A 22-year-old woman presents to the

Emergency Department requesting

'emergency contraception. She had
unprotected sexual intercourse (UPSI)
approximately 4 days earlier.
Question:
Which oral method of emergency
contraceptive could be prescribed in this
case? (1)
Your Answer:
Correct Answer:
EllaOne (Ulipristal Acetate) is licensed for
use within 5 days (120 hours) of UPSI

Question:

Which important drug interaction should

you be aware of when prescribing this
drug? (2)
Your Answer:
Correct Answer:
Ulipristal Acetate should not be used with
liver enzyme-inducing drugs and it is
recommended that it is not used in women
using liver enzyme-inducing drugs and for
28 days after these drugs are stopped.
Question:
Which non-oral form of emergency
contraception would be suitable to be
used in this case? (1)
Your Answer:
Correct Answer:

The copper-bearing intrauterine device

can be inserted up to 120 hours after
UPSI
Question:
List 4 contraindications to the non-oral
method of emergency contraception
chosen in part (c) above: (4)
Your Answer:
Correct Answer:
Any 4 of:

Significantly distorted uterine anatomy

Unexplained vaginal bleeding

Pelvic malignancy

Gestational trophoblastic disease with

persistently elevated beta-human chorionic
gonadotropin levels

Ongoing pelvic infection

Question:
Which two important things should be
discussed with the patient at this
presentation? (2)
Your Answer:
Correct Answer:
Women attending for emergency
contraceptions should be offered the
opportunity to undergo testing for STIs
including HIV. For women at risk of STIs, if
test results are unavailable before IUD
insertion, health professionals should
consider prophylactic antibiotics at least to
cover Chlamydia.
Women should be advised that neither of
these options will provide contraceptive
cover for subsequent acts of UPSI.
Ongoing contraception should be
discussed with all women even if they do

not plan to have sex in the foreseeable

future.

A 23 year-old Afro-Caribbean lady

presents to the Emergency
Department. She is 17 weeks pregnant
and is known to suffer from sickle-cell
anaemia. She has passed a large
amount of blood and clots vaginally
and is complaining of feeling dizzy.
She is also complaining of upper back
and arm pain. Her obstetric booking
bloods show that she is rhesus
negative. Her observations are: HR 46,
BP 82/43, RR 22 and SaO2 94% on air.
The resus nurse has cannulated the

patient and a full set of bloods

including a cross-match has been sent
to the lab.
Question:
Which fluid and how much would you
initially administer? (1)
Your Answer:
Correct Answer:
1-2 litres or 10-20 ml/kg of crystalloid e.g.
0.9% saline
Question:
Which diagnosis explains her presentation
and observations? What should be your
next management step? (2)
Your Answer:
Correct Answer:

Her presentation and observations

(vaginal bleeding with bradycardia and
hypotension) can be explained by a
diagnosis of cervical shock syndrome.
Products of conception (POC) are likely to
be within the os. In cervical shock
syndrome the cervix becomes dilated by
the POC causing increased haemorrhage
and a vasovagal reaction. A speculum
examination should be performed and the
POC removed with a sterile sponge
forceps.
Question:
What is the most likely cause for her pain?
(1)
Your Answer:
Correct Answer:
A painful vaso-occlusive sickle-cell crisis.

Question:
Outline 4 other immediate management
steps: (4)
Your Answer:
Correct Answer:
Any 4 of: ( mark each)

Keep the patient warm

Give high flow (15 L) oxygen

Give analgesia e.g. IV Morphine

titrated to response

Blood transfusion 4-6 units or activate

massive haemorrhage protocol

Empirical antibiotic therapy if infection

thought to be the trigger
Question:
Does she need treatment for her Rhesus
status and if so what and when? (2)
Your Answer:

Correct Answer:
She should be treated as she is rhesus
negative and bleeding in early pregnancy
is a sensitising event. Administer 250 U
Anti-D Ig IM immediately after the
sensitising event and organise for a
further 500 U to be given after 20 weeks.

