Professional Documents
Culture Documents
Correct
The correct answer is the Mann Whitney U test. See Campbell MJ,
Machin D, Walters SJ. Medical statistics: a textbook for the health
sciences (medical statistics). Wiley-Blackwell. 2007.
A 42-year-old primigravid woman presents in spontaneous labour at 37
weeks of gestation. She develops central crushing chest pain which
radiates to her left jaw.
Which of the following cardiac biomarkers is most reliable for diagnosing
acute myocardial infarction during labour and delivery?
Creatinine kinase
Isoenzyme MB
LDH (lactate dehydrogenase)
Myoglobin
Troponin I
Correct
The correct asnwer is Troponin I. Troponin I is unaffected by labour,
anaesthesia or delivery. SeeWuntakal R, Shetty N, Ioannou E, Sharma S,
Kurian J. Myocardial infarction and pregnancy. The Obstetrician &
Gynaecologist 2013;15:24755.
A 25-year-old primigravida woman is admitted to the labour ward with
regular contractions and draining clear liquor. She is a known carrier for
Streptococcus B in this pregnancy. Shortly after being given a loading
dose of benzylpenicillin, she becomes wheezy, develops a rash and has
difficulty breathing.
What is the most appropriate initial dose of intramuscular adrenaline?
0.01 mg (0.1 ml of 1:10000)
0.05 mg (0.5 ml of 1:10000)
0.1 mg (0.1 ml of 1:1000)
0.5 mg (0.5 ml of 1:1000)
10 mg (10 ml of 1:1000)
Correct
The correct answer is 0.5 mg (0.5 ml of 1:1000). The correct dose of
intramuscular (im) adrenaline in anaphylactic shock is 0.5mg. Doses of
0.01 mg, 0.05mg and 0.1 mg are too small for therapeutic effect in
circulatory collapse by im route and would be more appropriate doses for
iv route. 10mg is too large for an initial dose but if there is a suboptimal
4
age baby. Note that women with three or more minor risk factors for fetal
growth restriction should be referred for uterine artery doppler at 2024
weeks of gestation. See Royal College of Obstetricians and
Gynaecologists. The investigation and management of the small-forgestational-age fetus. Green-top Guideline 31. London: RCOG. 2013.
A 36-year-old woman attends the antenatal clinic at 20 weeks of
gestation. She has had three previous caesarean sections and has a
normal placental site. She consented for another caesarean section.
What is the most likely surgical complication?
Bladder injury
Blood transfusion
Bowel injury
Fetal laceration
Hysterectomy
Correct
The correct answer is blood transfusion. Elective repeat caesarean
section is associated with increasing risks that rise with each successive
pregnancy. Blood transfusion rises from 7.9% with a third caesarean
section to 14.1% with the fifth caesarean. See Royal College of
Obstetricians and Gynaecologists. Birth after previous caesarean birth.
Green-top Guideline 45. London: RCOG; 2007.
A 35-year-old woman has recently undergone gastric bypass surgery. She
is planning a pregnancy.
How long should she be advised to delay conception for?
1 year
2 years
3 years
4 years
5 years
Correct
The correct answer is 1 year. The majority of bariatric surgery is carried
out on women of childbearing years. Current advice is to delay conception
for a year. However, data to support this recommendation is lacking, with
many studies showing no difference in outcomes in those women
conceiving earlier than 12 months and those conceiving later. See Khan R
, Dawlatly B, Chappatte O. Pregnancy outcome following bariatric
surgery. The Obstetrician & Gynaecologist 2013;15:3743.
A 29-year-old primigravida presents with chest pain and is diagnosed with
myocardial infarction. Her BMI is 29 and she does not have any significant
medical or family history.
What is the most likely cause of acute myocardial infarction in this case?
6
Vitamin K
Correct
The correct answer is ursodeoxycholic acid. Pruritis in pregnancy is
common, affecting nearly a quarter of pregnant women. Obstetric
cholestasis is diagnosed when abnormal liver function tests are found in
association with pruritis. Normal pregnancy values should be used with an
upper limit of normal 20% below nonpregnant levels for transaminases, glutamyl transferase and bilirubin. Alkaline phosphatase is generally
raised in pregnancy due to placental production.
Topical emollients may provide temporary relief of pruritis. S-adenosyl
methionine is not recommended and dexamethasone should only be used
as part of a trial. Vitamin K should be prescribed if the prothrombin time is
prolonged, but is not an effective treatment. See Royal College of
Obstetricians and Gynaecologists. Obstetric cholestasis. Green-top
Guideline 43.London: RCOG; 2011.
A pregnant woman is identified as being susceptible to rubella from her
first trimester booking blood results.
When discussing this result at the next antenatal clinic appointment, what
is the most appropriate advice that she should be given?
