriate advice?
A. Avoid pregnancy for 6 months after stopping alcohol
B. There is no need to stop alcohol
C. Stop alcohol in 2nd trimester
D. Stop alcohol after positive pregnancy test
E. Stop alcohol now
3. Adele is a 23 years old primigravida woman who has a spontaneous
abortion at 12 weeks gestation 2 weeks ago. She has presented to you
because she wants to have another pregnancy as soon as possible as
she thinks this could help her husband and her get over with their loss.
She asks you when she can become pregnant again. Which one of the
following would be the best advice?
A. She should not become pregnant for at least 6 months and should
be on OCP for now.
B. She can start trying to conceive again immediately if she feels fit for
that.
C. She can conceive after 12 months.
D. She can conceive after 3 months.
E. She can conceive after 2 menstrual cycles.
4. An Aboriginal woman sees you in your office regarding antenatal
care. She is a smoker and has a history of hypertension. She does not
seem to be motivated to quit smoking. Which of the following is not
the effect of smoking during pregnancy if she continues to smoke?

A. Still birth
B. Premature birth
C. Hydrops fetalis
D. Placental abruption
E. Spontaneous abortion
Fetal complications • Low Birth Weight
• Preterm Birth
• Stillbirth
Health issues of • Respiratory Problems: higher risk of respiratory issues, such as
baby asthma and respiratory infections.
• Sudden Infant Death Syndrome (SIDS): Babies exposed to
maternal smoking have an increased risk of SIDS.
• Behavioral and Cognitive Problems

Maternal • Ectopic Pregnancy

complications • Placenta Problems including abruption,previa
• Complications During Labor: Pregnant smokers are more likely
to experience complications during labor, such as excessive
bleeding.
• Cancer and Cardiovascular Risks:
Long term increased risk of obesity, diabetes, and certain behavioral issues.
complications
5. A 26-year-old woman with history of chronic immune
thrombocytopenic purpura (ITP) presents to your clinic and seeks
advice regarding pregnancy. She has a platelet count of 70000/mm.
Which one of the following is the correct statement in counselling her?
A. She should have splenectomy before pregnancy.
B. She should avoid pregnancy in the next 2 years.
C. She can become pregnant.
D. If she becomes pregnant, the mode of delivery should be cesarean
section.
E. She cannot become pregnant while the platelet count is below
70000/mm 3
• Women with ITP generally do well in pregnancy. ITP is an
autoimmune disease, and exacerbations and remissions are common.
Pregnancy does not appear to affect the course of the disease.
• A platelet count between 20 and 30 × 10 9/L in a nonbleeding patient
is safe for most of pregnancy.
• Patients with a history suggestive of ITP or those with a platelet count
< 80 × 10 9/L should be investigated for possible ITP.
• At a platelet count ≥ 70 × 10 9/L, in the absence of other hemostatic
abnormalities, regional axial anesthesia can be safely performed.
• NSAIDs should be avoided for postpartum or postoperative analgesia
in women with platelet counts < 70 × 10 9/L because of increased
hemorrhagic risk.
• A platelet count ≥50 × 10 9/L should be obtained for delivery.
6. A 25-year-old woman presents at 20 weeks gestation for an
antenatal check-up. Laboratory studies reveal a platelet count of
90,000/mm³ with no other abnormalities in test results. She has no
symptoms and physical examination is unremarkable. Which one of the
following could be the most likely diagnosis?
A. Idiopathic thrombocytopenia.
B. Immune thrombocytopenia
C. Gestational thrombocytopenia.
D. Disseminated intravascular coagulation (DIC).
E. Preeclampsia.
Gestational thrombocytopenia
• Gestational thrombocytopenia is a condition characterized by a decrease in
platelet levels during pregnancy.
• It typically occurs in the second and third trimesters, affecting around 5-8% of
pregnant individuals.
• This condition is generally benign and not associated with significant bleeding
risks for the mother or fetus.
• The exact cause is unclear
• Diagnosis involves ruling out other potential causes of low platelet counts.
• Most cases of gestational thrombocytopenia require no specific treatment, as
platelet levels usually return to normal after childbirth.
• However, close monitoring by healthcare providers is essential to ensure the well-
being of both mother and baby.
7. A 28-year-old lady comes to your clinic at 10 weeks of pregnancy.
She is keen to know how she can minimise the chance of acquiring a
Toxoplasma infection. Which of the following advice is not helpful?

A. Wash hands and kitchen surfaces thoroughly after contact with raw
meat
B. Avoid untreated water while travelling
C. Wash fruits and vegetables before consumption
D. Avoid changing cat litter boxes
E. Daily shower after having lunch
8. You are asked to see a 21-year-old woman for preconceptual care.
She was diagnosed with generalised tonic-clonic epilepsy four years
ago. This is poorly controlled. She is currently on sodium valproate and
levetiracetam. What is the next step in her management?
A. Arrange MRI
B. Arrange an EEG
C. Commence aspirin 75 mg
D. Commence folic acid 5 mg
E. Review medication
9. A 20-year-old woman comes to your office for first- trimester pregnancy
counselling. She is an ex- Intravenous drug abuser. All the first
trimester Investigations are unremarkable except chronic hepatitis b
infection. What of the following statement about Hepatitis B Virus
infection during pregnancy is false?