A 32 year-old woman who is 30 weeks

pregnant has been exposed to
chickenpox at a child's birthday party.
She thinks that she has never had
chickenpox herself.

Question:
Which important blood test should you
organize? (1)
Your Answer:
Correct Answer:
Serum varicella antibody test
Question:
You obtain confirmation that she has
never had chickenpox. What should you
do and which 2 important pieces of advice
should you give her? (3)
Your Answer:
Correct Answer:
She should have Varicella Zoster
Immunoglobulin (VZIG) administered.
You should advise her that she is
potentially infectious from 8-28 days after

VZIG and that she should notify her GP or

midwife if a rash develops.
Question:
A second woman, who is also 30 weeks
pregnant, presents with chickenpox. The
rash has been present 12 hours. How
would you treat this? (please include any
drug doses) (1)
Your Answer:
Correct Answer:
Oral acyclovir 800mg five times per day
for 7 days
Question:
Name 3 serious complications that she is
at risk of developing: (3)
Your Answer:
Correct Answer:

Pneumonia
Hepatitis
Encephalitis
Question:
List 4 circumstances that should prompt a
GP to refer a pregnant woman with
chickenpox to Hospital for assessment: (2)
Your Answer:
Correct Answer:
Referral to Hospital should occur under
the following circumstances: ( mark
each)

Presence of chest symptoms

Presence of neurological symptoms

Haemorrhagic rash or bleeding

Dense rash with or without mucosal

lesions

Presence of significant
immunosuppression

Cigarette smokers

History of chronic lung disease

Taking corticosteroids

Consider referral in latter half of

pregnancy

A 28 year-old lady is referred to the

emergency Department by her GP with
elevated blood pressure and swelling
of her hands and face. She is 32 weeks
pregnant and the GP is concerned that
she may have pre-eclampsia.
Question:

What is the definition of pre-eclampsia?

(2)
Your Answer:
Correct Answer:
Pre-eclampsia is defined as new
hypertension (>140/90) in a pregnant
woman after 20 weeks gestation with
associated proteinuria (>300 mg protein in
a 24 hour sample)
Question:
List 3 features of severe pre-eclampsia:
(3)
Your Answer:
Correct Answer:
Any 3 of:

Sustained severe hypertension (>

160/90)

Severe proteinuria

Oliguria (urine output < 500 mls / 24

hours)

Neurological symptoms and signs e.g.

headache, papilloedema, clonus

Platelet count < 100 x 109/L

Epigastric pain and/or right upper

quadrant tenderness

Elevated liver enzymes (AST and ALT)

Question:
List 4 risk factors for pre-eclampsia: (2)
Your Answer:

Correct Answer:
Any 4 of: ( mark each)
First pregnancy
Multiple pregnancy
Obesity
Age older than 35
History of diabetes

History of hypertension
History of kidney disease
Question:
List 4 potential complications of preeclampsia: (2)
Your Answer:

Correct Answer:
Any 4 of: ( mark each)
Eclampsia
HELLP syndrome
Adult respiratory distress syndrome
Cerebral haemorrhage
Stroke
Cortical blindness
Rupture of liver
Pulmonary oedema
Renal failure

Disseminated intravascular
coagulation
Question:
Name 1 blood test that can be used to
predict maternal complications with preeclampsia. (1)
Your Answer:
Correct Answer:
Serum uric acid
A 28-year-old woman that is 35-weeks
pregnant presents with severe lower
abdominal pain. Whilst in the
department she suffers an episode of
vaginal bleeding. Her observations are
as follows: HR 136 bpm, BP 88/42,
SaO2 99% on air, temperature is 37.1C.
On examination she has rebound

tenderness and guarding in the lower

abdomen. You are concerned that she
may have suffered uterine rupture.
Question:
List 3 risk factors for non-traumatic uterine
rupture. (3)
Your Answer:

Correct Answer:
Any 3 of:
Previous Caesarean section
Previous myomectomy
Multiparity
Malpresentation
Cephalopelvic disproportion
Syntocinon augmentation of labour
Obstructed labour
Placenta percreta or increta