A single dose of MMR (mumps measles rubella vaccine) should be
offered at the six-week postnatal check
A single dose of MMR should be offered immediately postnatally
A single dose of rubella immunoglobulin should be offered as soon as
possible
A single dose of rubella vaccine should be offered as soon as possible
A single dose of MMR should be offered immediately postnatally with
a second dose at the six-week postnatal check
Correct
The correct answer is a single dose of MMR should be offered
immediately postnatally with a second dose at the six-week postnatal
check. The clinical diagnosis of rubella is unreliable and since the risk to
the fetus is in the first 16 weeks of pregnancy it is important that the
woman is immunised before she can become pregnant again. Between
2005 and 2009 there were six cases of congenital rubella, five of whom
were born to mothers who were born outside the UK. See theNHS
Screening Programme website: Infectious diseases in pregnancy
(accessed 02/07/2015) and the HPA Guidance on viral rash in pregnancy
(accessed 19/11/2014).
A 30-year-old woman books in the antenatal clinic at 12 weeks of
gestation with a BMI of 40. This is her first baby and she is normally fit and
well with no family history of note.
With regard to her BMI, which complication of pregnancy is the highest
risk compared to women with a normal BMI?
8
Emergency caesarean
Gestational diabetes
Postpartum haemorrhage
Stillbirth
Venous thromboembolism
Correct
The correct answer is venous thromboembolism. The risk of diabetes is
about three times higher. The risk of hypertensive disease is two-to-three
times higher. Caesarean section, stillbirth and postpartum haemorrhage
are about twice as likely in women with a high BMI. Venous
thromboembolism is, however, nine times higher in this group. See
the CMACE/RCOG Joint Guideline. Management of women with obesity
in pregnancy. CMACE. 2010.
A 27-year-old primigravida presents at 36 weeks of gestation in labour.
She reports watery vaginal discharge for a while. On examination her
temperature, pulse and blood pressure are normal. She is contracting
moderately and clear liquor can be seen draining. The fetal heart rate is
136 bpm. On vaginal examination the cervix is 3 cm dilated. Membranes
are absent.
What is the most appropriate management to reduce the risk of early
onset neonatal infection?
Intrapartum antibiotic prophylaxis if rupture of membranes occurred 18
hours before onset of labour
Intrapartum antibiotic prophylaxis if rupture of membranes occurred 24
hours before onset of labour
Intrapartum antibiotics if the mother develops signs of infection
Neonatal antibiotic prophylaxis
Prescribe intrapartum antibiotic prophylaxis with any duration of
prelabour rupture of membranes
Correct
The correct answer is prescribe intrapartum antibiotic prophylaxis with any
duration of prelabour rupture of membranes. In preterm labour, antibiotics
should be considered if membranes rupture at any time prior to the onset
of labour. If the woman is at term, antibiotics should only be given if the
woman has had a positive culture for GBS in this pregnancy or has clinical
signs of infection. SeeNational Institute for Health and Clinical
Excellence. Antibiotics for early onset neonatal infection: antibiotics for the
prevention and treatment of early-onset neonatal infection. London: NICE;
2012.
A 28-year-old woman attends for prepregnancy counselling. Her maternal
grandfather and her mother's brother have haemophilia A. Her husband is
healthy but she has been screened and is a carrier.
9
What is the risk that her future son would inherit this disease?
0%
25%
50%
75%
100%
Correct
The correct answer is 50%. Haemophilia A is an X-linked recessive
disorder so 50% of her sons will be affected and 50% of her daughters will
be carriers.
Gestational diabetes is a common complication of pregnancy.
What hormonal factor is predominantly responsible?
Cortisol
Estrogen
Human chorionic gonadotrophin
Human placental lactogen
Progesterone
Correct
The corerct answer is human placental lactogen. See Nelson-Piercy C.
Handbook of obstetric medicine. Fourth edition. CRC Press. 2010.
A 25-year-old woman is found to have a platelet count of 110 x 10*9/l
when tested routinely at 28 weeks of gestation. Her platelet count at 12
weeks of gestation was 352 x 10*9/l. She has no history of illness.
What is the most likely diagnosis from the list below?
Gestational thrombocytopenia
HIV
Immune thrombocytopenia
Thrombocytosis
Vitamin B12 deficiency
Correct
The correct answer is gestational thrombocytopenia. Gestational
thrombocytopaenia occurs in up to 1 in 20 pregnancies. If the count is
greater than 100 x 109/l no further investigations are required but other
disorders should be considered. If the count falls below this, further
investigations are indicated including blood film, coagulation screen, renal
and liver function tests, antiphospholipid antibodies and anti-DNA
antibodies. See Pavord S, Fairlie F. Obstetric haematology manual.
In:Dewhursts textbook of obstetrics and gynaecology, 7th edition. WileyBlackwell. 2007.
