Start Og Q & A From Rcog

3/6/2016
Antenatalmanagement
Fortheclinicalscenarios,youarethemostseniorobstetricianataconsultantledhospitalantenatalclinicandyoumust
determinethegestationforthenextreviewintheclinicandtheactionrequiredatthatvisitfromtheoptionlist.Allother
antenatalvisitswillbeperformedbythecommunitymidwife.Eachanswermaybeusedonce,morethanonceornotatall.
A:20weeksofgestationreviewwithresultsofthefetalanomalyscan
andfullbloodcount
B:22weeksofgestationreviewresultsofrecentglucosetolerancetest
C:28weeksofgestationperformanultrasoundscantomeasurefetal
biometry,fullbloodcountandredcellantibodydetectiontest
D:28weeksofgestationperformfullbloodcount,redcellantibody
detectiontestandreviewresultsoftherecentglucosetolerancetest
E:30weeksofgestationreviewwithresultsoffullbloodcount
F:30weeksofgestationreviewwithresultsoffullbloodcountandrecent
glucosetolerancetest
G:32weeksofgestationperformanultrasoundscanforplacental
localisation
H:32weeksofgestationperformanultrasoundscantomeasurefetal
biometry
I:36weeksofgestationarrangeanelectivecaesareansectionat39
weeksofgestation
J:36weeksofgestationwithapossibleinductionoflabourat3840
weeksofgestation
K:39weeksofgestationarrangeanelectivecaesareansectionat41
weeksofgestation
L:39weeksofgestationarrangeinductionoflabouratorabouttermifall
isnormalwiththepregnancy
M:41weeksofgestationperformcervicalassessmentandmembrane
sweepandarrangeinductionoflabouratterm+12days
N:41weeksofgestationtoassesswhetheravaginalbirthisstilla
realisticandachievableoption
A41yearoldwomanisseenat20weeksofgestationinherfirst
pregnancy.TheanomalyscanwasnormalandDownsyndrome
screeningwaslowrisk.Sheisanonsmokerandhasnorelevant
pastmedical,surgicalorfamilyhistory.Clinicalexaminationreveals,
BP:120/70mmHgBMI:23cardiovascularandrespiratorysystems
normal.BloodgroupisORhesusnegative,noredcellantibodies
detectedfullbloodcountnormal
PleaseSelect
Incorrect
Theansweris39weeksofgestationarrangeinductionoflabourator
abouttermifallisnormalwiththepregnancy.
RoyalCollegeofObstetriciansandGynaecologists.InductionofLabour
https://stratog.rcog.org.uk/tutorial/emqsforthepart2mrcogonlineresource/antenatalmanagement30288
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Antenatalmanagement
atTerminOlderMothers.ScientificImpactPaperNo34.London
RCOG2013.
pregnancy.TheDownsyndromescreeningwaslowrisk.Shewas
admittedtohospitalwithathreatenedmiscarriageat9weeksof
gestation,associatedwiththeultrasoundscanappearanceofsub
chorionichaematomashereceivedantiDimmunoglobulinthe
vaginalbleedingandabdominalpainresolvedspontaneouslyduring
3dayshospitalisation.Thesubchorionichematomahadreducedin
sizebythetimeofthe12weekscan.Sheisanonsmokerandhas
norelevantpastmedical,surgicalorfamilyhistory.Clinical
examinationreveals,BP:130/75mmHgBMI:26cardiovascularand
respiratorysystemsnormal.BloodgroupABRhesusnegative,no
redcellantibodiesdetectedfullbloodcountnormal
PleaseSelect
Incorrect
Theansweris28weeksofgestationperformanultrasoundscanto
measurefetalbiometry,fullbloodcountandredcellantibodydetection
test.
A26yearoldwomanisseenat14weeksinhersecondpregnancy
afteranormalultrasoundscan.Thefirstpregnancywascomplicated
byaplacentapraeviathatrequiredacaesareansectionat36weeks
ofgestationwithagoodoutcome.TheDownsyndromescreening
waslowrisk.Sheisanonsmokerandhasnorelevantpastmedical,
surgicalorfamilyhistory.Clinicalexaminationreveals,BP:110/60
mmHgBMI:21cardiovascularandrespiratorysystemsnormal.
BloodgroupBRhesuspositive,noredcellantibodiesdetectedfull
bloodcountisnormal.Sheisverykeentoattemptavaginalbirth
thispregnancyandthisisdiscussedindetail
PleaseSelect
Incorrect
Theansweris41weeksofgestationtoassesswhetheravaginalbirthis
stillarealisticandachievableoption.
A36yearoldwomanisseenat15weeksofgestationinhersecond
pregnancywiththesamepartner.Thefirstpregnancywas
complicatedbypreeclampsiaandrequiredacaesareansectionat
38weeksofgestation,thebirthweightwas3977g.TheDown
syndromescreeningwaslowrisk.Thereisastrongfamilyhistoryof
hypertensionanddiabetes.Clinicalexaminationreveals,BP:135/80
mmHgBMI:32cardiovascularandrespiratorysystemsnormal.
UrineanalysisisnegativebloodgroupORhesuspositive,redcell
antibodiesnotdetectedfullbloodcountisnormal.Youhave
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Antenatalmanagement
recommendeddailylowdoseaspirinduringthepregnancyandshe
isverykeentoattemptavaginalbirththispregnancy.
PleaseSelect
Incorrect
Theansweris28weeksofgestationperformfullbloodcount,redcell
antibodydetectiontestandreviewresultsofrecentglucosetolerancetest.
Withastrongfamilyhistoryofdiabetes,aglucosetolerancetestresultis
mostimportant,althoughthirdtrimesterultrasoundfetalbiometrymaybe
anaspectofthemanagementofthiscase.
pregnancy.TheDownsyndromescreeningwaslowrisk.Shehasa6
yearhistoryofsevereCrohnsdiseaseandcurrentlytaking
prednisone20mgdaily.Sheisanonsmokerandhasnorelevant
pastsurgicalorfamilyhistory.Onclinicalexaminationshelooked
paleBP:125/75mmHgBMI:18.1cardiovascularandrespiratory
systemsnormal.Urineanalysisshowsglucose2+arandom
capillarybloodsugar5.8mmol/lbloodgroupBRhesuspositive,no
redcellantibodiesdetectedfullbloodcountshowshaemoglobinof
91g/landotherwisenormal
PleaseSelect
Incorrect
Theansweris20weeksofgestationreviewwithresultsofthefetal
anomalyscanandfullbloodcount.
A24yearoldwomanisseenat14weeksofgestationinhersecond
pregnancy.Inthefirstpregnancyshewasdeliveredbyrotational
forcepsattermofahealthymaleinfant(birthweight3987g)witha3a
perineallacerationandrequiredintrapartumantibioticprophylaxis
forgroupBStreptococcus.TheDownsyndromescreeningwaslow
risk.Sheisanonsmokerandhasnorelevantpastmedical,surgical
orfamilyhistory.Clinicalexaminationreveals,BP:110/60mmHg
BMI:24cardiovascularandrespiratorysystemsnormal.Blood
groupORhesuspositive,noredcellantibodiesdetectedfullblood
countisnormal.Sheisunsureaboutthemodeofdeliveryforthis
pregnancy.Youcounselherabouttherisksandbenefitsofvaginal
birthandcaesareansection
PleaseSelect
Incorrect
Theansweris36weeksofgestationwithapossibleinductionoflabour
between38and40weeksofgestation.Sheneedstobeseenagaininthe
thirdtrimestertoreassessherpreferredoptionfordeliveryandagreea
planofmanagementthatmayincludeinductionoflabour
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Antenatalstatistics
NumberNeededtoTreat(NNT)topreventoneaffectedcaseisacommonlyusedstatistictocounselandinformwomen
aboutthevalueofinterventionsinobstetrics.Fromtherangeofnumberslistedbelow,choosethemostaccurateNNTforthe
clinicalsituations.Eachanswermaybeusedonce,morethanonceornotatall.
A:110
B:1150
C:51100
D:101250
E:251500
F:501750
G:7511500
H:15013000
I:30016000
J:600112000
Forsingletonbreechpresentationatterm:thenumberofplanned
caesareansectionsneededtobeperformedtopreventoneperinatal
deathorseriousneonatalmorbidityduringthe6weekperiodafter
thebirth,whencomparedwithplannedvaginalbirth
PleaseSelect
Incorrect
Theansweris1150(30).Ifyouneedmoreinformationabouthowto
calculateNNTsyoucanrefertotheGreentopGuidelineonthatparticular
topic.Anothersourceofinformationistodoaninternetsearchusingthe
term"numberneededtotreat"andbrowsingthroughthesearchresults
thatarerelevanttoyouandyourquestion.
Forsingletonpretermbirth:theuseofintramuscularcorticosteroids
administeredtothemotherpriortopretermbirthtopreventone
neonataldeath
PleaseSelect
Incorrect
Theansweris1150(23).Seeexplanationtoquestion1.
ForneonatalearlyonsetgroupBstreptococcal(GBS)disease:the
numberofwomenreceivingintrapartumantibioticstopreventone
caseofneonataldeathattributabletoGBSdisease
PleaseSelect
Incorrect
https://stratog.rcog.org.uk/tutorial/emqsforthepart2mrcogonlineresource/antenatalstatistics30301
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Antenatalstatistics
Forwomenatmoderateriskofdevelopingpreeclampsia:the
numberofwomentakinglowdoseaspirintopreventonecaseof
preeclampsiainpregnancy
PleaseSelect
Incorrect
Forpregnantwomenwithpreeclampsia:thenumberofwomen
receivingmagnesiumsulfatetopreventonecaseofseizure
PleaseSelect
Incorrect
Forroutineinductionoflabourat41weeksofgestation:thenumber
ofwomenwithasingletonuncomplicatedpregnancyundergoinga
plannedinductionoflabourand/orcaesareansectiontopreventone
perinataldeathwhencomparedwithwomenundergoing
spontaneouslabour
PleaseSelect
Incorrect
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Antenatalstatistics
NumberNeededtoTreat(NNT)topreventoneaffectedcaseisacommonlyusedstatistictocounselandinformwomen
aboutthevalueofinterventionsinobstetrics.Fromtherangeofnumberslistedbelow,choosethemostaccurateNNTforthe
clinicalsituations.Eachanswermaybeusedonce,morethanonceornotatall.
A:110
B:1150
C:51100
D:101250
E:251500
F:501750
G:7511500
H:15013000
I:30016000
J:600112000
Forsingletonbreechpresentationatterm:thenumberofplanned
caesareansectionsneededtobeperformedtopreventoneperinatal
deathorseriousneonatalmorbidityduringthe6weekperiodafter
thebirth,whencomparedwithplannedvaginalbirth
PleaseSelect
Incorrect
Theansweris1150(30).Ifyouneedmoreinformationabouthowto
calculateNNTsyoucanrefertotheGreentopGuidelineonthatparticular
topic.Anothersourceofinformationistodoaninternetsearchusingthe
term"numberneededtotreat"andbrowsingthroughthesearchresults
thatarerelevanttoyouandyourquestion.