Question:
Describe 3 factors that make the
evaluation of abdominal pain more difficult
in pregnancy. (3)
Your Answer:
Correct Answer:
Any 3 of:

The intra-abdominal organs change

position as the pregnancy progresses e.g.
bowel is displaced into the upper abdomen
and the appendix is shifted upwards
towards the gallbladder

Peritoneal signs may be absent as the

uterus can lift the abdominal wall away
from the area of inflammation

The uterus can obstruct the movement

of the omentum to the area of inflammation

The presence of the fetus and placenta

can cloud the picture further

Laboratory parameters can be nonspecific and are often altered due to the
physiological changes in pregnancy

Imaging is more difficult due to the

risks of radiation exposure to the fetus

Question:
Describe 2 things you would do to assess
the pregnancy and uterus as part of your
examination? (2)
Your Answer:
Correct Answer:
Any 2 of:

Palpate uterus for fundal height, fetal

position and presentation

Palpate for fetal movements

Assess the fetal heart beat (either with

Doppler scan or cardiotocography)

Question:
Name 2 potential complications of uterine
rupture. (2)
Your Answer:
Correct Answer:
Any 2 of:

Emergency hysterectomy

Fetal death

Maternal death

A 27-year-old woman presents to the

ED as she is concerned that she has
more vaginal discharge than usual. The
discharge is a grayish colour and has a
fishy smell. There is no significant
pain, irritation or erythema of the area.

Question:
You plan on performing a vaginal
examination and the patient has
requested that a chaperone is present.
According to the GMC an ideal chaperone
should fulfill several criteria. List 4 of these
criteria. (4)
Your Answer:
Correct Answer:
According to the GMC a chaperone
should usually be a health professional
and you must be satisfied that the
chaperone will:

Be sensitive and respect the patients

dignity and confidentiality

Reassure the patient if they show

signs of distress or discomfort

Be familiar with the procedures

involved in a routine intimate examination

Stay for the whole examination and be

able to see what the doctor is doing, if
practical

Be prepared to raise concerns if they

are concerned about the doctors
behaviour or actions.

Question:
What is the most likely diagnosis in this
case? (1)
Your Answer:
Correct Answer:
Bacterial vaginosis
Question:
What is the commonest causative
organism for this condition? (1)
Your Answer:
Correct Answer:

Gardnerella vaginalis
Question:
List 3 tests that could be used to confirm
this diagnosis. (3)
Your Answer:
Correct Answer:
Vaginal pH testing (> 4.5).
Addition of potassium hydroxide to vaginal
fluid resulting in a fishy odour.
Microscopy of vaginal fluid revealing
vaginal epithelial cells coated with a large
number of bacilli.
Question:
What is the treatment for this diagnosis?
(1)
Your Answer:
Correct Answer:

Oral metronidazole 400 mg BD for 5-7

days.

A 30-year-old woman that is 36-weeks

pregnant is brought in by ambulance
having been involved in a road traffic
accident.
Question:
At what level would you expect the uterus
to be palpated at her current gestation?
(1)
Your Answer:
Correct Answer:
At 34-36 weeks gestation the uterus has
reached the level of the costal margin.

Question:
Why can pregnant trauma patients lose a
significant amount of blood before signs of
hypovloaemia develop? (2)
Your Answer:
Correct Answer:
Increased angiotensin II encourages water
and sodium retention, leading to an
increased intravascular volume. Because
of this increased intravascular volume
pregnant patients can lose a significant
volume of blood before tachycardia,
hypotension and other signs of
hypovolaemia develop.
Question:
GIve two other important changes to the
cardiovascular system that must be

considered in the assessment of pregnant

trauma patients. (2)
Your Answer:
Correct Answer:
Any 2 of:

Cardiac output increases by 30 to 50%

Heart rate increases by 10 to 15

beats/min

Systolic and diastolic blood pressure

falls by 5 to 15 mmHg during mid
pregnancy by returns back to normal by
week 36

In the supine position vena cava

compression can compromise venous
return
Question:
Give two ECG changes that can occur
secondary to pregnancy. (2)

Your Answer:
Correct Answer:
Any 2 of:

The axis may shift leftward by up to 15

degrees

Flattened or inverted T waves can

occur in leads III, aVF, V1 and V2

Q waves can occur in leads III and

aVF

Ectopic beats occur more frequently in

pregnancy
Question:
List 3 modifications that should occur in
this case compared to a standard trauma
call. (3)
Your Answer:
Correct Answer:
Any 4 of:

An obstetrician should be present

The uterus should be manually
displaced to the left to remove caval
compression

The table should be put in a left lateral

tilt (ideally 15-30 degrees of tilt)

Continuous cardiotocography (CTG)

monitoring should be performed

A 29-year-old woman that is 8-weeks

pregnant presents with vaginal
bleeding. She states that she had a
positive pregnancy test at home last
week. Her observations are as follows:

Temperature 36.6C, HR 80, BP 125/78,

RR 14.
Question:
Which bedside test should be performed
for this patient? (1)
Your Answer:
Correct Answer:
A urinary pregnancy test should be
performed to confirm pregnancy.
Question:
List 3 features that would support a
threatened miscarriage over an inevitable
miscarriage. (3)
Your Answer:
Correct Answer:
A threatened miscarriage would be
suggested by:

Minimal bleeding
No pain
Cervical os closed on speculum
examination
Question:
List 4 risk factors for miscarriage. (4)
Your Answer:

Correct Answer:
Any 4 of:

Age over 35

History of previous miscarriage

Connective tissue disorders e.g. SLE

Poorly controlled diabetes mellitus

Drug and alcohol abuse

Invasive prenatal tests e.g. chorionic

villus sampling

Uterine or cervical abnormalities

Excessively high or low body mass

index (BMI)
Question:
List 4 of the TORCH infections. (2)
Your Answer:

Correct Answer:
Any 4 of ( mark each):

T = Toxoplasmosis

O = Other (any of syphilis, HIV,

parvovirus B19 and gonorrhoea)

R = Rubella

C = Cytomegalovirus

H = Herpes

A 33-year-old woman presents with a

painless swelling on the right side of

her labia. It has developed over the

past few days. On examination you see
the following:

Question:
What is the diagnosis? (1)
Your Answer:
Correct Answer:
Right sided Bartholins cyst

Image sourced from Wikipedia(link is

external)
Courtesy of Medimage CC BY-SA 3.0(link
is external)
Question:
What is the pathophysiology of this
condition? (1)
Your Answer:
Correct Answer:
A Bartholins cyst develops when the duct
that drains the gland becomes blocked.
Obstruction of the duct results in the
accumulation of secretions and cyst
formation.
Question:
Before conducting an intimate
examination, which 4 things do the GMC

recommend should be done in their

guidance on intimate examinations? (4)
Your Answer:
Correct Answer:
The 2013 GMC guidelines on intimate
examinations and chaperones
recommend that the following occur prior
to the intimate examination:
1.
Explain to the patient why the
examination is necessary and give the
patient an opportunity to ask questions
2.
Explain what the examination will
involve, in a way the patient can
understand, so that the patient has a clear
idea of what to expect, including any pain
or discomfort
3.
Get the patients permission before the
examination and record that the patient has
given it
4.
Offer the patient a chaperone

Question:
The same patient returns a couple of
weeks later because the lump has
become painful and red. On examination
the lump feels fluctuant. Which
complication has occurred? (1)
Your Answer:
Correct Answer:
A Bartholins abscess has developed.
Question:
How would you manage this patient in the
Emergency Department? (2)
Your Answer:
Correct Answer:
Any 2 of:

Provide appropriate analgesia

Commence antibiotics (e.g.

flucloxacillin 500 mg QDS)