10
A woman presents for booking in the first trimester, she is taking lithium
for her mental health.
How often should her serum lithium levels be checked?
Every 1 week until 36 weeks of gestation
Every 2 weeks until 36 weeks of gestation
Every 4 weeks until 36 weeks of gestation
Every 8 weeks until 36 weeks of gestation
Once in each trimester
Correct
The correct answer is every 4 weeks until 36 weeks of gestation. Lithium
is an important drug in maintaining mental health but taking it in
pregnancy is not without risks as the incidence of fetal heart defects are
increased. If it is not for the woman to stop taking the drug prior to
conception, lithium levels should be monitored every 4 weeks until 36
weeks of gestation, and then weekly until delivery. Lithium levels should
be checked again within 24 hours of delivery and the dose should be
adjusted to maintain a level in the lower part of the therapeutic range.
See National Institute for Health and Clinical Excellence. Antenatal and
postnatal mental health. CG45. London: NICE; 2007.
A 34-year-old primigravida presents to the maternity assessment unit with
a second episode of decreased fetal movements at 34+4 weeks of
gestation. She is known to be low risk and has had an otherwise
uneventful pregnancy.
What is the most appropriate management option?
Advise formal kick counting and review in two days
Arrange a biophysical profile and, if normal, reassure
Offer two doses of Betamethasone 12 hours apart and deliver within
48 hours
Perform a CTG and arrange a scan
Perform a CTG and, if normal, reassure
Correct
The correct answer is to perform a CTG and arrange a scan. Counselling
of women in the antenatal period about the significance of fetal
movements and relationship of this to still births is increasingly being
offered in UK. Delivery would not be warranted unless further testing
reveals an abnormality, e.g. an abnormal Doppler scan or a pathological
CTG. There is no evidence that any formal definition of reduced fetal
movements is of greater value than subjective maternal perception in the
detection of fetal compromise. Biophysical profiling has not shown to be of
benefit. See Unterscheider J, Horgan R, O'Donoghue K, Greene R.
Reduced fetal movements. The Obstetrician &
11
Obturator nerve
Perianeal nerve
Correct
The correct answer is the common peroneal nerve. The common peroneal
nerve is prone to compression at the fibular head during positioning in
stirrups. See Kuponiyi O, Alleemudder DI, Latunde-Dada A, Eedarapalli P.
Nerve injuries associated with gynaecological surgery. The Obstetrician &
Gynaecologist 2014;16:2936.
A 25-year-old woman with sickle cell disease is considering having a child
with her partner who has sickle cell trait.
What is the probability that the child will have sickle cell disease?
25%
33%
50%
75%
100%
Correct
The correct answer is 50%. Following screening, this couple is identified
as 'at risk'. They need counselling and advice about their reproductive
options, including the methods and risks of prenatal screening and
termination of pregnancy. See Royal College of Obstetricians and
Gynaecologists. Management of sickle cell disease in pregnancy. Greentop Guideline 61. London: RCOG; 2011.
A 35-year-old woman presents at 16 weeks in her first pregnancy with a
severe throbbing headache lasting for the last 5 days, which is aggravated
with eye movements and associated with occasional blurred vision,
nausea and photophobia. The only abnormalities on examination are
bilateral papilloedema and squint of the left eye, which turns inwards. A
computer tomography scan shows no abnormality.
What is the most likely diagnosis?
Cerebral venous thrombosis
Idiopathic intracranial hypertension (IIH)
Migraine
Severe pre-eclampsia
Trigeminal neuralgia
Correct
The correct answer is idiopathic intracranial hypertension (IHH). IHH is a
diagnosis of exclusion in a pregnant woman with a headache. It is more
wommen in women, with a female:male ratio of 8:1. IHH is also more
comment in obese women, with an incidence of 19/100 000 compared
15
with <1/100 000 in non-obese women. Rising obesity rates will therefore
lead to an increasing incidence of IHH. See Thirumalaikumar L,
Ramalingam K, Heafield T. Idiopathic intracranial hypertension in
pregnancy. The Obstetrician & Gynaecologist 2014;16:9397.
An 18-year-old woman is pregnant with a male fetus. She has cystic
fibrosis and her partner is a carrier. She is worried that the baby will inherit
cystic fibrosis.
What is the likelihood that the baby will be affected?
0%
25%
50%
75%
100%
Correct
The correct answer is 50%. The woman is heterozygous so will inevitably
pass on the CF gene and there is a 50% chance of her baby acquiring the
gene from her partner. The child will be either a carrier or affected.
A 28-year-old woman attends for pre-pregnancy counselling. Her maternal
grandfather and her mother's brother have haemophilia A. Her husband is
healthy and there is no history of haemophilia in the family.