Forsingletonpretermbirth:theuseofintramuscularcorticosteroids
administeredtothemotherpriortopretermbirthtopreventone
neonataldeath
PleaseSelect
Incorrect
ForneonatalearlyonsetgroupBstreptococcal(GBS)disease:the
numberofwomenreceivingintrapartumantibioticstopreventone
caseofneonataldeathattributabletoGBSdisease
PleaseSelect
Incorrect
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Antenatalstatistics
Forwomenatmoderateriskofdevelopingpreeclampsia:the
numberofwomentakinglowdoseaspirintopreventonecaseof
preeclampsiainpregnancy
PleaseSelect
Incorrect
Forpregnantwomenwithpreeclampsia:thenumberofwomen
receivingmagnesiumsulfatetopreventonecaseofseizure
PleaseSelect
Incorrect
Forroutineinductionoflabourat41weeksofgestation:thenumber
ofwomenwithasingletonuncomplicatedpregnancyundergoinga
plannedinductionoflabourand/orcaesareansectiontopreventone
perinataldeathwhencomparedwithwomenundergoing
spontaneouslabour
PleaseSelect
Incorrect
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Consentmanagement
Foreachofthescenariosdescribedchoosethesinglemostappropriatestatementconcerningtheobtainingofpatient
consentwithrespecttothelawinEngland.Eachoptionmaybeusedonce,morethanonce,ornotatall.
A:Abandonoperativeprocedureandreschedule
B:Defertheoperativeprocedure
C:Frasercompetencemustbedemonstrablebeforeobtainingconsent
D:Obtainlegaladviceonindividualswhowithholdconsentfortreatment
E:ObtainlegaladviceoninterpretationontheAbortionAct1967
F:ObtainlegaladviceoninterpretationontheHumanFertilisationand
EmbryologyAct1990andtheCodeofPracticeofHumanFertilisationand
EmbryologyAuthorityAct2009
G:ObtainlegaladviceoninterpretationontheMentalCapacityAct2005
H:Parentalconsentmustbeobtainedbeforeproceeding
I:Paternalconsentmustbeobtainedbeforeproceeding
J:Performadditionalprocedurewithoutexplicitconsenttodoso
K:Proceedwithoutconsentinordertosavethefetuslife
L:Proceedwithoutconsentinordertosavethewomanslife
M:Respecttherightsoftheputativefatherofthefetustowithhold
consent
N:Respecttherightsoftheunbornfetusandproceedtodelivery
O:Respecttherightsofthewomantowithholdconsentfortreatment
P:Specificconsentisunnecessary
Q:Verbalconsentaloneisacceptable
R:Verbalconsentwithwitnessandcasenotedocumentation
S:Writtenconsentmustbeobtained
Acouplearereferredtothefertilityservicebecausethe24yearold
malepartnerhasdevelopedtesticularcancerthatwillrequire
orchidectomyfollowedbychemotherapy.Theywishtohavehis
semenstoredforartificialinseminationofhiswifeifhewereto
becomeazoospermicinthefuture
PleaseSelect
Incorrect
Theansweriswrittenconsentmustbeobtained.
RoyalCollegeofObstetriciansandGynaecologists.ObtainingValid
Consent.ClinicalGovernanceAdvice6.London:RCOG2015.
A13yearoldgirlrequiresahymenotomytotreather
cryptamenorrhoea
https://stratog.rcog.org.uk/tutorial/emqsforthepart2mrcogonlineresource/consentmanagement30289
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Consentmanagement
PleaseSelect
Incorrect
Theanswerisparentalconsentmustbeobtainedbeforeproceeding.
A14yearoldgirlattendsthegynaecologyclinicrequestinga
terminationofpregnancy.Herlastperiodwas10weeksago.She
doesnotwantherparentstoknow
PleaseSelect
Incorrect
TheanswerisFrasercompetencemustbedemonstrablebeforeobtaining
consent.
A19yearoldwomansufferingfromDownsyndromeisreferredto
thegynaecologyclinicwithanabdominalmassthatneedsan
exploratorylaparotomy.Sheisanorphanandlivesinaresidential
carehomeandisaccompaniedtotheclinicbyoneofthehomes
healthcareassistants.ShehasalowIQ
PleaseSelect
Incorrect
TheanswerisobtainlegaladviceoninterpretationontheMentalCapacity
Act2005.
An18yearoldwomanistobeseenbytheconsultantgynaecologist
whoisaccompaniedbyamedicalstudentasapartofhisclinical
attachment
PleaseSelect
Incorrect
Theanswerisverbalconsentaloneisacceptable.
A39yearoldwoman,P4,hasattendedthedaycasesurgicalunitfor
asurgicalterminationofpregnancyandinsertionofaMirenaIUS
forwhichsheconsentedforaweekbeforeintheoutpatientclinic.
Shenowappearssomewhatupsetandreticentaboutundergoingthe
procedure
PleaseSelect
Incorrect
Theanswerisdefertheoperativeprocedure.
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Coresurgicalskills
Fromeachofthescenariosdescribedchoosethesinglemostsuitableproductfortheprocedurefromthelistbelow.Each
optioncanbeusedonce,morethanonceornotatall.NotethatthetableistakenfromtheformerRCOGBasicSurgicalSkills
course.
Option Product
Description
Needle
Gauge
Coatedvicryl
Braidedpolyglactin
Halfcircle,roundbodied
30
Coatedvicryl
Braidedpolyglactin
Jneedle,roundbodied,
heavy
20
Coatedvicryl
Braidedpolyglactin
Dermabond
Topicalskinadhesive
None
Endoloop
ligature
Braidedpolyglactin
None
Mersilene
Polyesterfibre
Bluntpoint,halfcircle,
double
5mm
Monocryl
Monofilament:polypropylene
Nylon
Monofilament
Straightcutting
PDS
Monofilament:polydioxanone
30
PDS
Monofilament:polydioxanone
, Blunt,taperpoint,halfcircle,
looped
heavy
Prolene
Monofilament:polypropylene Curveddouble
60
Prolene
Monofilament:polypropylene Curved,reversecutting
40
Stainlesssteel
wire
Multifilament
Tapercut,roundbodied
2mm
Steristrips
Skinadhesivestrips
None
VicrylRapide
Braidedpolyglactin
Tapercut,halfcircle
20
A:Coatedvicryl/Braidedpolyglactin/Halfcircle,roundbodied/30
B:Coatedvicryl
/Braidedpolyglactin
/Jneedle,roundbodied,heavy/
20
C:Coatedvicryl/Braidedpolyglactin/Halfcircle,roundbodied/0
D:Dermabond
/Topicalskinadhesive/None
E:Endoloop
ligature/Braidedpolyglactin/None/0
F:Mersilene
/Polyesterfibre/Bluntpoint,halfcircle,double/5mm
G:Monocryl
/Monofilament:polypropylene/Halfcircle,roundbodied/1
H:Nylon/Monofilament/Straightcutting/0
I:PDS/Monofilament:polydioxanone/Halfcircle,roundbodied/30
J:PDS/Monofilament:polydioxanone
,looped/Blunt,taperpoint,half
circle,heavy/0
K:Prolene
/Monofilament:polypropylene
/Curveddouble/60
L:Prolene
/Monofilament:polypropylene
/Curved,reversecutting/40
M:Stainlesssteelwire/Multifilament/Tapercut,roundbodied/2mm
https://stratog.rcog.org.uk/tutorial/emqsforthepart2mrcogonlineresource/coresurgicalskills30279
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Coresurgicalskills
N:Steristrips/Skinadhesivestrips/None
O:VicrylRapide
/Braidedpolyglactin
/Tapercut,halfcircle/20
A29yearoldwoman,P2,hashadarapidbirthofahealthymale
infantattermwithextensiveperinealtrauma.Intheatre,afourth
degreetearisdiagnosedandtheanorectalmucosahasbeen
suturedandtheexternalandinternalanalsphinctersnowneedtobe
sutured
PleaseSelect
Incorrect
Theansweriscoatedvicryl/braidedpolyglactin/halfcircle,round
bodied/30.
RoyalCollegeofObstetriciansandGynaecologists.Managementof
ThirdandFourthdegreePerinealTears.GreentopGuideline
29.London:RCOG2015.
A27yearoldwomanhashadtwosecondtrimestermiscarriages
andhashadadiagnosisofcervicalweakness.Sheisnow14weeks
pregnantandisgoingtohaveacervicalcerclageprocedureinan
attempttogainasuccessfuloutcomeforthispregnancy
PleaseSelect
Incorrect
TheanswerisMersilene/polyesterfibre/bluntpoint,halfcircle,double
/5mm.
A37yearoldwoman,P4andwithaBMIof32,hasundergonea
laparotomyusingamidlinesubumbilicalincisiontoremovean
abdominalmasswhichwasconfirmedasabenignenlargedfibroid
uterusnowtheplanistoclosetheperitoneumandrectussheath
PleaseSelect
Incorrect
TheanswerisPDS/monofilament:polydioxanone,looped/blunt,
taperpoint,halfcircle,heavy/0.
A39yearoldwomaninherfirstpregnancyhasarotationalforceps
deliverywithanepisiotomyintheatrewitheffectiveepidural
analgesiaafteraprolongedlabour.Inspectionofthelowergenital
tractrevealsdamageabovetheepisiotomyincisionanda2cm
buttonholedefectinthevaginathatincludestheanorectalmucosa
isidentifiedandnowhastobesutured
PleaseSelect
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Coresurgicalskills
Incorrect
TheanswerisCoatedvicryl/braidedpolyglactin/halfcircle,round
bodies/30.
RoyalCollegeofObstetriciansandGynaecologists.Managementof
ThirdandFourthdegreePerinealTears.GreentopGuideline
29.London:RCOG2015.
A16yearoldwomanhadanormalbirthofahealthymaleinfantwith
theaidofarightmediolateralepisiotomyperformedbythemidwife.
Thethirdstageoflabouriscompletedwithminimalbloodlossthe
vaginaandperinealmusclelayerhavebeensuturednowthe
perinealskinneedstobeclosed
PleaseSelect
Incorrect
TheanswerisVicryRapide/braidedpolyglactin/tapercut,halfcircle/
20.
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Earlypregnancycare
Fromthefollowingclinicalscenariosbelow,choosethesinglemostappropriatemanagementoptionfromtheoptionlist.
Whererelevant,itcanbeassumedthatineachcasethewomanhasbeenregisteredwiththenearestTrophoblastic
ScreeningandTreatmentCentre.Eachanswermaybeusedonce,morethanonceornotatall.