Refer to gynaecology for consideration

of incision and drainage or balloon catheter
insertion
Question:
What is the definitive management of this
condition? (1)
Your Answer:
Correct Answer:
Marsupialisation

A 27-year-old woman that is 31-weeks

pregnant presents with vaginal
bleeding. She has been bleeding for

approximately 5 hours and the

bleeding has become heavier over the
past 30 minutes. Her observations are
as follows: Temperature 36.4C, HR
112, BP 114/58, RR 22.
Question:
List 4 clinical features that would support
a diagnosis of placenta praevia over
abruptio placentae. (4)
Your Answer:
Correct Answer:
Any 4 of:

Painless vaginal bleeding

Obstetric shock in proportion to the

amount of vaginal blood loss

Non-tender uterus on examination

Foetus has normal presentation and lie

No signs of foetal distress present

Question:
Which examination should not be
performed and why? (2)
Your Answer:
Correct Answer:
A vaginal examination should not be
performed as it may provoke severe
haemorrhage in the presence of placenta
praevia by disturbing blood vessels lying
across the cervical os.
Question:
List 4 factors that predispose to placenta
praevia. (2)
Your Answer:
Correct Answer:
Any 4 of ( mark each):

Past history of placenta praevia

Large placenta e.g. multiple pregnancy

High parity
Abnormal uterus e.g. fibroids present
History of previous Caesarian section
Question:
List 4 management points in the ED. (2)
Your Answer:

Correct Answer:
Any 4 of ( mark each):

Insert 2 large-bore IV cannulae

Take bloods U&Es, LFTs, clotting

Cross match 6 units of blood

Refer urgently to on-call obstetrician

Commence cardiotocography (CTG)

monitoring

A 30 year-old woman is brought in by

ambulance following a road traffic
accident where she was a passenger in
a car hit by a lorry at high speed. She
is 34 weeks pregnant. Her observations
are as follows: HR 122, BP 100/64,
SaO2 98% on high-flow oxygen, RR 25,
temperature 36.6C. Her C-spine is
triple immobilised. The airway is patent
and her chest examination is normal.
She has had a small amount of vaginal
bleeding and is complaining of
abdominal pain and abdominal
tenderness. Two wide-bore cannulae
have been inserted in her antecubital
fossae and a full set of bloods have
been sent to the lab, including a
request for a cross-match. She has had
a small amount of vaginal bleeding and
is complaining of abdominal pain.

Question:
Where does the uterus lie at 34 weeks
gestation? (1)
Your Answer:
Correct Answer:
At 34-36 weeks gestation the uterus lies at
the costal margin.
Question:
Give one main differences to how the
primary survey should be performed in
trauma involving a pregnant patient. (1)
Your Answer:
Correct Answer:
The uterus should be displaced manually
to the left side to relieve pressure on the
inferior vena cava.

Question:
What are the two main causes of foetal
death in trauma? (2)
Your Answer:
Correct Answer:
1.
Maternal shock
2.
Abruptio placentae
Question:
List 4 clinical features that are suggestive
of abruptio placentae. (4)
Your Answer:

Correct Answer:
Any 4 of:
Vaginal bleeding
Uterine tenderness
Frequent uterine contractions
Uterine tetany

Uterine irritability (uterus contracts

when touched)
Question:
You can see from the patients antenatal
booking bloods that she is rhesus D
negative. What should the patient be
given and within what time frame? (2)
Your Answer:
Correct Answer:
Anti-D immunoglobulin should be given
within 72 hours.