What is the risk that any daughter of hers will have haemophilia A?
0%
25%
50%
75%
Correct
The correct answer is 0%. The patients mother must be a carrier. She will
have inherited the gene from her father. However the patients
grandmother must also be a carrier since the patients uncle has the
disease but her mother did not inherit the gene since she is well. The
patient has a 50% chance of being a carrier, but with a healthy husband it
is very unlikely any daughter of hers will have the disease since she will
only inherit an affected gene from her mother unless her husbands sperm
has a new mutation.
A primigravida presents at the antenatal clinic with a monochorionic
diamniotic (MCDA) twin pregnancy at 24 weeks of gestation. Ultrasound
shows that twin 1 has oligohydramnios with absent end-diastolic flow in
the umbilical artery (UA) doppler. Twin 2 has polyhydramnios with positive
end-diastolic flow in the UA doppler.
What would be the best management for this finding?
Preparation for immediate delivery
16
made 3 cm below the level of the anterior superior iliac spines. The
subcutaneous tissue and rectus sheath are opened in the midline and
extended laterally with blunt finger dissection. Blunt dissection is used to
separate the rectus muscles and enter the peritoneum.
Which transverse abdominal incision is described above?
Cherney
Joel-Cohen
Kstner
Maylard
Pfannenstiel
Correct
The correct answer is Joel-Cohen. Pfannenstiel and Kustner are curved
incisions using sharp dissection. Cherney and Maylard are muscle cutting
incisions. Raghavan R, Arya P, Arya P, China S. Abdominal incisions and
sutures in obstetrics and gynaecology. The Obstetrician &
Gynaecologist 2014;16:1318.
You have been asked to review a postnatal woman with known type 1
insulin dependent diabetes mellitus who was successfully delivered
overnight. She is now eating and drinking normally and the postdelivery
capillary blood glucose readings are all between 4 and 7 mmol/l. The plan
is to stop the intravenous insulin/dextrose sliding scale and recommence
subcutaneous insulin. She wishes to breastfeed her baby.
What is the most appropriate advice for the woman regarding
recommencing her subcutaneous insulin?
Reduce the dose of insulin she was taking prior to induction by 25%
Continue on the dose of insulin she was taking prior to her induction
Increase her prepregnancy dose by 25%
Reduce her prepregnancy insulin dose by 25%
Revert to her prepregnancy dose of insulin
Correct
The correct answer is to reduce her prepregnancy insulin dose by 25%.
Once women with type 1 diabetes are eating normally, subcutaneous
insulin should be recommenced at a 25% lower dose of her prepregnancy
dose if she intends to breastfeed. Breastfeeding is associated with
increased energy expenditure. Nelson-Piercy C. Handbook of obstetric
medicine. Fourth edition. CRC Press. 2010.
At the evening handover of a busy labour ward, you are informed that a
cord prolapse has been diagnosed after amniotomy with the presenting
part at 3 station. On CTG, the baseline is 115 bpm with 10 bpm
variability and one variable deceleration lasting less than 30 seconds over
the last 10 minutes. The obstetric emergency theatre is currently being
used for a manual removal of the placenta.
18
Depo Provera
Combined oral contraceptive pill
Progestogen only pill
Levonorgestrel-releasing intrauterine system
Correct
The correct answer is the combined oral contraceptive pill. Estrogencontaining contraceptives should be avoided in women who have had
obstetric cholestasis. See Royal College of Obstetricians and
Gynaecologists. Obstetric cholestasis. Green-top Guideline 43. London:
RCOG; 2011.
You see a patient who is 35 weeks pregnant in your day assessment unit.
She presents with itching. Your differential diagnosis is polymorphic
eruption of pregnancy.
What clinical feature is most helpful in diagnosing this condition?
Facial pigmentation
Inflamed abdominal striae
Itching of palms of hands
Itching of soles of feet
Umbilical rash
Correct
The correct answer is inflamed abdominal striae. Polymorphic eruption of
pregnancy classically affects the abdominal striae, sparing the umbilicus.
The differential diagnosis is intrahepatic cholestasis of pregnancy, atopic
eruption of pregnancy and pemphigoid gestationis. See Nelson-Piercy
C. Handbook of obstetric management, 4th edition. CRC Press 2010
and Maharajan A, Aye C, Ratnavel R, Burova E. Skin eruptions specific to
pregnancy: an overview. The Obstetrician & Gynaecologist 2013;15:233
40.
You see a patient who is 35 weeks pregnant in your day assessment unit.
She presents with itching. Your differential diagnosis is obstetric
cholestasis. Your ST1 asks you if she should prescribe vitamin K but is
not sure how it works.
Vitamin K is responsible for manufacturing which of the following
coagulation factors?