A. Woman with a high viral load in the third trimester should be offered
antiviral therapy
B. A fetal scalp blood sampling in labour should be avoided
C. A Screening for HBV is not recommended for a pregnant woman with
previous vaccination
D. Caesarian section does not reduce the risk of hepatitis B transmission
E. The risk of a fetal infection is likely to be higher with chorionic villus
sampling than amniocentesis
• Even if a pregnant woman has been previously vaccinated against HBV, it is still essential to screen her for
HBV infection during pregnancy. Vaccination does not guarantee lifelong immunity in all cases, and some
individuals may not have developed sufficient immunity from vaccination alone.
• Antiviral therapy may be recommended for pregnant women with a high HBV viral load during the
third trimester to reduce the risk of vertical transmission to the newborn.
• Fetal scalp blood sampling may pose a risk of HBV transmission to the baby if the mother is infected.
• A cesarean section does not significantly reduce the risk of HBV transmission from mother to baby
unless there are other specific indications for the procedure. The main interventions to reduce perinatal
transmission include antiviral therapy for the mother and vaccination and hepatitis B immune globulin
(HBIG) for the newborn.
• CVS carries a slightly higher risk of maternal-fetal transmission of HBV compared to amniocentesis
because it involves direct sampling of placental tissue, which may be more likely to contain the virus.
10. Which antenatal investigation/ combination of markers is
considered the best for detecting Down syndrome (trisomy 21) during
pregnancy?
A.Maternal serum AFP and beta-HCG
B.Nuchal translucency (NT) and maternal serum inhibin-A
C.Maternal serum PAPP-A and beta-HCG
D.Harmoney test ( NIPT)
E.Maternal serum triple screen
11. Which one of the following maternal serum screening markers can
be used in both first and second trimesters for screening of Down
syndrome?
A. Unconjugated estriol level
B. Inhibin A level
C. Alpha fetoprotein level
D. Pregnancy-associated plasma protein A level
E. Free beta HCG level
 First Trimester DS Screening Methods
Screening Method
1. Nuchal Translucency
2. Pregnancy-Associated
Plasma Protein-A (PAPP-A)
3. Free Beta-hCG (human
chorionic gonadotropin)
4. Combined First-Trimester
Screening
Timing Description
Measurement of the thickness of the nuchal
fold in the fetus' neck during an ultrasound.
11-13 weeks
Increased thickness may indicate a higher
risk.
Blood test measuring PAPP-A levels; low
11-13 weeks
levels can indicate an increased risk.
Blood test measuring hCG levels; abnormal
11-13 weeks
levels can indicate an increased risk.
A combination of nuchal translucency, PAPP-
11-13 weeks A, and free beta-hCG results to assess the
risk more accurately.
 Second Trimester Screening Methods

Screening Method Timing Description

Blood test measuring alpha-fetoprotein (AFP),
1. Quadruple or Triple hCG, unconjugated estriol (uE3), and
15-20 weeks
Screen sometimes inhibin A. Abnormal levels can
indicate an increased risk.
Combines first and second-trimester results
for a more accurate risk assessment. It
2. Integrated Screening Both trimesters
involves multiple blood tests and ultrasound
measurements.
Similar to integrated screening but with two
3. Sequential Screening Both trimesters separate assessments in each trimester to
provide early risk information.
 NIPT (Non-Invasive Prenatal
Factor Testing)
Typically between 9-12 weeks
When Performed
of pregnancy
Blood test analyzing cell-free
Method
fetal DNA
Risk to Pregnancy Minimal risk (non-invasive)
Accuracy High (very accurate)
Common chromosomal
Detection of Chromosomal
trisomies and sex
Abnormalities
chromosome abnormalities
Timing of Results Usually within a few days
Diagnostic vs. Screening Screening test
Procedure Duration Quick blood draw
May be recommended for
Need for Genetic Counselor
interpreting results
Cost AUD 400 to AUD 700 or more.
CVS (Chorionic Villus
Sampling)
Usually between 10-13
weeks
Sampling of chorionic villi
Small risk (invasive
procedure)
High (very accurate)
Common chromosomal
trisomies and some genetic
disorders
Within 1-2 weeks
Diagnostic test
Short procedure (usually 10-
20 minutes)
Typically recommended for
pre-test counseling and
result interpretation
Medicare
Amniocentesis
Usually between 15-20
weeks
Sampling of amniotic fluid
Small risk (invasive
procedure)
High (very accurate)
Common chromosomal
trisomies and genetic
disorders
Within 1-2 weeks
Diagnostic test
Short procedure (usually 15-
30 minutes)
Typically recommended for
pre-test counseling and
result interpretation
Medicare
12. Which of the following infections is not routinely done as a part of
antenatal screening ?
A. Hep B
B. Hep C
C. HIV
D. Syphilis
E. CMV
13. A pregnant 24 year old female presents to your GP office after
she found that one of the students in her class has been recently
diagnosed with rubella by his GP; the diagnosis however was not
confirmed by serologic studies. Her last vaccination against rubella
was when she was 12 years. Which one of the following would be the
next best step in management?
A. Confirm the diagnosis of rubella in the sick child with rubella
serology testing
B. Give her a booster dose of MMR vaccine
C. Advise her to terminate the pregnancy
D. No action is required: reassure her
E. Check rubella serology
• Checking rubella serology (blood tests) for the pregnant woman is
important to determine her immunity status. If she is already immune
to rubella based on her serology results, she does not require further
vaccination or specific interventions.
• Giving her a booster dose of MMR vaccine: This is a safe and
effective way to provide immunity if she is not already immune.
However, the MMR vaccine is a live vaccine and should not be
administered during pregnancy. If she is found to be non-immune,
the vaccine should be administered after she gives birth.
14. A 27-year-old woman comes to your clinic at 16 weeks of
gestation for review of her blood tests. She Is cytomegalovirus IgM
positive but IgG negative. She is otherwise asymptomatic. Which of
the following is the MOST appropriate next step in management?