A 26 year-old female presents with left

iliac fossa pain. Her last menstrual
period was 7 weeks ago. You are

concerned that she is having an

ectopic pregnancy.
Question:
List 6 predisposing risk factors for ectopic
pregnancy: (3)
Your Answer:
Correct Answer:
Any 6 of: ( mark each)

Pelvic inflammatory disease

Previous pelvic or abdominal surgery

Previous history of ectopic pregnancy

Previous tubal surgery

Use of intrauterine contraceptive

device

Endometriosis

History of IVF or assisted fertilisation

techniques

History of sub-fertility

Diethylstilboestrol exposure
Advanced maternal age
Cigarette smoking
Question:
List 2 additional history points that would
support a diagnosis of ectopic pregnancy:
(2)
Your Answer:

Correct Answer:
Any 2 of:

Sudden onset severe unilateral pain

Vaginal bleeding

Recent use of morning after pill

Shoulder tip pain (indicating

peritonism)

Vomiting during pain

Episode of syncope or collapse

Question:
List 2 additional examination findings that
would support a diagnosis of ectopic
pregnancy: (2)
Your Answer:
Correct Answer:
Any 2 of:

Cervical excitation

Adnexal tenderness

Peritonism on abdominal palpation

Palpable adnexal mass

Features of haemodynamic
compromise (tachycardia and hypotension)
Question:
List 3 alternative diagnoses of LIF pain.
(3)
Your Answer:
Correct Answer:

Any 3 of:
Pelvic inflammatory disease
Ruptured corpus luteum cyst
Threatened miscarriage
Salpingitis
Ovarian torsion
Urinary tract infection
Renal colic

A 29 year-old lady presents with

bleeding in early pregnancy. You plan
on performing a speculum
examination.
Question:

Which 4 things should occur prior to

performing an intimate examination
according to the current GMC guidelines:
(4)
Your Answer:
Correct Answer:
Before conducting an intimate
examination you should:

Explain to the patient why an

examination is necessary and give the
patient an opportunity to ask questions

Explain what the examination will

involve, in a way the patient can
understand, so that the patient has a clear
idea of what to expect, including any
potential pain or discomfort

Obtain the patient's permission before

the examination and record that permission
has been obtained

Give the patient privacy to undress and

dress and keep the patient covered as
much as possible to maintain their dignity.
Do not assist the patient in removing
clothing unless you have clarified with them
that your assistance is required
Question:
Which 3 things should occur during the
intimate examination according to the
current GMC guidelines:
Your Answer:

Correct Answer:
During the examination you should:

Explain what you are going to do

before you do it and, if this differs from
what you have already outlined to the
patient, explain why and seek the patient's
permission

Be prepared to discontinue the

examination if the patient asks you to

Keep discussion relevant and do not

make unnecessary personal comments.

Question:
How can you differentiate between a
threatened and inevitable miscarriage with
your examination? (2)
Your Answer:
Correct Answer:
A threatened miscarriage is defined as
bleeding in early pregnancy without the
passage of products of conception (POC)
or dilatation of the cervix. An inevitable
miscarriage is defined as bleeding in early
pregnancy without the passage of POC
but with accompanying dilatation of the
cervix. Therefore if no POC have been

passed and the os is open the diagnosis

of an inevitable miscarriage can be made.
Question:
What is an incomplete miscarriage? (1)
Your Answer:
Correct Answer:
An incomplete miscarriage is defined as
bleeding in early pregnancy with
accompanying cervical dilatation and the
partial passage of the POC. Once all of
the POC have been passed this becomes
a complete miscarriage.

A 36 year-old lady is brought to the

resuscitation area of your Emergency
Department by ambulance having a
tonic-clonic seizure. She is 34 weeks
pregnant and has been treated for preeclampsia antenatally with labetolol
100 mg bd. Her airway is patent and
her observations are as follows: HR
100, BP 162/94, SaO2 100% on high flow
oxygen.
Question:
What is the diagnosis and the underlying
pathophysiology of her seizure? (2)
Your Answer:
Correct Answer:
Eclampsia.
The seizure is a result of brain hypoxia

due to ischaemia secondary to cerebral

oedema and vasospasm.
Question:
What is the drug of choice for
management of her seizure (please
include the dose and route of
administration)? (2)
Your Answer:
Correct Answer:
IV Magnesium sulphate 4 g
Question:
What is the definitive treatment for this
condition? (1)
Your Answer:
Correct Answer:
Delivery of the baby