Factor V
Factor VIII
Factor X
Factor XI
Factor XII
20
Correct
The correct answer is factor X. Vitamin K is required for manufacturing
coagulation factors II, VII, IX, X. See Royal College of Obstetricians and
Gynaecologists. Obstetric cholestasis. Green-top Guideline 43. London:
RCOG; 2011.
You see a woman who is 35 weeks pregnant in your day assessment unit.
She presents with nausea, anorexia and generalised malaise. Her liver
function test demonstrates an alanine transaminase (ALT) of 634.
Which of the following features is most useful in distinguishing acute fatty
liver of pregnancy (AFLP) from HELLP syndrome?
Deranged renal function
Epigastric pain
Hypertension
Hypoglycaemia
Proteinuria
Correct
The correct answer is hypoglycaemia. Liver disorders are common in
pregnancy, but rarely cause long term problems. AFLP is a rare but
serious condition which will share many common features with HELLP.
However hypoglycaemia is common in AFLP and can be severe, but is
extremely unlikely in HELLP. See Nelson-Piercy C. Handbook of obstetric
management, 4th edition. CRC Press. 2010.
A 35-year-old woman with persistent tachycardia has thyroid function tests
at 18 weeks of gestation. The results are TSH <0.02 mU/l (normal range
0.45.0) and T4 of 67 pmol/l (normal range 1020).
What is the most likely cause for her hyperthyroidism?
Graves disease
Hashimoto thyroiditis
Subacute thyroiditis
Thyrotropic activity of HCG
Toxic multinodular goitre
Correct
The correct answer is Graves disease. 95% of cases of hyperthyroidism in
pregnancy are due to Graves disease. Thyroxine production increases in
pregnancy due to an increase in thyroxine binding globulin to maintain a
steady free thyroxine level (both T3 and T4). In assessing thyroid function
in pregnancy, free T3 and T4 levels reflect thyroid function rather than
total T3 and T4 levels. In monitoring hypo- and hyperthyroid disease the
TSH level may take longer to return to normal so free T3 and T4 levels are
a more accurate reflection. Hyperthyroidism is common in women of
reproductive years and is seen in approximately 1 in 500 pregnancies.
See Nelson-Piercy C. Handbook of obstetric medicine, 4th edition. CRC
21
Press. 2010.
A primigravida presents at 41 weeks into an uncomplicated pregnancy.
You arrange induction of labour.
According to NICE guidelines (2008), what is the rate of spontaneous
vaginal delivery following induction with prostaglandins alone?
3140%
4150%
5160%
6170%
7180%
Correct
The correct answer is 6170%. Induction of labour should only be offered
to women in specific circumstances since there is an increased risk of
caesarean section. See National Institute for Health and Clinical
Excellence. Induction of labour. Clinical guideline 70. London: NICE.
2008.
A 19-year-old woman is 28 weeks into her first pregnancy. On routine
blood tests, her haemoglobin is 95 g/l.
What is the best test to diagnose iron deficiency anaemia?
Blood film
Serum ferritin
Serum iron levels
Serum soluble transferrin receptor
Total iron binding capacity
Correct
The correct answer is serum ferritin. Although an approximation of iron
deficiency can be assessed by the mean corpuscular volume, serum
ferritin will give an accurate test of iron stores. See British Committee for
Standards in Haematology. UK guidelines on the management of iron
deficiency in pregnancy. London: BCSH: 2011.
A 26-year-old P1+0 woman booked under midwife-led care develops a
confirmed chickenpox infection at 38+6 weeks of gestation. She is a nonsmoker and is otherwise low risk. Clinically, the fetus appears
appropriately grown for gestation and is in a cephalic presentation. She
previously had an uncomplicated normal delivery of a 3.7 kg baby
following induction for postmaturity.
What is the most appropriate advice for her ongoing management?
Await the onset of spontaneous labour and give the newborn varicella
zoster immunoglobulin (VZIG)
Await the onset of spontaneous labour and give the newborn varicella
22
Enlarge
Reproduced with permission from Tang T et al. Cochrane Database Syst
Rev 2012;(5):CD003053
This analysis above is taken from a meta-analysis of ovulation rates in
women with polycystic ovarian syndrome (PCOS) taking metformin
compared with clomifene ovulation induction therapy. Subgroup analysis
was also carried out using a cut-off BMI level of 30 kg/m2.
Which statement of the following best describes the above findings?
Metformin is equally as effective as clomifene in the obese group (BMI
> 30)
Metformin is less effective than clomifene in the non-obese group
(BMI <30)
Metformin is less effective than clomifene in the obese group (BMI
>30)
24
Darifenacin
Desmopressin
Mirabegrone
Tolterodine
Transdermal oxybutynin
Correct
The correct answer is Desmopressin. The use of desmopressin may be
considered specifically to reduce nocturia in women with UI or OAB who
find it a troublesome symptom. Use particular caution in women with
cystic fibrosis and avoid in those over 65 years with cardiovascular
disease or hypertension. See National Institute for Health and Clinical
Excellence. Urinary incontinence in women. CG171. London: NICE; 2013.