A. Pregnancy termination
B. Antiviral medications during pregnancy
C. Amniocentesis
D. Reassurance
E. Repeat serology in 2 weeks
• Cytomegalovirus (CMV) is a common virus belonging to the herpesvirus family. It can infect people of all ages and is usually asymptomatic in
healthy individuals. However, CMV can cause serious complications in individuals with weakened immune systems and can be particularly
problematic during pregnancy.
• Diagnosis: Diagnosing CMV infection typically involves a combination of clinical evaluation and laboratory testing. Some common diagnostic
methods include:
• Blood Tests: Blood tests can detect the presence of CMV antibodies, which indicate a past or current infection. A rise in antibody
levels over time may suggest an active infection.
• PCR tests can detect CMV DNA in blood, urine, or other bodily fluids, helping confirm an active infection.
• Teratogenicity: It is a known teratogen, meaning it can cause birth defects. The virus can cross the placenta and infect the fetus, leading to
congenital CMV infection. This can result in a range of birth defects, including hearing loss, vision problems, developmental delays, and
intellectual disabilities.
• Prevention: Preventing CMV infection, especially during pregnancy, is crucial. Here are some strategies for prevention:
• Hand Hygiene: Practicing good hand hygiene, such as frequent handwashing with soap and water, can reduce the risk of CMV
transmission, as the virus is often found in bodily fluids like saliva and urine.
• Avoiding Contact with Bodily Fluids: Pregnant women, in particular, should avoid close contact with young children's saliva and urine,
as these are common sources of CMV transmission.
• Safe Sexual Practices: Using condoms or abstaining from sexual contact with a partner who has an active CMV infection can reduce
the risk of sexual transmission.
• Blood Screening: In some cases, blood screening for CMV antibodies may be recommended for women planning to become pregnant
or those at higher risk for CMV infection.
• Education: Raising awareness about CMV and its potential risks, especially during pregnancy, can help individuals take necessary
precautions.
• At present there is no approved vaccine
 Critical Period for Congenital
Infection Effect on Fetus Infection
Can cause brain and eye damage, intellectual disability,
Infection during the first trimester is
Toxoplasmosis and developmental delays. May also lead to stillbirth
most critical.
or miscarriage.
Can result in various congenital abnormalities,
Transmission throughout pregnancy
Syphilis including bone deformities, hearing loss, intellectual
can lead to congenital syphilis.
disability, and stillbirth.
Can lead to congenital varicella syndrome, which may
VZV (Varicella- Infection during the first 20 weeks of
cause skin scarring, limb hypoplasia, eye and brain
Zoster Virus) pregnancy is critical.
abnormalities, and developmental issues.
Infection during the first half of
Parvovirus B19 Can cause fetal anemia, hydrops fetalis, and stillbirth.
pregnancy is most concerning.
CMV May lead to hearing loss, intellectual disability, vision Infection early in pregnancy carries a
(Cytomegalovirus) problems, developmental delays, and microcephaly. higher risk.
Neonatal herpes if transmitted during childbirth, which
HSV (Herpes Risk of transmission is highest during
can cause severe health issues, including brain
Simplex Virus) childbirth.
damage, organ failure, and death.
15. As part of routine antenatal care in Australia, which investigation is
commonly recommended to assess the risk of neural tube defects in
the developing fetus?
A.Alpha-fetoprotein (AFP)
B.Nuchal translucency
C.PAPP-A
D.Beta –HCG
E.Inhibin-A
16. A 35-year-old pregnant woman undergoes a 12-week ultrasound (USS), which
shows markers suggestive of Down syndrome (trisomy 21). The nuchal
translucency measurement is increased, and other findings are indicative of a
higher risk. What is the most appropriate course of action to confirm the
diagnosis
A. Perform an amniocentesis to obtain a sample for karyotyping.
B. Wait until the 20-week anatomy scan to assess further markers.
C. Initiate non-invasive prenatal testing (NIPT) to assess fetal DNA.
D. Order a second-trimester maternal serum screening for Down syndrome.
E. Repeat the 12-week ultrasound in a few weeks to verify findings.
• When markers suggestive of Down syndrome (trisomy 21) are observed during a 12-week
ultrasound, the most appropriate course of action is to initiate non-invasive prenatal testing
(NIPT). NIPT is a blood test that screens for chromosomal abnormalities by analyzing fetal DNA
present in the maternal bloodstream. It can provide a high level of accuracy in detecting
conditions such as Down syndrome.
• NIPT is a low-risk, non-invasive method that can confirm the presence of trisomy 21 without the
need for invasive procedures like amniocentesis or chorionic villus sampling. It is typically
recommended for women with increased risk based on ultrasound findings, maternal age, or
other factors.
• While amniocentesis (Option A) can provide definitive diagnostic information, it's usually
reserved for cases where confirmatory testing is needed after positive NIPT results or for cases
with high risk. Waiting for the 20-week anatomy scan (Option B) or repeating the 12-week
ultrasound (Option E) may delay necessary information, and second-trimester maternal serum
screening (Option D) might not be as accurate as NIPT in this context.
NIPT
17. In Australia, shared care model of care is used for care and
management of pregnant women. Antenatal care Is a major
component of care in General Practice. Which of the following is true
regarding antenatal investigations in pregnancy?