Question:
List 2 neurological features of severe preeclampsia: (2)
Your Answer:

Correct Answer:
Any 2 of:
Headache
Visual disturbance
Confusion
Papilloedema
Clonus
Question:
List 3 abnormalities found on blood tests
that are indicative of severe preeclampsia: (3)
Your Answer:
Correct Answer:

Raised creatinine
Low platelet count (< 100 x 109 /L)
Elevated liver enzymes (AST and ALT)

A 31 year-old lady presents to the

Emergency Department with
abdominal pain and vomiting. She is 34
weeks pregnant and has been under
follow up for pregnancy induced
hypertension. She has had 2 previous
uneventful spontaneous vaginal
deliveries and has no other medical
history of note. On examination she
has marked right upper quadrant
tenderness. Her observations are as
follows: HR 100, BP 159/96, SaO2 99%
on air, temperature 36.8C. Her urine

dipstick reveals 2+ protein and her

venous bloods are shown below:
Venous bloods:

Hb: 8.4 g/dL

WCC: 13.8

Platelets: 36 x 109/L

Urea: 12.2 mmol/L

Creatinine: 134 mmol/L

Na: 137 mmol/L

K: 3.8 mmol/L

LDH: 789 IU/L

AST: 276 IU/L

ALP: 368 IU/L

Bilirubin: 23 micromol/L

Question:
What is the definition of pregnancy
induced hypertension? (PIH). (2)

Your Answer:
Correct Answer:
The development of new hypertension
with blood pressure higher than 140/90
without the presence of protein in the
urine after 20 weeks of gestation.
Question:
What is the most likely diagnosis in this
case? (1)
Your Answer:
Correct Answer:
HELLP syndrome. (Haemolytic anaemia,
Elevated Liver enzymes, Low Platelets)
Question:
What is the definitive management for this
condition? (1)
Your Answer:

Correct Answer:
Delivery of the baby
Question:
Outline 2 treatments that should be
initiated prior to this definitive
management. (2)
Your Answer:
Correct Answer:
Anti-hypertensive medications e.g.
labetolol 100 mg bd
Corticosteroids for fetal lung development
e.g. betamethasone 12 mg IM
Question:
The mother develops vaginal bleeding and
her Hb drops to 7.3. Outline your
immediate management. (2)
Your Answer:

Correct Answer:
Any 4 of: ( mark each)

Gain IV access (large bore cannulae

x2 in antecubital fossae)

Commence IV fluids

Start blood transfusion

Start platelet transfusion

Urgent referral to obstetricians for

expedited delivery of baby
Question:
List 4 potential complications of this
condition: (2)
Your Answer:
Correct Answer:
Any 4 of: ( mark each)

Disseminated intravascular
coagulation

Pulmonary oedema

Acute renal failure

Liver failure
Liver haemorrhage
Placental abruption

A 27-year-old woman presents to the

ED as she is concerned that she has
more vaginal discharge than usual. The
discharge is a grayish colour and has a
fishy smell. There is no significant
pain, irritation or erythema of the area.
You suspect a diagnosis of bacterial
vaginosis (BV).
Question:

List Amsels criteria used for the diagnosis

of bacterial vaginosis. (4)
Your Answer:
Correct Answer:
Amsels criteria can be used for the
diagnosis of BV, where three of the
following four criterion should be present:

Vaginal pH greater than 4.5

The addition of potassium hydroxide

results in a fishy smell (positive smell test)

Clue cells on microscopy

A thin, white homogenous discharge

Question:
What is the commonest causative
organism for this condition? (1)
Your Answer:
Correct Answer:
Gardnerella vaginalis

Question:
You plan on carrying out a vaginal
examination on the patient. According to
the GMC guidelines on intimate
examinations which 4 things should you
do before conducting the examination? (4)
Your Answer:
Correct Answer:
Before conducting an intimate
examination, you should:

Explain to the patient why an

examination is necessary and give the
patient an opportunity to ask questions

Explain what the examination will

involve, in a way the patient can
understand, so that the patient has a clear
idea of what to expect, including any pain
or discomfort

Get the patients permission before the

examination and record that the patient has
given it

Offer the patient a chaperone

Question:
What is the treatment for bacterial
vaginosis? (1)
Your Answer:
Correct Answer:
Oral metronidazole 400 mg BD for 5-7
days.