A:Dilatationofthecervixanduterinecurettage
B:Hysterectomyandbilateralsalpingooophorectomy
C:Intramuscularmethotrexateandfolinicacid
D:Intravenousmultiagentchemotherapy
E:MeasureserumhCG68weeksafterthepregnancy
F:Medicalterminationofpregnancy
G:Oxytocininfusiontostoputerinehaemorrhagepriortosuction
evacuationoftheuterus
H:Prenatalinvasivetestingforfetalkaryotype
I:Prostaglandincervicalripeningpriortosuctionevacuationoftheuterus
J:Secondsuctionevacuationoftheuterus
K:Suctionevacuationoftheuterus
L:SuctionevacuationoftheuterusandinsertionofMirenaintrauterine
deliverysystem
M:SuctionevacuationoftheuterusandpostoperativeantiDprophylaxis
N:Suctionevacuationoftheuteruswithantibioticprophylaxis
O:Testsandtreatmentnotrequired
A28yearoldwomanhadasurgicalevacuationoftheuterusforan
incompletespontaneousmiscarriage3monthsagoandthe
histologyconfirmedamolarpregnancy.Shehashadirregular
vaginalbleedingsincetheprocedurewithepisodesofdyspnoeaand
haemoptysis.Investigationresultsareasfollows:
fullbloodcount:haemoglobin9.6g/l,otherwisenormal
liverandrenalfunctiontests:normal
bloodgroup:ARhpositive
serumhCG:98457IU/lCA125:275U/lAFP:24u/lTSH:1.4mU/l
pelvicultrasoundscan:4.5cmintrauterinelesion?polyp
bilateralovarianenlargementwithmultiplesmallcystsinboth
ovaries(6cmand7cmmaximumdiameters)nofreefluid
CXR:threeparenchymalnodulesrangingfrom1.02.5cminleft
upperlobeheartsizenormalnohilarenlargement
MRIscan:noevidenceofothermetastaticlesions
PleaseSelect
Incorrect
Theanswerisintramuscularmethotrexateandfolinicacid.
RoyalCollegeofObstetriciansandGynaecologists.Gestational
TrophoblasticDisease.GreentopGuideline38.London:RCOG2010.
https://stratog.rcog.org.uk/tutorial/emqsforthepart2mrcogonlineresource/earlypregnancycare30290
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Earlypregnancycare
A34yearoldwoman,P3,presentswithsomevaginalbleedingat16
weeksofgestationandapelvicultrasoundscanindicatesa
diagnosisofapartialmolarpregnancy.Onexaminationtheuterusis
palpatedattheleveloftheumbilicusthecervixlooksnormalandis
closedthereisfreshbloodandclotsinthevaginal.Investigation
resultsareasfollows:
Liverandrenalfunctiontestsnormal
bloodgroup:ABRhpositive
serumhCG:148457IU/lTSH:3.1mU/l
PleaseSelect
Incorrect
Theanswerismedicalterminationofpregnancy.
A24yearoldnulliparouswomanpresentswithsomevaginal
bleedingat10weeksofgestationandapelvicultrasoundscan
indicatesadiagnosisofamolarpregnancy.Onexaminationthe
uterusis14weeksizedthecervixlooksnormalandisclosedthere
isfreshbloodandclotsinthevaginal.Investigationresultsareas
follows:
bloodgroup:ABRhnegative
serumhCG:148457iu/lTSH:1.9mU/l
PleaseSelect
Incorrect
TheanswerissuctionevacuationoftheuterusandpostoperativeantiD
prophylaxis.
A27yearoldwoman,P1,presentswithheavyvaginalbleedingand
crampyperiodlikepainsat10weeksofgestation.Onexamination
shelookspaleBP:100/60mmHgpulserate:104bpmtheuterusis
14weeksizedthecervixisopenandthereisalotfreshbloodand
clotsinthevaginaltogetherwithcopiousvesicularplacentaltissue.
Investigationresultsareasfollows:
bloodgroup:ORhpositive
PleaseSelect
Incorrect
Theanswerissuctionevacuationoftheuterus.
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Earlypregnancycare
A41yearoldwomanhasasurgicalevacuationoftheuterusforan
incompletespontaneousmiscarriageinherfirstpregnancy6
monthsagoandthehistologyshowedamolarpregnancy.Shehas
hadirregularvaginalbleedingsincetheprocedurewithnoother
symptoms.Investigationresultsareasfollows:
bloodgroup:ARhnegative
serumhCG:488457IU/lCA125:121U/l
thyroidfunctiontests:normal
pelvicultrasoundscan:5.5cmintrauterinelesion?polyp
bilateralovarianenlargementwithmultiplesmallcystsinboth
ovaries(6cmand7cmmaximumdiameters)nofreefluid
CXR:normal
MRIscan:noevidenceofmetastaticlesions
PleaseSelect
Incorrect
Theanswerisintravenousmultiagentchemotherapy.Althoughthismay
seemabittoospecialisedforanST5itisintheguidelineandtrainees
shouldbeawareoftheconditionsaretowarrantintravenous
chemotherapy,thatistosay,adeepknowledgeofthesubjectratherthan
asuperficialone.
A39yearoldwoman,P4,presentsat10weeksofgestationwith
recurrentvomiting.Onexaminationtheuterusispalpatedat
approximately16weeksized.Apelvicultrasoundscanindicatesa
twinpregnancywithapossiblediagnosisofapartialmolar
pregnancyinoneofthetwins.Investigationresultsareasfollows:
bloodgroup:ABRhpositive
serumhCG:348457IU/l
thyroidfunctionfreeT4:26pmol/lfreeT3:6.3pmol/lTSH<
0.1mU/l
PleaseSelect
Incorrect
Theanswerisprenatalinvasivetestingforfetalkaryotype.
A39yearoldwomanhasjustdeliveredahealthyfemaleinfantafter
anuncomplicatedsecondpregnancyandplanstobreastfeedher
bloodgroupisBRhnegative.Tenyearsbeforeshehada
terminationofpregnancyforapartialmolarpregnancywith
appropriatemonitoringandwasdischargedafter6monthswithno
furthertreatmentnecessary
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Earlypregnancycare
PleaseSelect
Incorrect
TheanswerismeasureserumhCG68weeksafterthepregnancy.
A23yearoldnulliparouswomanpresentswith1weekofbrown
vaginalbleedingherLMPwas14weeksagoshedoesnotfeelasif
sheispregnantanymore.Onexaminationtheuterusis10week
sizedthecervixlooksnormalandisclosedthereisoldbloodand
browndischargeinthevagina.Apelvicultrasoundscanshowsa
smallfetuswithnofetalheartactionandacollapsedgestationalsac.
Investigationresultsareasfollows:
bloodgroup:ABRhnegative
serumhCG:2057IU/l
thyroidfunction:normal.
Afteranevacuationoftheuterusthehistologyconfirmsfetalparts
andnormaltrophoblastwithareasofmolardegeneration
PleaseSelect
Incorrect
Theansweristestsandtreatmentnotrequired.
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Gynaecologicaloncology
Fromtheclinicalscenarioschoosethesinglemostlikelydiagnosisfromtheoptionlist.Eachanswermaybeusedonce,more
thanonceornotatall.
A:Bcelllymphomaoftheovary
B:Carcinomatosis
C:Cervicalcarcinoma
D:Choriocarcinoma
E:Endodermalsinustumour
F:Endometrialadenocarcinoma
G:Krukenbergtumour
H:Malignantdermoidteratoma
I:Malignantmelanoma
J:Mixedmesodermaltumour
K:Mucinouscystadenocarcinoma
L:Ovarianendometroidcarcinoma
M:Pelvicactinomycoticgranulomata
N:Squamouscellcarcinoma
O:Tuboovarianabscess
P:Uterinesarcoma
A29yearoldwoman,P2+1isreferredwithirregularvaginalbleeding
sinceshehadanuncomplicatedterminationofpregnancy3months
ago.OnexaminationBMI:19shelookspaleandunwellthe
abdomenissoftandnottenderthevaginalexaminationrevealeda
bulkyuterus,normalclosedcervixnopelvicmassesasmallred
friablelesionof2cmintheleftperiurethralspace
PleaseSelect
Incorrect
Theanswerischoriocarcinoma.Presentationsofadvanced
gynaecologicaltumoursareselfexplanatorybutyoucandiscussthese
withyourlocaltraineefriendlygynaecologicaloncologistifyouwouldlike
furtherinformation.
Ahealthy23yearoldwoman,P0+1,presentstoherGPwithpelvic
pain.Ultrasoundexaminationofthepelvisshowsan8cmdiameter,
solidmassarisingfromtheleftovary,thereisnofreefluid,andthe
rightovaryanduterusarenormal.Shehadanuncomplicated
terminationofpregnancy6monthsago.Herperiodshavebeen
normalandshehasaMirenaIUSforcontraception.Thereisno
relevantpastmedicalorsurgicalhistoryandherfamilyhistoryis
unremarkable.Thefollowingbloodresultswereobtained:
liverfunctiontests:normal
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fullbloodcount:normal
urea,creatinineandelectrolytes:normal
hCG<5IU/l
AFP:24600U/ml
CA125:27U/ml
PleaseSelect
Incorrect
Theanswerisendodermalsinustumour.
A69yearoldP4womanisreferredbyherGPwithincreasing
drowsinessandconfusion.Abdominalexaminationisnormaland
thereisnolymphadenopathyrectalexaminationrevealsafirmfixed
pelvicmass.Bloodtestsrevealthatsheisuraemic.
PleaseSelect
Incorrect
Theansweriscervicalcarcinoma.
A42yearoldwoman,P3,isadmittedtotheintensivecareunitin
statusepilepticus.Shehasnotsufferedfromepilepsyinthepast.
Shesmokes25cigarettesadayandotherwiseisingoodhealth.She
hasbeensterilised.Whileshewasbeingcatheterisedthenurse
noticedasmalldarkbrownraisedlesionneartheuretheralorificeon
theleftlabiaabout1cmindiameterandwithbilateralinguinal
lymphadenopathy
PleaseSelect
Incorrect
Theanswerismalignantmelanoma.
A64yearoldwomanisadmittedwithabowelobstruction.Shehasa
2dayhistoryofabdominalpainandvomiting.Shehasapast
medicalhistoryofirritablebowelsyndrome,diverticulosisand
breastcancer,whichwastreatedsuccessfullyover5yearsago.
Duringthelaparotomythesurgeonconfirmsadiverticularabscess
andobstructionofthesigmoidcolon.Hecallsforagynaecologistto
giveanopinionaboutbilateralovarianenlargementuptoabout67
cm,solidwithnodulescoveringthesurfaces
PleaseSelect
Incorrect
TheanswerisKrukenbergtumour.
A59yearoldwoman,P2,isreferredwithvagueabdominalpains,
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malaise,heartburnandweightloss.Anultrasoundscanshows
bilateralenlarged(910cmdiametereach)ovarieswithmultiple
cysts,anormaluterus,nofreefluidnormalliverandkidneys.There
isafamilyhistoryofbowelcancerandshehasbeenoncombined
HRTsincethemenopause.Bloodresults:
liverfunctiontests:normal
fullbloodcount:normal
urea,creatinineandelectrolytes:normal
hCG<5IU/l
AFP:19U/ml
CA125:251U/ml
PleaseSelect
Incorrect
Theanswerismucinouscystadenocarcinoma.
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Managementofgynaecologicalproblems
Foreachoftheclinicalscenariosdescribed,choosethemostappropriatemanagementoptionfromthelist.Eachoptionmay
beusedonce,morethanonce,ornotatall.