A. Syphilis serology is performed on all pregnant women

B. A glucose tolerance test should be conducted on all pregnant
women in early pregnancy
C. Performing a Pap test in pregnancy is contraindicated
D. Hepatitis E antibody level should be carried out on all women
E. Screening for Down syndrome with chromosomal analysis for all
pregnant women
 Shared antenatal care
• In Australia, shared antenatal care refers to a model of care in which a
pregnant woman receives prenatal care and check-ups from both her
general practitioner (GP) and a hospital or maternity care provider.
This collaborative approach involves the GP and the maternity care
provider working together to provide comprehensive prenatal care
throughout the pregnancy.
• Shared antenatal care offers several benefits, including increased
accessibility to care, shorter waiting times for appointments, and
convenience for women who prefer to maintain a relationship with
their trusted GP throughout their pregnancy. It's important to note
that shared care may not be suitable for all pregnancies, particularly
those with higher-risk factors that require specialized medical
attention.
• Choice of Care: A pregnant woman has the option to choose shared antenatal care if her pregnancy is
considered low-risk and doesn't require specialized medical attention.
• Regular Check-ups: The woman receives prenatal care through a combination of appointments with
her GP and appointments at a hospital or maternity care clinic. The frequency of visits may vary based
on the stage of pregnancy and individual needs.
• Coordination: The GP and maternity care provider communicate and coordinate the woman's care,
sharing relevant medical information and test results to ensure continuity and comprehensive care.
• Check-ups with the GP: During GP visits, routine assessments, screenings, and discussions about the
pregnancy's progress are conducted. The GP can also address general health concerns and provide
advice about nutrition, exercise, and overall well-being.
• Hospital/Maternity Care Provider Appointments: Periodic visits to the hospital or maternity care
provider involve more specialized assessments, such as ultrasounds, fetal monitoring, and discussions
about birth planning.
• Referral to Specialists: If any complications or concerns arise during the pregnancy, the GP or
maternity care provider may refer the woman to a specialist for further evaluation or management.
• Postnatal Care: After childbirth, the woman continues to receive care from her GP and may be
referred to other healthcare providers as needed for postnatal support.
18. A 24-year-old female presented to your clinic for human
papillomavirus vaccination during her second trimester of pregnancy.
What will you do?

A. Postpone vaccination until after delivery

B. Postpone vaccination until after breast feeding
C. Tell her that she is not required to get vaccinated for HPV
D. Give her vaccine now
E. Organize a follow up for human papilloma vaccine during third
trimester
19. A pregnant school teacher, aged 24 years, presents to your GP
office after she found that one of the students in her class has been
recently diagnosed with rubella by his GP; the diagnosis however was
not confirmed by serologic studies. Her last vaccination against
rubella was when she was 12 years. Which one of the following
would be the next best step in management?
A. Confirm the diagnosis of rubella in the sick child with rubella
serology testing
B. Give her a booster dose of MMR vaccine
C. Advise her to terminate the pregnancy
D. No action is required: reassure her
E. Check rubella serology
20. A pregnant woman with Rh-negative blood type is carrying an Rh-
positive fetus. Which of the following scenarios has the least risk for
maternal sensitization to Rh antigens, potentially requiring Rh
immunoglobulin (RhIg) administration?
A.Undergoing chorionic villus sampling (CVS)
B.Threatened abortion with minimal vaginal bleeding
C.Ruptured Ectopic pregnancy
D.Amniocentesis
E.Abdominal trauma with vaginal bleeding
21. A woman who is rhesus negative undergoes amniocentesis at 16
weeks. What dose of anti D immunoglobulin should she receive
immediately after the procedure?
A. 250 IU
B. 500IU
C. 1000IU
D. 1500IU
E. 2000IU
• The dose of Rh(D) immunoglobulin to be administered after amniocentesis
is typically determined by the volume of fetal Rh-positive blood that might
have entered the maternal circulation during the procedure.
• The standard recommendation is to administer 300 micrograms (μg) of
Rh(D) immunoglobulin for every 1 mL of fetal Rh-positive blood that is
estimated to have entered the maternal circulation.
• All Rh(D) negative women (who have not actively formed their own Anti-D)
should be offered a prophylactic dose of 625 IU at approximately 28 weeks
gestation and again at approximately 34 weeks gestation.
• All women who deliver an Rh(D) positive baby should have quantification
of fetomaternal haemorrhage to guide the appropriate dose of anti-D
prophylaxis, and the dose should be given within 72 hours if possible.
• All women who are given Anti-D in response to a potentially sensitizing
event after the first trimester should have the magnitude of potential feto-
maternal haemorrhage assessed and if necessary further Anti-D
administered as appropriate.
 Kleihauer test
• The Kleihauer-Betke (KB) test is a
blood test used during pregnancy
to screen maternal blood for the
presence of fetal red blood cells. It
is mainly used to assess the
severity of a fetomaternal
hemorrhage (FMH)
22. A 32-year-old pregnant woman presents to the emergency
department with vaginal bleeding and abdominal pain at 10 weeks of
gestation. She reports passing some tissue-like material. On
examination, her vital signs are stable, and she appears distressed.
Ultrasound reveals an intrauterine gestational sac with no fetal
heartbeat. What is the most likely diagnosis?
A. Missed miscarriage
B. Threatened abortion
C. Incomplete abortion
D. Inevitable abortion
E. Complete abortion
23. A21-year-old woman, G1PO comes to your clinic at vaginal
bleeding for the past 12 hours, week 12 of pregnancy. She is
complaining of mild with bouts of mild cramping lower abdominal
pain. On vaginal examination, the cervical os is closed and there is
mild discharge containing blood clots. Ultrasonography confirms the
presence of a live fetus with normal heart rate. Which one of the
following is the most likely diagnosis?