A 29-year-old woman that is 8-weeks

pregnant presents with vaginal
bleeding. Whilst in the Emergency
Department she suddenly complains of

feeling dizzy and you notice that she is

diaphoretic. You organise a set of
observations, which are as follows:
Temperature 36.6C, HR 40, BP 80/48,
RR 14.
Question:
What has happened to cause these
symptoms? Describe the mechanism of
how this occurs. (3)
Your Answer:
Correct Answer:
This patient has developed cervical shock.
In incomplete miscarriage, products of
conception passing through the cervix can
become caught and cause vagal
stimulation. The patient will experience

vaso-vagal symptoms and become

hypotensive and bradycardic.
Question:
Describe your immediate management of
this patient. (2)
Your Answer:
Correct Answer:
The immediate management of this
patient should involve:

Immediate intravenous cannulation

and fluid resuscitation

Speculum examination and removal of

products of conception using a sponge
holding forceps
Question:
After the above management the patients
symptoms settle and her blood pressure

and pulse return to normal. After a further

45 minutes her bleeding becomes much
heavier. Name two drugs that could be
administered in the ED to reduce her
bleeding. (Please include dose and route
of administration) (2)
Your Answer:
Correct Answer:
Tranexamic acid 1 g PO
Ergometrine 0.5 mg IM or IV
Question:
What is a septic abortion and how does it
tend to present clinically? (3)
Your Answer:
Correct Answer:
A septic abortion is a spontaneous
miscarriage that is associated with an

infected uterine cavity. It tends to present

clinically with the following features:
Fever and/or signs of sepsis
Offensive vaginal discharge
Abdominal pain and cramping
Prolonged or heavy vaginal bleeding

A 32-year-old woman that is 39-weeks

pregnant becomes suddenly very
breathless shortly after going into
labour. An ambulance is called and she
is blue lighted in to the resus area of
your Emergency Department. She
appears cyanosed and states that her
heart feels like it is beating very
quickly. Her observations are as

follows: HR 130 bpm, BP 88/42,

SaO2 90% on air, temperature is 36.4C.
Shortly after the observations are
taken she becomes unresponsive. You
notice a change in rhythm on the
cardiac monitor and are unable to
detect a pulse or any signs of life. Her
rhythm strip is shown below:

Question:
What does the rhythm strip show? (1)
Your Answer:
Correct Answer:
Ventricular fibrillation
Question:

What are the 2 most likely causes of the

cardiac arrest in this case? (2)
Your Answer:
Correct Answer:
Amniotic fluid embolus
Pulmonary embolus
Question:
List 4 modifications that should occur in
this case compared to a standard cardiac
arrest. (4)
Your Answer:
Correct Answer:
Any 4 of:

An obstetrician should be present

A paediatrician or neonatologist should

be present

The uterus should be manually

displaced to the left to remove caval
compression

The table should be put in a left lateral

tilt (ideally 15-30 degrees of tilt)

Early tracheal intubation should be

performed to reduce aspiration risk (expert
anaesthetic assistance should be sought)

Start preparing for an emergency

Caesarean section

Question:
Your initial attempts at resuscitation are
unsuccessful. What should occur within 5
minutes of the onset of this cardiac arrest?
Why should this be done? (3)
Your Answer:
Correct Answer:

Peri-mortem Caesarean section should be

performed within 5 minutes of the onset of
the cardiac arrest. Delivery will relieve
caval compression and improve the
likelihood of successful resuscitation by
permitting an increase in venous return
during the CPR attempt. It will also
maximise the chances of the infants
survival as the best survival rate occurs
when delivery is achieved within 5 minutes
of the onset of the mothers cardiac
arrest.