A 55-year-old woman is due to come in for total abdominal hysterectomy
and bilateral salpingo-oophorectomy for a large mucinous ovarian cyst.
She takes sequential HRT for menopausal symptoms.
What is the approximate overall risk of serious complications from
abdominal hysterectomy?
1 operation in every 100
2 operations in every 100
3 operations in every 100
4 operations in every 100
5 operations in every 100
Correct
The correct answer is 4 operations in every 100. The overall risk of
serious complications from abdominal hysterectomy is approximately four
women in every 100 (common). See National Institute of Health and
Clinical Excellence. Venous thromboembolism: reducing the risk. Clinical
Guideline 92. London: NICE; 2010 and Royal College of Obstetricians and
Gynaecologists.Abdominal hysterectomy for benign conditions. Consent
Advice 4. London: RCOG; 2009.
A 46-year-old para 2 woman is referred to your gynaecology clinic
complaining of regular but heavy menstrual bleeding which is affecting her
quality of life.
Which of the following associated features indicates the need for
endometrial biopsy?
BMI greater than 30
26
Dysmenorrhoea
Failure of previous medical therapy
Iron deficiency anaemia
Uterus enlarged on vaginal examination
Correct
The correct answer is failure of previous medical therapy. An endometrial
biopsy should be taken if there is persistent intermenstrual bleeding or if
treatment is ineffective in women over 45. An ultrasound is the first line
diagnostic tool for identifying structural abnormalities and should be
performed if the uterus is palpable abdominally, vaginal examination
reveals a pelvic mass or if drug treatment fails. See National Institute for
Health and Clinical Excellence. Heavy menstrual bleeding. London: NICE;
2013.
A woman has been recommended to undergo hysterectomy and bilateral
salpingo-oophorectomy for benign disease. You discuss the risks and
benefits of an open versus a laparoscopic procedure.
Which sort of injury is more common at laparoscopic hysterectomy
compared to an open procedure?
Bowel
Nerve
Ovary
Urinary tract
Vascular
Correct
The correct answer is urinary tract injury. Laparoscopic surgery involves
risks to bowel, urinary tract and major blood vessels. These risks are
higher in women who are obese or significantly underweight, however the
risks of laparotomy are significantly greater in the morbidly obese. Urinary
tract injury and vaginal cuff dehiscence are more common in the
laparoscopic approach with an odds ratio of 2.61 for urinary tract
injury. Royal College of Obstetricians and Gynaecologists. Preventing
entry-related gynaecological laparoscopic injuries. Green-top Guideline
49. London: RCOG; 2008.
A 65-year-old had a hysterectomy for endometrial cancer. She recovered
well but complained of dribbling urine 2 days later and was given a course
of antibiotics for a presumed UTI. On review at 4 weeks she complains of
continued urinary incontinence. She has no dysuria, no sensation of
urgency, needs to wear a pad at night, and intermittently voids good
27
28
aged 50-79, 45% of whom had a BMI of 30 or more. The MWS looked at 1
084 110 women aged 50-64, only 18% of whom had a BMI of 30 or more
See theBritish National Formulary. Hormone replacement therapy.
Accessed online November 2014.
You see a 48-year-old woman opting for a hysterectomy for management
of her heavy menstrual bleeding. While obtaining her consent for the
operation you explain to her that haemorrhage requiring transfusion is a
'common' procedural risk.
What is the numerical ratio for a complication when it is quoted as
'common'?
1/1 to 1/10
1/10 to 1/100
1/100 to 1/1000
1/1000 to 1/10 000
Less than 1/10 000
Correct
The correct answer is 1/10 to 1/100. See Royal College of Obstetricians
and Gynaecologists.Obtaining valid consent for complex gynaecological
surgery. Clinical Governance Advice 6b. London: RCOG; 2010.
A 36-year old woman undergoes laparoscopic resection of deep infiltrating
endometriosis. You advise her regarding the risk of injury to her ureters
during the surgery and the fact that this may be a direct injury or a thermal
injury related to electrocautery.
If she does receive a thermal injury, when would you expect her to
present?
12 days post surgery
57 days post surgery
1014 days post surgery
34 weeks post surgery
56 weeks post surgery
Correct
The correct answer is 1014 days after surgery. Thermal injuries to the
ureter may result in delayed necrosis and/or fistula formation that will
typically present clinically between 10 and 14 days postoperatively.
See Minas V, Gul N, Aust T, Doyle M, Rowlands D. Urinary tract injuries in
laparoscopic gynaecological surgery; prevention, recognition and
31
agent. Care must be taken for women with high body mass index.