A. Threatened abortion
B. Inevitable abortion
C. Complete abortion
D. Incomplete abortio
E. Missed abortion
Missed miscarriage refers to the retention of a nonviable pregnancy within the uterus. It is characterized by the
absence of fetal cardiac activity on ultrasound, but the gestational sac is still present. Patients may experience
symptoms such as vaginal bleeding and abdominal pain. Treatment options include expectant management,
medical management with medications to induce the passage of tissue, or surgical intervention (dilation and
curettage).
Threatened abortion: A threatened abortion occurs when a pregnant woman presents with vaginal bleeding
and/or abdominal pain, but the cervix is closed, and the pregnancy is still viable. The bleeding and pain in
threatened abortion are not severe and may subside without progressing to a miscarriage. The fetus and
gestational sac are typically visible on ultrasound with a normal fetal heartbeat. Bed rest and close monitoring are
often recommended, as the pregnancy can still progress normally.
Incomplete abortion: An incomplete abortion occurs when some of the products of conception (tissue from the
uterus) are passed, but some remain inside. It can be associated with heavy bleeding and abdominal pain. On
ultrasound, there might be evidence of retained products of conception. This condition often requires medical or
surgical intervention to remove the remaining tissue and prevent complications such as infection.
Inevitable abortion refers to a situation in early pregnancy where the cervix is dilated, accompanied by heavy
vaginal bleeding and strong uterine cramping. This indicates that a miscarriage is likely to occur due to the
structural changes in the cervix. The term "inevitable" suggests that the pregnancy may not be salvageable at this
point. Medical or surgical intervention is often needed to manage the bleeding and complete the miscarriage
process.
Complete abortion: A complete abortion occurs when all products of conception are expelled from the uterus. It
presents with heavy bleeding, abdominal cramps, and passage of tissue. Ultrasound may show an empty uterus.
24. A 35 yearold woman developed deep vein thrombosis at 20
weeks of her pregnancy. Which of the following statement is true
regarding this condition during pregnancy?
A. LMWH is the treatment of choice
B. Deep vein thrombosis is rare condition in pregnancy
C. DVT of right leg is more common than left leg
D. Increased level of protein C and S
E. Decreased level of factor V and VII
• Deep vein thrombosis (DVT) during pregnancy is a well-recognized complication
that is associated with an increased risk due to changes in the coagulation system
and blood flow dynamics.
• Low-molecular-weight heparin (LMWH) is generally considered the treatment of
choice for DVT during pregnancy. LMWH has a favorable safety profile and is
preferred over other anticoagulants like warfarin, which can cross the placenta
and potentially harm the fetus.
• Deep vein thrombosis is not a rare condition during pregnancy. Pregnancy is a
prothrombotic state, meaning it increases the risk of blood clot formation due to
changes in blood clotting factors.
• The occurrence of DVT in the right leg compared to the left leg doesn't show a
consistent trend. It can affect either leg, and the risk might be influenced by
various factors such as genetics, previous medical history, and lifestyle.
• Pregnancy can lead to changes in the coagulation system, including increased
levels of certain coagulation factors like factor VII and decreased levels of natural
anticoagulants like protein S and protein C.
 Risk factors for venous thromboembolism
Strong clinical risk Moderate clinical risk Weak clinical risk
factors (odds ratio factors (odds ratio 2-9 factors (odds ratio <2)
>10)
• Fracture of the • Arthroscopic knee • Immobilisation
hip or lower limb surgery (eg bed rest >3
• Hip or knee • Hormonal therapy (eg. days, air travel
replacement oral contraceptives, >8hours)
surgery hormone replacement • Pregnancy-
• Major general therapy) antepartum
surgery • Pregnancy -postpartum • Obesity
• Major trauma • Paralytic stroke • Advancing age
• Spinal cord • Previous venous
injury thromboembolism
Conditions increasing D-Dimers False negative forD-Dimers
• Surgery and/or trauma • Small thrombus (eg.
• s Haemorrhage and extensive bruises isolated distal deep vein
• Ischaemic heart disease thrombosis)
• stroke • Time lag between
• Infections symptom onset and
• Malignancy laboratory testing
• PVD • Concomitant
• Pregnancy anticoagulation (with
• Advanced age heparin or warfarin)
• Extensive Burns
• Compression ultrasonography • Sensitivity and specificity exceed 95% and
98% respectively for symptomatic proximal DVT • Sensitivity of 11–100%
and specificity of 90–100% for symptomatic distal DVT • Noninvasive: can
be performed relatively rapidly and a portable technique allowing for the
bedside assessment of critically ill patients • Does not visualise the pelvic
veins well and cannot be used in obese patients or in patients whose limbs
are in plaster casts
• CT• Sensitivity and specificity of 96% and 95% respectively in a meta-
analysis of studies predominantly examining its use for the diagnosis of
proximal DVT • Can visualise the pelvic veins, define the upper limit of
thrombus extension into the iliac veins and inferior vena cava
• Magnetic resonance imaging • Sensitivity and specificity for the diagnosis
of symptomatic DVT is 96% and 93% respectively • Sensitivity for distal DVT
is much lower (about 62%) • Can be performed without the use of contrast
medium • Can visualise the pelvic veins, define the upper limit of thrombus
extension into the iliac veins and inferior vena cava
• Venography (phlebography) • Reference standard technique • Reliably
detects isolated distal DVT and thrombosis in the iliac veins and inferior
vena cava
25. A 33-year-old lady with a past history of two second- trimester
pregnancy losses, presented at 16 weeks of gestation with a
backache, pre-menstrual-like cramping and increased vaginal
discharge for the last one week. On pelvic examination, the cervix is
dilated 4cm and effaced 80%. What is the most likely diagnosis?
A. Placenta previa
B. Missed miscarriage
C. Cervical insufficiency
D. Placenta percreta
E. Placental abruption
• Cervical insufficiency, also known as incompetent cervix, is a
condition in which the cervix begins to dilate and efface
prematurely in the absence of contractions, often leading to
preterm labor and miscarriage.
• It is a potential cause of second-trimester pregnancy losses.
• The patient's history of two second-trimester pregnancy
losses and her current presentation of backache, cramping,
increased vaginal discharge, and cervical dilation are
indicative of cervical insufficiency
26. Which of the following is NOT a recognized risk factor for
pre-eclampsia?