A:Combinedoralcontraceptivepillcontaining20micrograms
ethinylestradiol
B:Desogestrel75microgramstabletdailyandreviewin3months
C:Endometrialresection
D:Hysterectomywithbilateralsalpingooophorectomy
E:Hysteroscopyandendometrialcurettage
F:LevonorgestrelIUS(Mirena)
G:Medroxyprogesteroneacetate10mgtabletdailyfor90daysthen
review
H:Medroxyprogesteroneacetate10mgtabletfor10daysinevery28for
6months
I:Norethisterone5mgtabletdailyfor7daysevery6weeks
J:Performacervicalcytologicalsmear
K:Raloxifene60mgtabletdaily
L:Reassureanddischarge
M:SequentialcombinedHRT
N:Subtotalhysterectomy
O:Totalhysterectomy
P:Vaginalestrogentherapy
A44yearoldnulliparouswomanwithtype2diabetesandaBMIof
37isshowntohaveendometrialcomplexhyperplasiawithout
cellularatypiafollowingahysteroscopyandbiopsyfor
intermenstrualandprolongedvaginalbleeding.Arecentcervical
smearwasnormal
PleaseSelect
Incorrect
TheanswerislevonorgestrelIUS(Mirena).Notethatthemanagement
ofwomenwithendometrialhyperplasiaisgenerallyansweredpoorlyin
thePart2MRCOGexamination.Itmustbeunderstoodthatthe
endometrialhistologyremainingintheuterusmaybeworsethanthe
reportonthebiopsiedsampleandtheoverallriskofdevelopingan
endometrialtumourshouldbeconsidered.Also,notalluterinetumours
arehormonedependent.
OtifyM,FullerJ,RossJ,ShaikhH,JohnsJ.Endometrialpathologyin
thepostmenopausalwomananevidencebasedapproachto
management.TheObstetrician&Gynaecologist201517:29938.
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A52yearoldwoman,P3withaBMIof32presentstohergeneral
practitionerwithirregularvaginalbleeding.Atransvaginal
ultrasoundscanofthepelvisdemonstratesanendometrial
thicknessof14mmandthehistologyofanoutpatientbiopsyofthe
endometriumrevealedsimplehyperplasiawithnocellularatypia.
Abdominalandpelvicexaminationisnormalapartfromagrade1
cystocele
PleaseSelect
Incorrect
Theanswerishysteroscopyandendometrialcurettage
.
A48yearoldwoman,P1withaBMIof27,hadanendometrial
ablationforheavymenstrualbleedingandwasfoundtohave
complexendometrialhyperplasiawithmoderatecellularatypiaona
biopsytakenatthetimeoftheprocedure,althoughthepretreatment
hysteroscopywasrecordedasnormalintheoperativenotes.The
pelvicexaminationatthesametimewasunremarkable
PleaseSelect
Incorrect
Theanswerishysterectomywithbilateralsalpingooophorectomy.
A53yearoldwoman,P2withaBMIof25presentswithlightvaginal
bleedingfollowing6monthsofamenorrhoea.Abdominalandpelvic
examinationsarenormalapartfromaslightlyenlargeduterus.A
transvaginalultrasoundscanofthepelvisshowsseveralsmall
subserosalfibroidswitharegularendometrialthicknessof3.9mm.
SheisconcernedbecausethereisafamilyhistoryofLynch
syndrome(hereditarynonpolyposiscoloniccancer)
PleaseSelect
Incorrect
Theanswerishysteroscopyandendometrialcurettage.
A44yearoldnulligravidwomanwithtype2diabetesandaBMIof37
isshowntohaveendometrialcomplexhyperplasiawithoutcellular
atypiaafterahysteroscopyandbiopsyinvestigatingintermenstrual
andprolongedvaginalbleeding.Arecentcervicalsmearwasnormal
andsheisknowntohaveasignificantuterineMllerianfusion
defectassociatedwithastructuralrenaltractabnormalitywith
normalrenalfunction
PleaseSelect
Incorrect
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Theanswerismedroxyprogesteroneacetate10mgtabletdailyfor90
days.
A40yearoldwoman,P2,istakingtamoxifenfollowingsurgeryfor
anestrogenreceptorandprogesteronepositivebreastcancer2
yearsago.Sheisreferredbyherbreastsurgeonforconsultation
becauseshehasbeenexperiencingirregularvaginalbleedingfor
thelastfewmonths.Thehistologyfollowingahysteroscopyand
curettageshowsendometrialhyperplasiawithmildcellularatypia
andsegmentsofabenignendometrialpolyp.Shehasbeen
sterilisedandherlastroutinecervicalsmearwasnormal
PleaseSelect
Incorrect
Theanswerishysterectomywithbilateralsalpingooophorectomy.
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Managementoflabouranddelivery
Forthefollowingclinicalscenarios,chosethesinglemostappropriatemanagementoptionfromthelist.Eachanswermaybe
usedonce,morethanonceornotatall.
A:Administerterbutalinetothemother
B:Asktheattendantmidwifetoperformavaginalexaminationand
artificialruptureoffetalmembranes
C:Commenceoxytocininfusionandreassessprogressofthelabourin30
minutes
D:Commenceoxytocininfusionandreassessprogressofthelabourin2
hours
E:Commenceoxytocininfusionandreassessprogressofthelabourin4
hours
F:Deliverbycategory1caesareansection
G:Deliverbycategory2caesareansection
H:Epiduralanalgesiatobecommencedfollowedbyoxytocininfusion
I:InducelabourbyARMandcommenceoxytocininfusion
J:Manualcervicaldilationpriortoinstrumentaldeliveryintheatre
K:PerformfetalbloodsampleforapHestimation
L:Prepareforassisted/instrumentaldeliveryinthelabourroom
M:Reassessprogressofthelabourin30minutes
N:Reassessprogressofthelabourin2hours
O:Transfertooperatingtheatreforareassessmentwithviewtoan
instrumentaldelivery
P:Ultrasoundscanningtoconfirmthefetalpresentingpartandplacental
localisation
A23yearoldhasundergoneaninductionoflabourat41weeks+6
daysinherfirstpregnancy.Theantenatalcarewascomplicatedwith
anadmissiontohospitalwithasmallpainfulantepartum
haemorrhageat34weeksofgestation.Thesymptomssettled
spontaneouslyandallinvestigationsandmonitoringwerenormal
herbloodgroupisABRhpositive.Vaginalprostaglandingel
insertionestablishedlabourwithin3hoursandthelabour
progressedsuchthat6hourslaterthecervixwas8cmdilatedwith
meconiumstainedliquorwithasatisfactoryCTG,andepidural
anaesthesiawasinstigated.Threehourslater,thefetalheadwas
onefifthpalpableabdominallythecervixwas9cmdilatedthe
positionwasleftocciptolateralwithminimalcaputandmoulding
theCTGhadabaselineof165beatsperminutewithnobaseline
variabilitynoaccelerationsordecelerationsandasmallamountof
postexaminationvaginalbleedingwasnoted.Thefetalheartrate
thenunexpectedlydropsto85beatsperminute
anddoesnot
recover
PleaseSelect
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Incorrect
Theansweristransfertotheoperatingtheatreforareassessmentwith
viewtoaninstrumentaldelivery.
A34yearoldwoman,P2,isadmittedinstronglabourat37weeksof
gestation.Shehashadallherantenatalcarewithhercommunity
midwife.Shehashadtwonormalbirthsofhealthybabiesboth
weighingover3.3kg.Therehavebeennoproblemsduringthis
pregnancy.Asshearrivesshebeginsinvoluntarypushing,
meconiumstainedliquorisdrainingandtheattendingmidwife
examinesheranddiagnosesabreechpresentationwithsacro
anteriorposition.Thefetalheartrateisdroppingto80beatsper
minute
witheachcontractionwithslowrecoverybackto120beats
perminute
inbetweencontractions.Sheiscontractingthreetimes
every10minutesandisdistressedwithpainbutpushingwell.The
breechisdescendingthroughthebirthcanalsatisfactorilyandthe
stationisnowwellbelowtheischialspines.Thefetalheartrate
baselineisnow100beatsperminutewithdecelerationsdownto50
beatsperminuteduringmaternalpushingeffort
PleaseSelect
Incorrect
Theanswerisprepareforassisted/instrumentaldeliveryinthelabour
room.
A31yearoldwomaninherfirstpregnancyandwithaBMIof25is
admittedinspontaneouslabourat41weeksofgestationaftera
straightforwardnormalpregnancy.Shehashadmostofher
antenatalcarewithhercommunitymidwife.Shereportsreduced
fetalmovementsforthelast24hoursandasmallamountoffresh
vaginalbleedingpriortoadmission.Sheisdistressedand
contractingfourtimesevery10minutes.Onexamination:SFHis34
cmlongitudinalliepresentingpartiscephalicwithtwofifths
palpable.Avaginalexaminationrevealsthatthecervixis5cm
dilatedpresentingpartvertexrightocciptolateralpositionwith
minimalcaputandmouldingbloodstainedliquorisdraining.The
CTGshows40minutesoftracewithanormalbaselinerateof140
littleornobaselinevariability,noaccelerationsnodecelerations
PleaseSelect
Incorrect
Theanswerisdeliverbycategory1caesareansection.
A21yearoldwoman,P1andwithaBMIof22,isadmittedin
spontaneouslabourat37weeksofgestationafterastraightforward
normalpregnancy.Shehashadallherantenatalcarewithher
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communitymidwifeandhadanormalbirthofherfirstchild,
birthweight3305g.Shereportsreducedfetalmovementsforthelast
24hoursthereisnohistoryofanyvaginalbleeding.Sheis
contractingtwiceevery10minutes.Onexamination:symphysial
fundalheight(SFH)is38cmlongitudinalliepresentingpartis
cephalicwiththreefifthspalpable.Thefetalheartrateis140beats
perminuteandregularwithoneaudibledeceleration.TheCTG
shows20minutesoftracewithanormalbaselinerateof140littleor
nobaselinevariability,noaccelerationsnodecelerations
PleaseSelect
Incorrect
Theanswerisasktheattendantmidwifetoperformavaginalexamination
andartificialruptureoffetalmembranes.
A17yearoldwoman,inherfirstpregnancyandwithaBMI21,is
admittedfromhomeat23weeksofgestationinspontaneouslabour
afteralargeamountofvaginalbleedingandabdominalpain,which
wokeherup.Priortothisepisodeherpregnancyhadbeen
progressingnormally.Sheisverydistressedandpale.On
examinationherBPis140/85mmHgpulseis104beatsperminute
uterushardandtenderfetalheatrate104beatsperminutewith
audibledecelerationsto60beatsperminutevaginalexamination
cervixis6cmdilatedpresentingpartbreechwithmembranesintact
andfreshbleedingandclots
PleaseSelect
Incorrect
Theansweriscommenceoxytocininfusionandreassessprogressofthe
labourin30minutes.Notethatthisisarealliveexamplecaesarean
section/hysterotomyisdangerousforthemotherandthefetusisvery
unlikelytosurvivetheinsultsofextremeprematurityandabruptionthe
onlywaytostopthehaemorrhageisbyuterinecontractionuntilthebaby
isdelivered/miscarried.Althoughthisisaconsultantdecision,thisisa
goodvicariouslearningopportunity.