See Swingler R, Awala A, Gordon U. Hirsutism in young women. The
Obstetrician & Gynaecologist 2009;11:1017.
A 16-year-old girl presents to the gynaecology outpatient clinic with
primary amenorrhea. She is 148 cm tall and weighs 54 kg (BMI
24.7). Breast development is assessed as Tanner stage 2 and her pubic
hair is noted to be sparse. Further examination identifies cubitus
valgus. She has no other dysmorphic features.
What is the most likely diagnosis?
Congenital adrenal hyperplasia
Down syndrome
Mayer-Rockitansky-Kusterhauser syndrome
Testicular feminisation
Turner syndrome
Correct
The correct answer is Turner syndrome. The karyotype is 45 XO in Turner
syndrome. It is the most common cause of gonadal dysgenesis. These
patients may have additional renal and cardiac anamolies. Some women
may menstruate due to mosaicism, but premature ovarian failure is more
common. See Bondy CA, and for The Turner Syndrome Consensus Study
Group. Care of girls and women with Turner syndrome: a guideline of the
Turner Syndrome Study Group. J Clin Endocrinol Metab 2007;92:1025.
A 48-year-old woman presents 1 week after a total abdominal
hysterectomy. She has persistent weakness of hip flexion and
paraesthesia over the anterior and medial aspects of her left thigh.
Damage to which nerve is the most likely cause?
Femoral
Genito-femoral
Ilio-inguinal
Lateral cutaneous of the thigh
Obturator
Correct
The correct answer is the femoral nerve. Gynaecological surgery,
especially abdominal hysterectomy, is the most common cause of
iatrogenic femoral nerve injury, and injury to the femoral nerve is the most
common nerve injury in gynaecological practice. This is usually caused by
33
Mirena IUS
Levonorgestrel (LNG)
Mifepristone
Ulipristal acetate (UA)
Correct
The correct asnwer is ulipristal acetate (UA). The Mirena coil is not
licensed for EC. LNG is recommended only within 72 hours of UPSI. A
copper IUCD can be used within 5 days of first UPSI in a cycle but is not
indicated in the presence of a uterine anomaly. Mifepristone is not
licensed for EC in the UK. UA is licensed for use within 120 hours of UPSI
so is the recommended choice. SeeFaculty of Sexual and Reproductive
Health Care. Emergency contraception. London: FSRH; 2011.
A 46-year-old nulliparous woman has been referred by her GP having
been treated for heavy regular menstrual bleeding with cyclical
progestogens for a period of 6 months. The treatment has failed to
improve her symptoms.
What is the most appropriate next line of management?
Endometrial biopsy
Levonorgestrel intrauterine system
Non-steroidal anti-inflammatory drugs
Pelvic ultrasound
Tranexamic acid
Correct
The correct answer is endometrial biopsy. Endometrial biopsy should be
performed if a women over 45 years of age fails to respond to first line
treatment. See: National Institute for Health and Clinical
Excellence. Heavy menstrual bleeding. CG44. London: NICE; 2007.
A 45-year-old woman is due to have a total abdominal hysterectomy and
bilateral salpingo oopherectomy for chronic pelvic pain. You receive a
letter from her GP informing you that her recent cervical smear has shown
borderline changes in endocervical cells.
What arrangement will you make, if any, prior to her admission?
Endometrial sampling
HPV testing
No change in her management
Referral to colposcopy
Repeat cervical cytology
Correct
The correct answer is referral to colposcopy. All women being considered
41
What are the most likely genetic features of the partial molar pregnancy?
46 XY
46 YY
46 YYY
69 XYY
69 YYY
Correct
The correct answer is 69 XYY. Complete moles are usually diploid and all
chromosomes are of paternal origin. Partial molar pregnancies are usually
triploid, with the additional set of chromosomes of maternal origin.
Incidence varies worldwide, ranging from 2 in 1000 pregnancies in Japan
to 0.61.1 per 1000 in Europe and North America. See Royal College of
Obstetricians and Gynaecologists. Gestational trophoblastic disease.
Green-top Guideline 38. London: RCOG; 2010.
A 40-year-old woman has regular heavy menstrual bleeding. The history
and investigations indicate that pharmacological treatment is appropriate.
Her GP has tried tranexamic acid without success.
What is the most appropriate next pharmaceutical treatment?
Etamsylate
Gonadotrophin-releasing hormone analogues
Injected long acting progestogens
Levonorgestrel-releasing intrauterine system (LNG-IUS)
Norethisterone 15 mg daily from day 5 to day 26 of cycle
Correct
The correct answer is levonorgestrel-releasing intrauterine system (LNGIUS). The LNG-IUS is first line treatment in women complaining of heavy
menstrual bleeding and NICE recommends it's use before tranexamic
acid. See National Institute for Health and Clinical Excellence. Heavy
menstrual bleeding. CG44. NICE; 2007.