A. First pregnancy
B. Chronic hypertension
C. Multiple gestation
D. Obesity
E. Blood type O-negative
28. Which one of the following women is most likely to develop pre-
eclampsia during pregnancy?
A. A 40-year-old woman, gravida 6, para 5, with no previous history of
any pregnancy- related complications.
B. A 16-year-old primigravida woman.
C. A 35-year-old woman with primary hypertension.
D. A 25-year-old woman who is gravida 4. para 3.
E. A 25-year-old primigarvida with family history of pre-eclampsia in
her mother and sister
Risk factors for pre-eclampsia
• chronic hypertension
• pre-eclampsia in a previous pregnancy
• other medical problems, such as kidney disease, diabetes or an
autoimmune disease
• first pregnancy
• aged 40 years or more
• twins or triplets
• family history of pre-eclampsia
• BMI 35 or more
• Have had a gap of 10 years or more since your last pregnancy
• Conceived with in vitro fertilisation (IVF)
Risk Factor Increased Risk
First pregnancy 2-4 times higher risk
Previous pre-eclampsia 4-7 times higher risk
Family history 2-5 times higher risk
Multiple gestation 2-3 times higher risk
Maternal age
- Younger than 18 years 2 times higher risk
- Older than 35 years 2-3 times higher risk
Obesity 2-3 times higher risk
Chronic hypertension 6-7 times higher risk
Diabetes (type 1 or 2) 2-4 times higher risk
Renal disease 5-10 times higher risk
Varies depending on the specific
Autoimmune disorders
condition
Nulliparity (never having given birth) 2-3 times higher risk

Poor maternal nutrition Increased risk (exact multiplier varies)

History of thrombophilia Increased risk (exact multiplier varies)

History of pre-eclampsia in a sibling Increased risk (exact multiplier varies)

Pre-eclampsia= Hypertension+ 1 or more of
1. Proteinuria (spot urine protein/creatinine >30 mg/ mmol [0.3
mg/mg+ or >300 mg/day or at least 1 g/L *‘2 + ’+ on dipstick testing)
2. Other maternal organ dysfunction:
• renal insufficiency (creatinine >90 umol/L; 1.02 mg/ dL)
• liver involvement (elevated transaminases – at least twice upper limit of normal ± right
upper quadrant or epigastric abdominal pain)
• neurological complications (examples include eclampsia, altered mental
status, blindness, stroke, or more commonly hyperreflexia when accompanied
by clonus, severe headaches when accompanied by hyperreflexia, persistent
visual scotomata)
• haematological complications (thrombocytopenia – platelet count below
150,000/dL, DIC, haemolysis)
3. Uteroplacental dysfunction :foetal growth restriction
Diagnosing
white coat
hypertension
in pregnancy
29. Which of the following criteria are commonly considered when
determining the appropriate mode of delivery in cases of pre-
eclampsia?