A41yearoldwoman,inherfirstpregnancyandwithaBMIof32,is
admittedinspontaneouslabourat39weeksofgestationaftera
straightforwardnormalpregnancy.Shehashadmostofher
antenatalcarewithhercommunitymidwife.Shereportsreduced
fetalmovementsforthelast24hoursthereisnohistoryofany
vaginalbleeding.Sheisdistressedandcontractingfourtimesevery
10minutes.Onexamination:symphysialfundalheight(SFH)is35
cmlongitudinalliepresentingpartiscephalicwithonefifth
palpable.Thefetalheartrateis140beatsperminuteandregular
withoneaudibledeceleration.Avaginalexaminationrevealsthe
cervixis8cmdilatedpresentingpartvertexocciptoanterior
positionwithminimalcaputandmouldingclearliquorisdraining.
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TheCTGshows20minutesoftracewithanormalbaselinerateof
140littleornobaselinevariability,noaccelerationsno
decelerations
PleaseSelect
Incorrect
TheanswerisperformfetalbloodsampleforapHestimation.
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Managementofsexualandreproductivehealth
Foreachofthescenariosdescribedbelow,choosethesinglemostcosteffectiveandappropriatecontraception.Eachoption
maybeusedonce,morethanonce,ornotatall.
A:CopperT380Aintrauterinecontraceptivedevice
B:Desogestrel75microgramtablets
C:Ethinylestradiol35microgram+cyproteroneacetate2mgtablets
D:Ethinylestradiol30microgram+desogestrel150microgramtablets
E:Ethinylestradiol30microgram+drospirenone3mgtablets
F:Ethinylestradiol35microgram+gestodene75microgramtablets
G:Ethinylestradiol30microgram+levonorgestrel150microgramtablets
H:Ethinylestradiol20microgram+norethisteroneacetate1mgtablets
I:IMinjectionofmedroxyprogesteroneacetate150mg
J:Implantcontainingetonogestrel68mg
K:Levonorgestrelreleasingintrauterinedeliverysystem
L:Mestranol50microgram+norethisterone1mgtablets
M:Norethisterone350microgramtablets
N:Siliconecontraceptivediaphragmwithnonoxinol92%gel
O:Transdermalpatchcontainingethinylestradiol+norelgestromin
P:Vaginalringcontainingethinylestradiol+etonogestrel
A28yearoldnulliparouswomangotoffabusandslippedand
sufferedadepressedfractureoftheacetabulum.ADEXAbone
mineraldensityscanrevealsosteopeniaofthehipandlumbar
vertebrae(Tscore2.0,2.2respectively).Shehasbeen
amenorrhoeicsinceinsertionsofNexplanon(etonogestrel),which
shehasbeenusingfor8years.HerBMIis17BPis120/60mmHg
PleaseSelect
Incorrect
Thecorrectanswerisethinylestradiol30microgram+levonorgestrel150
microgramtablets.
ThekeytoansweringthequestionsinthisEMQisthephraseinthe
instructions:thesinglemostcosteffectiveandappropriate
contraception.SeealsotheBritishNationalFormulary.
A40yearoldP3marriedwomanhasfinishedhertamoxifen
treatmentforbreastcancer,whichwasdiagnosed5yearsago.Her
periodsarenowregularandnormalandhercervicalsmearsand
followupmammogramshaveallbeennormal.Sheisnowseeking
adviceaboutcontraception.HerBMIis23BPis135/75mmHg
PleaseSelect
Incorrect
https://stratog.rcog.org.uk/tutorial/emqsforthepart2mrcogonlineresource/managementofsexualandreproductivehealth30296
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Managementofsexualandreproductivehealth
ThecorrectansweriscopperT380Aintrauterinecontraceptivedevice.
EstrogencontainingpreparationsarecontraindicatedforwomenwithER+
breastcancer,whichthismustbeasshehasbeentreatedwithtamoxifen.
ProgestagenstooarecontraindicatedwithPR+tumoursandgenerally
bestavoidedaltogether.Pregnancymustbeavoidedtooandsothemost
reliableoptionforthismultiparouswomanistheCuT380Aandwilllastfor
10years.Strictlyspeaking,theMirenamaybeusedoncetamoxifen
treatmenthasbeencompletedbutismoreexpensiveandiseffectivefor5
yearsaccordingtothelicenceintheUK.
A37yearolddivorcedwoman,P4,presentswithheavyregular
periodsafterbeingadvisedtostopthecombinedoralcontraceptive
pill2yearsago.Theuseofcondomshasbecomeunacceptable.Her
BMIis29BPis135/85mmHg
PleaseSelect
Incorrect
Thecorrectanswerislevonorgestrelreleasingintrauterinedelivery
system.Thisisthemosteffectivechoiceforthismultiparouswomanwith
heavyregularperiodsandcontraceptiveneeds.
A24yearoldnulliparouswomanissoontobemarriedandrequests
contraception.Shecomplainsofunsightlyacneandsomehair
growthonherupperlipandchin.Herperiodsarenormalandcome
every56weeks.Onexamination:sheismoderatelyhirsuteandhas
somemildfacialacneandseborrhoeabutotherwiseisnormalBPis
120/66mmHgBMIis28
PleaseSelect
Incorrect
Thecorrectanswerisethinylestradiol35microgram+cyproteroneacetate
2mgtablets.ThiscombinedOCPislicensedtotreathirsutismandacne.
Allandrogenbasedprogestagensshouldbeavoidedinthiscase,i.e
thosederivedfrom19nortesterone(anythingwitha'nor'inthename).
Cyprotoneacetateisanandrogenantagonistwithaprogestagenicaction
(agonist).
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Managementofthelabourward
YouaretheST5registrarforlabourwarddoingareviewoftheactivitiescurrentlygoingoninthe14labourwardroomswith
theseniorlabourwardmidwife,anST2traineeforlabourwarddutiesandanST1traineewhoismainlyresponsibleforthe
gynaecologywardbutisavailableforlabourwarddutieswhennecessary.Thereisalsoalabourwardclerkavailablefor
logisticandadministrativedutiesonly.
Choosethesinglemostappropriateprofessionalneededtoperformthetaskineachoftheroomsdescribedwiththe
appropriateprioritylevelfromtheoptionlist.
A:Professional:ObstetricregistrarST5Prority:Now
B:Professional:ObstetricregistrarST5Prority:Afterfirsttaskwithin30
minutes
C:Professional:ObstetricregistrarST5Prority:Aftersecondtask
within60minutes
D:Professional:SeniormidwifeinchargePrority:Now
E:Professional:SeniormidwifeinchargePrority:Afterfirsttaskwithin
30minutes
F:Professional:SeniormidwifeinchargePrority:Aftersecondtask
within60minutes
G:Professional:ObstetricdoctorST2Prority:Now
H:Professional:ObstetricdoctorST2Prority:Afterfirsttaskwithin30
minutes
I:Professional:ObstetricdoctorST2Prority:Aftersecondtaskwithin
60minutes
J:Professional:GynaecologyoncalldoctorST1Prority:Now
K:Professional:GynaecologyoncalldoctorST1Prority:Afterfirsttask
within30minutes
L:Professional:GynaecologyoncalldoctorST1Prority:Aftersecond
taskwithin60minutes
M:Professional:LabourwardclerkPrority:Now
N:Professional:LabourwardclerkPrority:Afterfirsttaskwithin30
minutes
O:Professional:LabourwardclerkPrority:Aftersecondtaskwithin60
minutes
Room1:A23yearoldwomanwithdiabetesbeinginducedat37
weeksofgestationneedsanintravenouslineandcommencementof
adextrose/insulinslidingscalemostrecentbloodsugar7.9mmol/l
PleaseSelect
Incorrect
TheanswerisProfessional:Gynaecologyoncalldoctor
ST1Prority:Afterfirsttaskwithin30minutes
Room2:P1inspontaneouslabourat41weeksofgestationwith
clearliquorandgoodprogressneedsCTGreview
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PleaseSelect
Incorrect
TheanswerisProfessional:SeniormidwifeinchargePrority:Now
Room3:P1justabouttodeliverthickfreshmeconiumstained
liquorneedtosummonpaediatriciantobepresentatthebirth
PleaseSelect
Incorrect
TheanswerisProfessional:LabourwardclerkPrority:Now
Room4:P0,22weeksofgestation,justadmittedinwhatappearsto
beearlyspontaneouslabourmidwifecannothearthefetalheart
PleaseSelect
Incorrect
TheanswerisProfessional:ObstetricregistrarST5Prority:After
secondtaskwithin60minutes.
Room5:Womandeliverednormallyneedstransferringtothe
postnatalwardtoallowtheroomtobemadereadyforthewoman
labouringinthewaitingroom
PleaseSelect
Incorrect
TheanswerisProfessional:LabourwardclerkPrority:Afterfirsttask
within30minutes.
Room6:P1withpreviouscaesareansectionwithgrade1anterior
placentapraeviaadmittedat36weeksofgestationwithasmallAPH
CTGnormalbloodcrossmatchedHb113g/lconsultantneededto
docaesareansection,whichwasagreedandarrangedfor1hours
time
PleaseSelect
Incorrect
TheanswerisProfessional:SeniormidwifeinchargePrority:After
secondtaskwithin60minutes.
Room7:P1whohadanormalbirth65minutesagowitharetained
placentanotbleedingobservationsnormalbladdercatheterised
manualremovalofplacentaneedstobeorganised
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PleaseSelect
Incorrect
TheanswerisProfessional:ObstetricdoctorST2Prority:Now.
Room8:P1innormalspontaneouslabour,fetalbradycardia(80b/m)
insecondstageoflabourclearliquor
PleaseSelect
Incorrect
TheanswerisProfessional:ObstetricregistrarST5Prority:Now.
Room9:19yearoldwoman,P3withaBMI43,justadmittedin
labour.Allisnormalsofarbutthewomanforgotherhandheld
noteshospitalcasenotesareneeded
PleaseSelect
Incorrect
TheanswerisProfessional:LabourwardclerkPrority:Aftersecond
taskwithin60minutes.
Room10:41yearoldwomanhavingasecondtrimestertermination
ofpregnancyfortrisomy13hasjustabortedandisbleeding
placentadeliveredintravenouslineneedsreinsertingfor
administrationofoxytocininfusion
PleaseSelect
Incorrect
TheanswerisProfessional:Gynaecologyoncalldoctor
ST1Prority:Now.