A 67-year-old woman is referred to the rapid access clinic with a 2 day
history of postmenopausal bleeding, which has since resolved. She is
otherwise fit and well. The endometrial thickness is 7 mm on transvaginal
ultrasound scan, the endometrium appears polypoidal at hysteroscopy
and histology on an endometrial sample is reported as showing irregular
and tightly packed glands with large and vesicular nuclei containing
prominent nucleoli.
What is the most appropriate management for this woman?
Bilateral oophorectomy
Combined estrogen and progestogen hormone replacement therapy
Expectant management
43
Hysterectomy
Insertion of a levonorgestrel-releasing intrauterine system
Correct
The correct answer is hysterectomy. The endometrial sample has features
that are diagnostic of complex atypical hyperplasia. Atypical hyperplasia is
a premalignant condition and will progress to malignancy in 29% of cases.
It can co-exist with an invasive carcinoma. Less aggressive abnormalities
are complex hyperplasia which will progress to malignancy in only 4% of
women, but will persist in 22%. The majority of simple hyperplasias will
regress spontaneously although 3% progress to complex atypical
hyperplasia. Current advice is that these women should be offered a
hysterectomy, especially with the risk of co-existing carcinoma. In younger
women high doses of progestagens have been used with success, and
there have been reported pregnancies following treatment. See Palmer
JE, Perunovic B, Tidy JA. Endometrial hyperplasia. The Obstetrician &
Gynaecologist 2008;10:2116.
A 37-year-old woman is undergoing a diagnostic laparoscopy for
investigation of pelvic pain. Following insertion of the laparoscope through
the umbilical port you find bowel adherent to the anterior abdominal wall in
the midline. You are worried that bowel may be adherent under the
umbilicus.
What is the recommended course of action?
Continue with procedure as Palmers test was normal
Convert to laparotomy
Remove port and reinsert at Palmers point
Seek surgical advice
Visualise the primary trocar site from a secondary port site
Correct
The correct answer is visualise the primary trocar site from a secondary
port site. If there are adhesions within the abdomen it is advisable to
check the umbilical port by inspecting it through a preferably 5 mm scope
via a secondary port. If damage has occurred seek surgical advice.
SeeRoyal College of Obstetricians and Gynaecologists. Preventing entryrelated gynaecological laparoscopic injuries. Green-top Guideline 49.
London: RCOG; 2008.
A 25-year-old woman develops a wound infection after a straight forward
elective subtotal hysterectomy.
What is the single most likely causative organism?
Escherichia coli
Haemophilus influenzae
Methicillin resistant Staphylococcal aureus
44
Staphylococcal aureus
Streptococcus milleri
Correct
The correct answer is Staphylococcal aureus. All wounds are colonised
with bacteria. This does not mean all wounds will become infected. If there
is an infection it is likely to be from skin flora which have colonised the
wound and thus Staphylococcal aureus is the most likely bacteria.
A 15-year-old girl attends sexual health clinic requesting termination of
pregnancy. She is 7 weeks pregnant. Her boyfriend is also 15-years-old
and studies in the same school. She has not informed anyone of this
pregnancy.
What is your most likely immediate action?
Encourage her to inform her parents
Inform specialist youth worker
Inform the GP
Inform the school head teacher
Reject the request without parental consent
1.
2.
3.
4.
5.
Correct
The correct answer is encourage her to inform her parents. Fraser
guidelines relate to a case in 1984 Gillick v West Norfolk and provide a
framework for dealing with children under the age of 16. It revolves around
whether a child is capable of making a reasonable assessment of the
advantages and disadvantages of treatment and thus their ability to
consent to treatment. In his guidance Fraser stated that a doctor could
prescribe contraceptives "provided he is satisfied in the following criteria:
That the girl (although under the age of 16 years of age) will
understand his advice
That he cannot persuade her to inform her parents or to allow him
to inform the parents that she is seeking contraceptive advice
That she is very likely to continue having sexual intercourse with or
without contraceptive treatment
That unless she receives contraceptive advice or treatment her
physical or mental health, or both, are likely to suffer
That her best interests require him to give her contraceptive advice,
treatment, or both, without the parental consent."
The same guidelines relate to termination of pregnancy. See Royal
College of Obstetricians and Gynaecologists. The care of women
requesting induced abortion. Evidence-based Clinical Guideline 7.
London: RCOG; 2011.
Your consultant asks you to prescribe a 3 month course of ulipristal
acetate to a patient with fibroids prior to having a hysterectomy.
To which class of drugs does ulipristal acetate belong?
Aromatase inhibitor
45
Reprod 2014;29:40012.
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