A. Maternal blood pressure and gestational age

B. Fetal weight and maternal age
C. Maternal ethnicity and fetal heart rate
D. Maternal weight gain and fetal gender
E. Maternal education level and fetal position
30. 30-year-old woman is seeing you In your clinic in a small rural
town . She is 34 weeks pregnant and all her past 3 pregnancy has
been uncomplicated. Today her blood pressure Is 140/95 mmHg
which is higher than her usual blood pressure 110/70 mmHg.
Urinalysis shows protein 2+. She feels well. What is the most
appropriate next step?
A. Recheck blood pressure tomorrow and then decide what to do next
B. Send her to the local hospital for urgent review
C. Arrange 24-hour ambulatory blood pressure monitoring
D. Labetalol 100mg twice a day
E. Refer for obstetric ultrasound and liver function tests
31. Which of the following is not an indication for delivery in a
pregnant mother with pre eclampsia

A. At 37th week of gestation with no complication

B. At 33rd weeks with uncontrollable blood pressure
C. At 34th week with a Reversed end-diastolic flow in the umbilical
artery Doppler
D. At 36th week with elevated uric acid levels
E. At 36th week with a CTG abnormality
Delivery in pre-eclampsia-ISSHP
a. Women with pre-eclampsia at P37 weeks gestation should be delivered
b. Women with pre-eclampsia between 34 and 37 weeks can be managed
with an expectant conservative approach, as below.
c. women with pre-eclampsia at <34 weeks gestation should be managed
with a conservative (expectant) approach at a centre with Maternal and
Foetal Medicine expertise, delivery being necessary when one or more of the
following indications emerge:
I. Inability to control maternal blood pressure despite antihypertensives.
II. Maternal pulse oximetry <90% or pulmonary oedema unresponsive to initial
diuretics
III. Progressive deterioration in liver function, GFR, haemolysis or platelet count
IV. ongoing neurological symptoms, as described above, or eclampsia
V. Placental abruption
VI. Reversed end-diastolic flow in the umbilical artery Doppler velocimetry, a non
reassuring CTG, or stillbirth.
Of note, neither the serum uric acid nor the level of proteinuria should be
used as an indication for delivery.
32. A 23-year-old G1 female from a remote location in Outback presented to the local
hospital at 32 weeks gestation following 2 episodes of tonic-clonic seizures. On immediate
assessment, she was GCS 15, post-ictal and hypertensive (170/118); vaginal examination
and foetal status was reassuring. Her urine dipstick was +++ for protein and no
contractions were present. The patient was admitted to hospital, commenced on
Magnesium Sulphate, and a Hydralazine infusion, and corticosteroids were administered
for promotion of foetal lung maturation. Arrangements were made to transfer the patient
to the nearest tertiary centre by air within next 24 hour. Despite rapid initiation of medical
treatment the blood pressure remained elevated, and continuous foetal monitoring
detected recurrent late decelerations and decreased foetal variability on CTG. What is the
next best option ?
A. Faster transfer to tertiary care hospital
B. Urgent LSCS
C. Increase the dose of Hydralazine
D. add methyldopa
E. Midazolam infusion
• Eclampsia is characterized by seizures and severe hypertension. When fetal
distress is evident, as indicated by recurrent late decelerations and decreased
fetal variability on continuous fetal monitoring, the best course of action is to
expedite delivery. An urgent cesarean section is often necessary to protect both
the mother and the baby. It allows for rapid delivery and reduces the risks
associated with prolonged exposure to maternal hypertension and fetal distress.
• While transferring to a tertiary care hospital (Option A) is important for
specialized care, it may not be feasible to wait for an extended period when fetal
distress is ongoing. Increasing the dose of Hydralazine (Option C) or adding
methyldopa (Option D) may help manage maternal hypertension but would not
address the immediate fetal distress. Midazolam (Option E) is not the appropriate
choice in this situation; the priority is to manage the eclampsia and fetal distress
33. What is the best way to measure proteinuria in
pregnancy?
A. Albumin-to-Creatinine Ratio
B.24-hour urine collection for proteinuria
C. Spot Urine Protein-to-Creatinine Ratio
D. Urine Dipstick test
E. urinalysis
• In pregnancy, especially when assessing proteinuria accurately, the gold standard
method is the 24-hour urine collection.
• This method involves collecting all urine over a 24-hour period, excluding the
first morning void, and measuring the total amount of protein excreted in the
collected urine.
• The 24-hour urine collection provides a comprehensive assessment of
proteinuria over an extended time period and is considered highly accurate for
quantifying protein excretion.
• A. Albumin-to-Creatinine Ratio (ACR): This is a useful method for assessing
kidney function and detecting microalbuminuria, particularly in conditions like
diabetes. It may not be the primary choice for measuring proteinuria in all
pregnancy cases.
• C. Spot Urine Protein-to-Creatinine Ratio: This method is a quicker alternative to
the 24-hour collection and is often used for screening purposes. It provides an
estimate of protein excretion over a shorter time frame and can be helpful in
clinical practice.
34. 32-year-old woman with a history of type 2 diabetes
mellitus presented for your opinion as she is planning to
conceive next few months. Her fasting blood sugar is
10.5mmol/L, and HbA1c is 9%.What will be your advice?
A. Achieve HbA1c value less than 7% before she gets pregnant
B. Start her on insulin and check her blood sugar in 24 hours
C. Repeat HbA1c in 2 weeks
D. She can be pregnant anytime she likes
E. Increase her medication dose