Room11:P2inspontaneouslabourwhohasjuststartedfeeling
urgestopushwithabreechpresentationnormalprogressinthe
firststageoflabourplannedvaginalbirthCTGnormalfresh
meconiumstainedliquorisdraining
PleaseSelect
Incorrect
TheanswerisProfessional:ObstetricregistrarST5Prority:Afterfirst
Room12:23yearoldP0havinganinductionoflabourat37weeks
ofgestationforpreeclampsianeedsareviewofbloodresults,urine
outputandbloodpressurecurrentlyasymptomaticandBPis145/95
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mmHg
PleaseSelect
Incorrect
TheanswserisProfessional:ObstetricdoctorST2Prority:Aftersecond
Room13:P2innormalspontaneouslabournoproblemsdelivery
imminentattendantmidwifeneedsassistancewithmanagementof
thethirdstageoflabour
PleaseSelect
Incorrect
TheanswerisProfessional:SeniormidwifeinchargePrority:Afterfirst
Room14:P1deliveredandthirdstagecompleteestimatedblood
lossof300mlneedsperineallacerationtobesutured
PleaseSelect
Incorrect
TehanswerisProfessional:ObstetricdoctorST2Prority:Afterfirsttask
within30minutes.
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Maternalmedicinemanagement
Foreachoftheclinicalscenariosdescribed,choosethesinglemostappropriateactiontohelpreducethe
riskofthrombosisfromtheoptionlist.Eachoptionmaybeusedonce,morethanonce,ornotatall.
A:Aspirin75mgtabletsdaily
B:Assessmaternalclottingscreentestsand,ifabnormal,commencelowmolecularweight
heparin(LMWH)bysubcutaneousinjectionsdaily
C:CheckmaternalDdimerslevelsand,ifraised,commencedailyLMWHbysubcutaneous
injectionsdaily
D:Clopidogrel75mgtabletsdailyforatleast6weeksafterdelivery
E:Commenceaninfusionwithunfractionatedheparinandmonitormaternalactivatedpartial
thromboplastintime(APTT)testeachday
F:CommencedailyantenatalLMWHbysubcutaneousinjections
G:Earlymobilisationavoidingmaternaldehydration
H:Liaisewithphysicianinvolvedinthehaematology/obstetricclinictoconsiderthe
administrationofantenatalLMWHbysubcutaneousinjectionsdaily
I:Postnatalwarfarintreatmentforatleast6weeksmaintainingmaternalinternationalnormalised
ratiolevelsbetween2.0and2.5
J:PrescribeLMWHbysubcutaneousinjectiondailyforatleast7daysafterdelivery
K:PrescribepostnatalLMWHbysubcutaneousinjectionsdailyforatleast6weeks
L:Thromboprophylaxisnotrequiredatpresentperformamaternalthrombophiliascreenand
reviewtheresultswiththewoman
M:Tranexamicacid1gthreetimesadayforatleast6weeksafterdelivery
A35yearoldP2womanwithaBMIof29deliveredahealthymaleinfantof4.4kgbynon
rotationalforcepsforapersistentoccipitoposteriorpositionaftera22hourlabour
complicatedbyan800mlprimarypostpartumhemorrhage.Shesmokesbetweentenand15
cigarettesadayandisotherwisewellandhadanuncomplicatedantenatalcourse.She
wishestobreastfeedherson
PleaseSelect
Incorrect
Theanswerisearlymobilisationavoidingmaternaldehydration.
Notethatthromboprophylaxisisnotrequiredasthereisonlyoneriskfactor(smoking).Inthis
casetheforcepsdeliverymusthavebeenanoutlettractionforcepsdeliveryandRCOG(2015)
states:'midcavityrotationaldeliveryoroperativedelivery'onlyasariskfactor.
RoyalCollegeofObstetriciansandGynaecologists.ReducingtheRisk
ofThrombosisandEmbolismduringPregnancyandthePuerperium.
GreentopGuideline37a.London:RCOG2015.
A37yearoldP1booksat12weeksofgestation.Herfirstpregnancywascomplicatedby
preeclampsialateinthethirdtrimesterthatwarrantedaninductionoflabourandresultedin
anormalbirthofa2.6kghealthyfemaleinfant.Thepueriperiumwascomplicatedbyleftleg,
belowtheknee,provendeepveinthrombosisthatwastreatedsuccessfullywith
anticoagulantsandasubsequentthrombophiliascreenwasnegative.Sheisanonsmoker
andisotherwisehealthyandthereisnofamilyhistoryofthrombosis.Physicalexamination
isunremarkableapartfromsomevaricoseveinsintheleftlowerlegBPis125/75mmHg
BMIis32
https://stratog.rcog.org.uk/tutorial/emqsforthepart2mrcogonlineresource/maternalmedicinemanagement30295
1/3
3/6/2016
PleaseSelect
Incorrect
TheansweriscommencedailyantenatalLMWHbysubcutaneousinjections.
A19yearoldnulliparoussinglewomanwithaBMIof21wasdeliveredofahealthymale
infantbyrotationalforcepsdeliverycomplicatedbya1200mlpostpartumhemorrhage.She
receivedantenataldailyLMWHsubcutaneousinjectionsasshehadastrongfamilyhistory
ofthromboembolicdiseaseandhasafactorVLeidengenemutation(heterozygote)although
shehasneverhadathromboticepisodes.Sheisadamantthatshedoesnotwanttocontinue
toinjectherselfwhilebreastfeedingandcaringforherbaby
PleaseSelect
Incorrect
Theanswerispostnatalwarfarintreatmentforatleast6weeksmaintainingmaternalinternational
normalisedratiolevelsbetween2.0and2.5.
A34yearoldP2attendsherantenatalbookingvisitandstatesthathermotherhadaclotin
herlegafterherlastpregnancy.Shehasnomedicalproblemsandnopreviousvenous
thromboembolicepisodes.Shenottakinganyregularmedicationsbutisallergictocodeine
andsmokes5cigarettesaday.Anultrasoundscanrevealsadichorionicdiamniotictwin
pregnancyat12weeksofgestation.PhysicalexaminationisnormalBPis130/70mmHg
BMIis28
PleaseSelect
Incorrect
Theansweristhromboprophylaxisnotrequiredatpresentperformamaternalthrombophilia
screenandreviewtheresultswiththewoman.
A23yearoldnulliparouswomanisreferredtothehospitalantenatalclinicbyacommunity
midwifeat23weeksofgestationwithpersistentproteinuria(+++to++++ondipstick
urinalysis)andpedalandperiobitalodemafollowinga'flulikeillness'earlierinthe
pregnancy.Numerousmidstreamurinesampleshavebeennegativeforinfection.Thereis
norelevantpastmedical,familyorsurgicalhistoryandsheisanonsmoker.Physical
examinationrevealspittingankleodemabutotherwiseisnormalBPis135/85mmHgBMI
is21.Testresults:
24hourproteinexcretiontest6gperday
normalserumelectrolytes
serumcreatinine95micromol/l(normal:50110micromol/l)
normalfullbloodcount
liverfunctionnormal
serumalbumin20g/l(normal:3550g/l)
urinemicroscopynegative
Shehasbeenseenbytherenalmedicineteamtoday
PleaseSelect
Incorrect
Theanswerisliaisewithphysicianinvolvedinthehaematology/obstetricclinictoconsiderthe
administrationofantenatalLMWHbysubcutaneousinjectionsdaily.
2/3
3/6/2016
A36yearoldP4womanwithaBMIof31whosmokestencigarettesadayunderwentan
uncomplicatedelectivecaesareansectionforatransverselieatterm.Thereisnorelevant
pastmedical,familyorsurgicalhistory.Sheplanstobottlefeedherhealthynewborn
PleaseSelect
Incorrect
TheanswerisprescribepostnatalLMWHbysubcutaneousinjectionsdailyforatleast6weeks.
3/3
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Naturalhistoryofmaternalmedicine
Foreachofthescenariosaboutchickenpoxinpregnancychoosethemostaccuratepercentagelikelihood.Eachoptionmay
beusedonce,morethanonce,ornotatall.
A:Lessthan1%
B:110%
C:1120%
D:2140%
E:4159%
F:6070%
G:7185%
H:8695%
I:Greaterthan95%
A32yearoldnulliparouswomanis12weekspregnantandis
anxioustoknowtheprevalenceofchickenpoxcomplicating
pregnancybecauseherfatherrecentlydiedofthediseaseinhis
early50swhilereceivingtreatmentfornonHodgkin'slymphoma
PleaseSelect
Incorrect
Theanswerislessthan1%(3/1000pregnancies).SeeRoyalCollegeof
ObstetriciansandGynaecologists.ChickenpoxinPregnancy.Greentop
Guideline13.London:RCOG.2015.Notethatnaturalhistoryquestions
areamongthetoughestinthePart2MRCOGexamination.
A19yearoldnulliparouswomanhascontractedchickenpoxat25
weeksofgestation.Shesuffersmildtomoderateasthmaandis
currentlyusingSynbicortTurbohaler200/6inhalationpowder
(budesonide200microgramandformoterolfumeratedehydrate6
microgramineachinhalation)andisundergoodsymptomatic
controlwithoutanyoralsteroids.Sheisanxioustoknowthe
chancesofdevelopingpneumoniaasacomplication
PleaseSelect
Incorrect
Theansweris110%(5%).Seeexplanationtoquestion1.
A28yearoldwoman,P2,hascontractedchickenpoxat40weeksof
gestationduringanotherwiseuncomplicatedpregnancyandsheis
worriedabouttherisksforherbabyand,inparticular,thechance
thathernewbornwilldevelopclinicalchickenpox
PleaseSelect
Incorrect
https://stratog.rcog.org.uk/tutorial/emqsforthepart2mrcogonlineresource/maternalmedicine30306
1/2
3/6/2016
Naturalhistoryofmaternalmedicine
Theasnweris2140%(23%).Seeexplanationtoquestion1.
A22yearoldwoman,P3,developedchickenpoxearlyinher
pregnancywhilelivingabroadinAfrica.Shedidnothaveaccessto
zosterimmunoglobulinatthattime.ShehasarrivedintheUKasan
asylumseekerat34weeksofgestation.Shenowenquiresaboutthe
riskofherbabybeingaffectedbychickenpoxinfectioninthewomb
(fetalvaricellasyndrome)
PleaseSelect
Incorrect
Theansweris110%(2.8%).Seeexplanationtoquestion1.
Amotherofa15yearoldenquireswhetherherdaughtershouldbe
immunisedagainstchickenpoxbecause,inthepast,themotherhad
achildseverelyaffectedbyfetalvaricellasyndrome.After
counselling,shewishestoknowifherdaughterweretohavean
immunitytestforchickenpox,whatwouldbethelikelihoodshewill
beseropositive
PleaseSelect
Incorrect
Theansweris8695%(90%).Seeexplanationtoquestion1.
https://stratog.rcog.org.uk/tutorial/emqsforthepart2mrcogonlineresource/maternalmedicine30306
2/2
3/6/2016
Postoperativecare
Forthefollowingclinicalscenarioschoosethesinglemostlikelydiagnosisfromtheoptionlistbelow.Eachanswermaybe
usedonce,morethanonceornotatall.