• Planning for pregnancy in a woman with diabetes requires careful management
to ensure optimal outcomes for both the mother and the developing fetus.
• High blood sugar levels, as indicated by the elevated fasting blood sugar and
HbA1c levels, can increase the risk of pregnancy complications such as birth
defects, preterm birth, and macrosomia (large birth weight).
• It is recommended that women with diabetes aim to achieve an HbA1c value of
less than 7% before conception. This helps reduce the risk of complications and
promotes a healthier pregnancy.
• Starting or adjusting diabetes medications may be necessary to achieve better
blood sugar control before pregnancy. Insulin is often the preferred treatment
during pregnancy due to its safety profile.
35. Sarah is a 32-year old female at the 28th week of her third pregnancy.
She visited you to have her "sugar checked" She has no symptoms
suggestive of diabetes mellitus otherwise. However, she has a family
history of type 2 diabetes mellitus and both her previous babies were of
good size. A 75g oral glucose tolerance test is performed. The result is as
follows:
• Fasting - Venous plasma: 4.9 mmol/L
• 1-hour-Venous plasma: 9.5 mmol/L
• 2-hour-Venous plasma: 8.5 mmol/L
Which of the following statement is correct regarding this situation?
A. She has gestational diabetes mellitus
B. She has glucose intolerance
C. She has normal glucose tolerance
D. The test should be repeated because she obviously has not fasted as
instructed
E. Premature rupture of membranes has no association with gestational
diabetes mellitus
36. Sarah is a 30-year-old woman who expect to give birth to her first
child. During her pregnancy, she was diagnosed with gestational
diabetes mellitus (GDM) at 28 weeks. It was initially managed
through dietary control and monitoring of blood sugar levels.
However, she lost her follow up during last six weeks due to change
of residence. What is the most likely neonatal complication
associated with Sarah's gestational diabetes mellitus (GDM) based on
the provided case history?
A) Neonatal Jaundice
B) Neonatal Hypoglycemia
C) Cleft lip
D) Respiratory Distress Syndrome
E) Neural tube defect
• When a pregnant woman with GDM does not receive appropriate
monitoring and management, there is an increased risk that her baby
will experience neonatal hypoglycemia after birth. This is because the
baby's insulin production may have been stimulated by the high
glucose levels in the mother's bloodstream, and when born, the
baby's insulin production can lead to a rapid drop in blood sugar
levels.
• Neonatal jaundice, cleft lip, respiratory distress syndrome, and neural
tube defects are also important considerations during pregnancy and
childbirth, but in this case, the scenario points toward the increased
risk of neonatal hypoglycemia due to uncontrolled GDM.
37.Lexi, a 25-year-old pregnant woman in her second trimester,
presents with symptoms of a urinary tract infection (UTI). You, as her
GP, need to prescribe an antibiotic pending the urine culture report.
Which of the following antibiotics is generally considered safe and
recommended as a first-line treatment for UTIs in pregnant women?
A) Tetracycline
B) Ciprofloxacin
C) Trimethoprim-sulfamethoxazole (TMP-SMX)
D) Nitrofurantoin
E) Azithromycin
38. A 34-year-old woman attends for her booking in her third
pregnancy. She had a caesarean section in her first pregnancy 4 years
ago and has had a successful vaginal birth after caesarean section
(VBAC) 2 years ago. She has a BMI OF 26. What is the best predictor for
a successful VBAC?
A. BMI of less than 30
B. Less than 35 years old
C. Previous vaginal birth
D. Short inter-pregnancy interval
E. Spontaneous onset of labour
39. A 28-year-old lady is found to have group B Streptococcus positive
on vaginal swab at 32 weeks of gestation. What is the most
appropriate treatment?
A. Repeat swab in a week and then treat if positive
B. Penicillin
C. Check full blood count
D. Give trimethoprim for 3 days
E. No treatment needed before labour
• Prevalence 20%, Complications only in 0.5%
• Maternal Infection: GBS can cause urinary tract infections, uterine infections
(chorioamnionitis), and other maternal infections during pregnancy. These infections can
lead to various complications, including preterm labor, premature rupture of membranes,
and maternal sepsis.
• Vertical Transmission: The primary concern with GBS during pregnancy is the potential for
vertical transmission, where the bacteria can be passed from the mother to the newborn
during childbirth.
• Neonatal Infections: GBS infections in newborns can lead to serious illnesses, including
sepsis , pneumonia, and meningitis
• Screening and Prevention: To reduce the risk of GBS transmission to newborns, many
countries recommend routine screening of pregnant women for GBS colonization at around
35-37 weeks of gestation. If a woman tests positive for GBS or is at increased risk, she may
be offered intravenous antibiotics during labor to prevent transmission to the baby.
• Some hospitals will test all pregnant women for GBS with a vaginal swab at around 36
weeks. Other hospitals only give antibiotics to women with specific risk factors, such as
preterm labour or prolonged rupture of membranes.
40. Georgia is a 29-year-old hospital nurse who is nine weeks
pregnant. She has been significantly exposed to shingles at work by
regular attending to facial sores of an elderly patient with herpes
zoster ophthalmicus. She has no history of chickenpox, What would
you advise her?
A. Reassure her that no further action required as shingles is not
contagious
B. She needs close monitoring of signs of shingles
C. Give Varicella Zoster Immunoglobulins as soon as possible
D. She needs vaccination against Varicella
E. If she had chicken pox immunization in the past, she needs to have
her Varicella-Zoster IgG antibodies checked to assure immunity