A:Acuterenalfailure
B:Allergicreaction
C:Bowelperforation
D:Chestinfection
E:Cerebrovascularaccident
F:Deepveinthrombosis
G:Deliriumtremens
H:Intraabdominalhaemorrhage
I:Myocardialinfarction
J:Paralyticileus
K:Pulmonaryatelectasis
L:Pulmonaryembolism
M:Smallbowelobstruction
N:Subcutaneoushaematoma
O:Subrectushaematoma
P:Septicshock
Q:Urinarytractinfection
R:Vaginalvaulthaematoma
S:Wounddehiscence
T:Woundinfection
A48yearoldwomanhadanabdominaltotalhysterectomyand
bilateralsalpingooophorectomytoremoveanovariantumourandis
seenonthewardroundonday2.Shehadapoornightwith
abdominalpainandbloatingandhasjuststartedvomiting.On
examination:shelookspaleandsweatytheabdomenisdistended
withminimalbowelsoundsandgeneralisedtenderness
temperatureis36.8Cpulserateis110bpmBPis120/65mmHg
respiratoryrateis14breaths/minBMIis36
PleaseSelect
Incorrect
Thecorrectanswerisparalyticileus.Thisisaclassicpostoperativeward
rounddiagnosisafteraproperexaminationofthecardiovascularand
respiratorysystems.
A25yearoldwomanunderwentanuncomplicatedlaparoscopyand
dyetesttoinvestigateprimarysubfertility.Therewassomeminimal
stageendometriosis,whichwasdiathermised,andthefallopian
https://stratog.rcog.org.uk/tutorial/emqsforthepart2mrcogonlineresource/postoperativecare30285
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Postoperativecare
tubeswerepatent.Eighthoursaftertheoperationthewomanis
experiencingalotofpainrequiringopiateanalgesia.Theabdomen
isverytenderaroundthesecondaryportsiteintheleftiliacfossais
slightlydistendedoozingbloodstainfluid,despiteapressure
dressing.Observations:pulserateis110bpmBPis140/75mmHg
temperatureis36.5Crespiratoryrateis18breaths/min
PleaseSelect
Incorrect
Theanswerissubrectushaematoma.Seeexplanationtoquestion1.
A38yearoldwoman,P4,hasjustarrivedbackonthegynaecology
wardafteranuncomplicatedsurgicalmanagementofmiscarriageto
stoputerinehaemorrhagefollowingaspontaneousmiscarriageat14
weeksofgestation.Theestimatedbloodlosswasrecordedas800
mlandhaemostasiswasachievedsatisfactorilywithintravenous
oxytocics,andhasbeenmaintained.Sheistakingdailythyroxine
150microgramandprenisolone10mgforarthritisandhadno
knownallergiesandisanonsmoker.Shebecomesacutelyunwell
andonexamination:shelooksunwellwithcoldextremitiesandis
drowsyabdomenissoftandnontenderwithnomassesorrashes
vaginalexaminationisnormalwithnovaginalbleeding.
Observations:pulserateis120bpmBPis90/50mmHgtemperature
is35.7Crespiratoryrateis26breaths/min
PleaseSelect
Incorrect
Thecorrectanswerissepticshock.Seeexplanationtoquestion1.
A42yearoldwomanhadavaginalhysterectomyontheafternoon
listthedaybeforeandisseenontheDay1wardround.Shelooks
paleandfeelsunwellandfaintandcomplainsofdifficultygettingher
breathandpainsinherchestandshoulders.Thereisnovaginal
bleedingandtheurinecathetersampleisclearbutshehaspassed
only100mlovernightdespitereceivingmorethanalitreofnormal
salineovernight.Theabdomenisslightlydistendedandtender
bowelsoundsarepresent.Observations:pulserateis105bpmBP
is120/50mmHgtemperatureis36.7Crespiratoryrateis25
breaths/min
PleaseSelect
Incorrect
Thecorrectanswerisintraabdominalhaemorrhage.Seeexplanationto
question1.
A75yearoldwoman,withaBMIof24andwhoisanonsmoker,had
2/3
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Postoperativecare
alaparotomythroughamidlinesurgicalincisionforanabdominal
andpelvicmass3daysagoandthetumourwasdeemedtobe
inoperable.Shehasdevelopedsomecentralandrightsidedchest
painandisfeelingunwellandbreathlessandhasbecomerestless.
Onexamination:abdomenissoftandnontenderwound
satisfactorychestdulltopercussionbothbasesandpoorairentry
withsomecrepitationsthatclearwithcoughing.Observations:pulse
rateis96bpmBPis110/60mmHgtemperatureis38.7C
respiratoryrateis21breaths/min
PleaseSelect
Incorrect
Thecorrectanswerischestinfection.Seeexplanationtoquestion1.
A70yearoldwoman,P1,withaBMIof34andtype2diabetesand
whoisasmoker(15cigarettesaday)hadanuncomplicated
laparoscopichysterectomyandbilateralsalpingooophorectomytwo
daysagototreatendometrialcancer.Shehasdevelopedsome
centralandrightsidedchestpainandisfeelingunwelland
breathlessandhasbecomerestless.Onexamination:shelookspale
andmoderatelydistressedabdomenissoftandnontender
woundssatisfactorychestpercussionandbreathsoundsare
normallowerlimbsnormalandmobile.Observations:pulserateis
102bpmBPis140/750mmHgtemperatureis36.7Crespiratory
rateis22breaths/min
PleaseSelect
Incorrect
Thecorrectanswerispulmonaryembolism.Seeexplanationtoquestion
1.
3/3
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Postpartumnaturalhistory
Eachoutcomeorcomplicationdescribedbelowreferstoa35yearoldwomaninherfirstpregnancywho
sufferedathirddegree(3c)injurytotheperineumfollowinganonrotationalforcepsdeliverywitha
rightmediolateralepisiotomyofa4.1kghealthyfemaleinfantaprimarysurgicalrepairwasperformed
intheatrewithoutcomplication.
Choosethesinglemostlikelypercentageriskat12monthsafterthebirth.Eachoptionmaybeusedonce,
morethanonce,ornotatall.
A:Lessthan1%
B:110%
C:1120%
D:2140%
E:4159%
F:6080%
G:8190%
H:9195%
I:Greaterthan95%
Thechancethatshewillsuffersomedegreeoffaecalurgency
PleaseSelect
Incorrect
Theansweris2140%.SeeRoyalCollegeofObstetriciansandGynaecologists.Managementof
ThirdandFourthdegreePerinealTears.GreentopGuideline29.London:RCOG.2015.Itis
importanttoknowcomplicationratesinordertoinformandcounselwomencorrectly.
Thelikelihoodthatshewillbeasymptomatic
PleaseSelect
Incorrect
Theansweris6080%.Seeexplanationtoquestion1.
Themaximumreportedriskthatshewilldevelopworseningfaecalsymptomsafterasecond
vaginalbirth
PleaseSelect
Incorrect
Theansweris2140%.Seeexplanationtoquestion1.
https://stratog.rcog.org.uk/tutorial/emqsforthepart2mrcogonlineresource/postpartumnaturalhistory30312
1/1
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Subfertilityinvestigations
Forthefollowingclinicalscenariosbelowchoosethenextmostappropriatetestorprocedurefromtheoptionlistto
investigatethecouplessubfertility.Eachanswermaybeusedonce,morethanonceornotatall.
A:Androstenedione,17hydroxyprogesterone,testosterone,
dihydroepiandrostenedionesulfate
B:Antimullerianhormonelevels
C:Estradiol,prolactin,FSH,LHtakensameday
D:Estradiol,prolactin,FSH,LHtakenintheearlyfollicularphaseofthe
menstrualcycle
E:Fullbloodcountandserumironlevels
F:Hysterosalpingocontrastsonography
G:Hysterosalpingogram
H:Hysteroscopy
I:Karyotype
J:Laparoscopyanddyehydrotubation
K:Moleculargenetictestforcysticfibrosis
L:Pelvicultrasoundscan
M:Postcoitaltest
N:Psychosexualassessmentandcounselling
O:Sexualtherapyassessmentandadvice
P:Spermantibodytitre
Q:Testosterone,prolactin,FSH,LH
R:Urinepregnancytest
AcouplearereferredtotheFertilityClinicafter2yearstryingto
conceive.Thewomanis26yearsoldwithaBMIof31.They
conceivedspontaneously3yearsagoandshegavebirthtoa
healthymale,birthweight3456g,bycaesareansectionforalate
secondaryarrestandobstructedlabour.Itwascomplicatedbya
postoperativepyrexiathatrequired48hoursofintravenous
antibiotics.Sheiscurrentlymenstruatingregularlyeachmonthwith
day21progesteroneestimationsof55nmol/land41nmol/lfrom
consecutivemonths,organisedbyherGP.Therearenoobvious
problemswithsexualintercourseanditsfrequency.Clinical
examinationofbothpartnersisnormal.Semenanalysisshows:25
millionsperm/mlvolume1.6mlnormalmorphologicalforms10%
progressivemotility41%.Rubellaantibodiesdetected
PleaseSelect
Incorrect
Theanswerislaparoscopyanddyehydrotubation.Tubalblockageisthe
mostcommoncauseofsecondarysubfertilityandisespeciallylikelyin
thiscasefollowingtheinfectionseriousinfectionafterthecaesarean
sectio
n.
https://stratog.rcog.org.uk/tutorial/emqsforthepart2mrcogonlineresource/subfertilityinvestigations30298
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AcouplearereferredtotheFertilityClinicafter2yearstryingto
conceive.Bothpartnershavebeenmarriedbeforethewomanis31
yearsoldandhasneverbeenpregnantthemalepartneris36years
oldhadonechild10yearsagoandchemotherapyforalymphoma3
yearsago.Thewomaniscurrentlymenstruatingregularlyeach
month,withday21progesteroneestimationsof45nmol/land32
nmol/lfromconsecutivemonths,organisedbyherGP.Thereareno
obviousproblemswithsexualintercourseanditsfrequency.Clinical
examinationsofbothpartnersarenormal.Semenanalysesshows:
0.51.0millionsperm/mlvolume1.11.7mlnormalmorphological
forms35%progressivemotility710%.Rubellaantibodiesarenot
detected
PleaseSelect
Incorrect
Thecorrectansweristestosterone,prolactin,FSH,LH.Investigationof
themalepartnerwithsevereoligospermiaafterphysicalexaminationis
essential.
AcouplearereferredtotheFertilityClinicafter1yeartryingto
conceiveforthefirsttime.Thewomanis29yearsoldandherLMP
was3weeksagoshesayssheusedtohaveregularperiodsbut
nowshemenstruatesinfrequentlyevery56monthsafterputtingon
alotofweight.Shehashadtype2diabetesfor2yearsandistaking
metformintwiceadayandfolicacid5mgdailyshesmokes510
cigarettesaday.Themalepartnerisa38yearsoldandhasthree
childrenfromapreviousrelationshipheisanonsmoker.Thereare
noobviousproblemswithsexualintercourseanditsfrequency.
Clinicalexaminationofbothpartnersisotherwisenormalapartfrom
afemaleBMIof34.Semenanalysisshows:15millionsperm/ml
volume2.6mlnormalmorphologicalforms3%progressivemotility
31%.Rubellaantibodiesnotdetected
PleaseSelect
Incorrect
Thecorrectanswerisestradiol,prolactin,FSH,LHtakenontheday.The
oligomenorrhoeainvestigationsmustincludeteststoexcludeovarian
failureandhyperprolactinaemiaaspossiblecauses.
AyoungcouplearereferredtotheFertilityClinicaftertryingto
conceiveforthefirsttimesincetheirarrangedmarriageover2years
ago.Thewomanis20yearsoldandiscurrentlymenstruating
regularlyeachmonth,withday21progesteroneestimationsof65
nmol/land39nmol/lfromconsecutivemonths,organisedbyherGP.
Clinicalexaminationsofbothpartnersarenormalalthoughthe
womanshymenalmembraneisnotedtobeintactandshehasaBMI
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of34.Semenanalysisshows:40millionsperm/mlvolume1.7ml
normalmorphologicalforms31%progressivemotility42%.Rubella
antibodiesnotdetected
PleaseSelect
Incorrect
Thecorrectanswerissexualtherapyassessmentandadvice.
conceive.Thewomanis34yearsoldwithaBMIof29.They
conceivedspontaneously15monthsagoandthepregnancywas
terminatedsurgicallyat14weeksofgestation,without
complications,afteradiagnosisofDownsyndromewasconfirmed
followingahighriskscreeningtestresult.Sincethepregnancythe
womanhasbeentroubledbyvaginalbleedinginbetweenher
periodseverymonthassociatedwithmoreperiodpainsandgeneral
pelvicdiscomfort.Herrecentcervicalsmearwasnormalvaginal
andendocervicalswabswerereportedas:normalvaginalflora.
Therearenoobviousproblemswithsexualintercourseandits
frequency.Clinicalexaminationsofbothpartnersarenormal.Semen
analysisshows:25millionsperm/mlvolume1.6mlnormal
morphologicalforms10%progressivemotility41%.Rubella
antibodiesdetected
PleaseSelect
Incorrect
Thecorrectanswerisurinepregnancytest.Incasesofirregularvaginal
bleedingafterpregnancyitisimportantfirsttoexcludegestational
trophoblasticdisease.
conceiveforthefirsttime.Thewomanis29yearsoldand3years
agoshehadanepisodeofheavypainfulmenstrualbleedingand
painfulsexualintercoursethatwastreatedsuccessfullybythe
insertionofaMirenaandsheisamenorrhoeic.Herhusbandis25
yearsoldhashadtype1diabetesfor10yearsandistakinginsulin
andsmokes510cigarettesaday.Therearenoobviousproblems
withsexualintercourseanditsfrequency.Clinicalexaminationof
bothpartnersisotherwisenormalapartfromafemaleBMIof33.
Semenanalysisshows:15millionsperm/mlvolume2.6mlnormal
morphologicalforms3%progressivemotility31%.Rubella
antibodiesnotdetected
PleaseSelect
Incorrect
Theanswerispelvicultrasoundscan.YouneedtoassessiftheMirenais
stillintheuterusasitispresumedthecoilstringswerenotseenifthe
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examinationwasnormal.
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Surgicalprocedures
Forthefollowingsurgicaldescriptionschosethecorrectpelvicstructurefromtheoptionlist.Eachanswermaybeusedonce,
morethanonceornotatall.
A:Analcanalmucosa
B:Arcustendinousfasciapelvis
C:Bulbospongiosis
D:Coccygeus
E:Deeptransverseperinealmuscle
F:Externalanalsphincter
G:Iliococcygeus
H:Ischiorectalfossa
I:Perinealbodyorcentralperinealtendon
J:Pubocervicalfasciaandpubovesicalligaments
K:Pubococcygeus
L:Puborectalis
M:Rectovaginalendopelvicfascia
N:Sacrospinousligaments
O:Sacrotuberousligaments
P:Superficialtransverseperinealmuscle
Q:Transversecervicalligaments
R:Uterosacralligaments
Theanatomicalstructurethatisdividedwhenamidlineepisiotomy
isperformed
PleaseSelect
Incorrect
Thecorrectanswerisperinealbodyorcentralperinealtendon.Applied
pelvicanatomyisessentialknowledgeforobstetriciansand
gynaecologists.
Theanatomicalstructurethatissupportedafteratransvaginaltape
isinsertedinthesurgicaltreatmentofgenuinestressincontinence
PleaseSelect
Incorrect
Thecorrectanswerispubocervicalfasciaandpubovesicalligaments.
Theanatomicalstructureusedtosupportthevaginalvaultinthe
surgicaltreatmentofthirddegreeuterovaginalprolapse
PleaseSelect
https://stratog.rcog.org.uk/tutorial/emqsforthepart2mrcogonlineresource/surgicalprocedures30281
1/2
3/6/2016
Surgicalprocedures
Incorrect
Thecorrectanswerissacrospinousligaments.
Theanatomicalstructurenormallyincludedinthefirstmajorpedicle
thatisdividedandsecuredduringavaginalhysterectomyandafter
thevaginaandbladderhavebeenreflectedoffthecervixand
surroundingtissuesandtheperitoneumofthepouchofDouglas
hasbeendividedandopened
PleaseSelect
Incorrect
Thecorrectanswerisuterosacralligaments.
Duringanabdominaltotalhysterectomy:theanatomicalstructure
normallyincludedintheclampingoftheparacervicaltissuesafter
theuterinearteryhavebeensecuredanddividedandbeforethe
vaginalangleandthesurroundingtissueissecuredandsutured
PleaseSelect
Incorrect
Theansweristransversecervicalligaments.
Theanatomicalstructurethatisreconstructedduringthesurgical
repairofarectocele
PleaseSelect
Incorrect
Thecorrectanswerisrectovaginalendopelvicfascia.
https://stratog.rcog.org.uk/tutorial/emqsforthepart2mrcogonlineresource/surgicalprocedures30281
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Teaching
Forscenarioslistedbelowchoosetheeducationalprincipleoractivitythatbestdescribesthesituationfromtheoptionlist.
Eachanswermaybeusedonce,morethanonceornotatall.
A:Appraisal
B:Bloomstaxonomyoflearning
C:Criterionreferencedstandardsetting
D:Educationalsupervision
E:Experientiallearning
F:Formativeassessments
G:Lifelongadultlearning
H:Linearequatingstandardsetting
I:Normreferencedstandardsetting
J:Pendletonsrulesforfeedback
K:Qualityassuranceineducation
L:Reflectivepractice
M:Reliability
N:Summativeassessments
O:Transformativelearning
P:Validity
Q:Vicariouslearning
Agroupoftraineesmeettogetheronthelabourwardwiththeduty
consultantonaMondaymorningtodiscussthenoteworthycases
duringwhichtheconsultantrelatesvariousexperiences,situations
andadvicetothetrainees
PleaseSelect
Incorrect
Thecorrectanswerisvicariouslearning.Thesequestionstestthebasic
principlesofteaching,learning,assessmentandappraisal.Forauseful
articleandreferencesee:DuthieSJ,GardenAS.Theteacher,thelearner
andthemethod.TheObstetrician&Gynaecologist201012:27380.
Aconsultanthasjustperformedanonlinelearningexerciseonher
Trustsclinicalgovernanceissuesasaprerequisiteforher
consultantappraisal.TheTrusthasdeterminedthateveryconsultant
mustscore15ormoreoutof25beforetheassessmentcanbe
signedoffbytheappraiser
PleaseSelect
Incorrect
Theanswerisnormreferencedstandardsetting.
https://stratog.rcog.org.uk/tutorial/emqsforthepart2mrcogonlineresource/teaching30282
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Teaching
Aspecialisttraineeinobstetricsandgynaecologymustbecomea
memberoftheRoyalCollegeofObstetriciansandGynaecologists
beforeprogressingtoadvancedtraining
PleaseSelect
Incorrect
Theanswerissummativeassessments.
AnST1traineedescribestohisclinicalsupervisorhowhemanaged
apostpartumhaemorrhagebyhimselfforthefirsttimeandnow
feelsmuchmoreconfidentaboutdealingwiththiscomplication,
morethanafterdoingaskillsdrillsonthesubject
PleaseSelect
Incorrect
Thecorrectanswerisexperientiallearning.
AnST7advancedtraineepresentsacasebaseddiscussiontoher
educationalsupervisorwhorealisesthatthetraineehasonly
superficialknowledgewithknowledgedeficitsonthesubjects
discussed.Thesupervisorrecommendssometargetedreadingto
addresstheidentifiededucationalneeds.Theymeettogetherafew
weekslaterandthetraineedescribeshowreadingaroundthe
subjecthasenabledalotoftheconceptstofallintoplaceto
enhanceherclinicalpracticeasaspecialistobstetricianand
gynaecologist.Thetraineealsodescribesthatshenowunderstands
theneedforindepthlearningtobeanexpertinthefield
PleaseSelect
Incorrect
Theansweristransformativelearning.
Afewtraineeswereaskedtosubmitsomequestionsforalocal
MRCOGPart2course.Mostofthequestionsweregratefully
acceptedandincorporatedintothecoursebytheorganisertwo
questionswererejectedbecausetheyweredeemedtobeoutside
thescopeoftheMRCOGPart2syllabus
PleaseSelect
Incorrect
Theanswerisvalidity.
https://stratog.rcog.org.uk/tutorial/emqsforthepart2mrcogonlineresource/teaching30282
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Urogynaecologyandpelvicfloorproblems
Foreachclinicalscenariodescribedbelowchoosethesinglemostlikelydiagnosisorcauseofurinarysymptomsfromlistof
options.Eachoptionmaybeusedonce,morethanonceornotatall.
A:Atonicbladder
B:Bladdercalculus
C:Bladderdiverticulum
D:Bladdertumour
E:Chroniccystitis
F:Detrusoroveractivity
G:Endometriosisofthebladder
H:Overactivebladder
I:Overflowincontinence
J:Painfulbladdersyndrome
K:Sensoryurgency
L:Tuberculosisoftherenaltract
M:Urethralsyndrome
N:Urinarytractinfection
O:Urodynamicstressincontinence
P:Uterinetumour
Q:Vesicovaginalfistula
A31yearoldnulliparouswomanisreferredwithalonghistoryof
frequency,passingurineasmuchasevery3060minutesduringthe
dayandassociatedwithpainandirritation.Thereisveryoccasional
nocturiaandshealsosuffersfromintermittentlowerabdominal
pains.HerLMPwas2weeksagoandherperiodsareirregularand
heavycomingevery57weeks.Sheisnotsexuallyactiveand
smokes510cigarettesaday.TheGPhastakenseveralurine
samplesforcultureandtheyhaveallbeennegative.On
examination:BPis120/65mmHg,BMIis24abdominalandvaginal
examinationisnormalapartfromsomevaguesuprapubic,vaginal
andurethraltenderness.Urineanalysisisnormalfullbloodcountis
normalthyroidandrenalfunctionarenormal
PleaseSelect
Incorrect
Theanswerisurethralsyndrome.Historytakingisessentialin
gynaecology.
A35yearoldwoman,P4,complainsaboutmanyyearsofurinary
urgency,frequencyandoccasionalincontinence.Sheisateacher
anddescribesanalmostconstantsensationofneedingtopass
urineandfindsitimpossibletowaitforthebreakbetweenclassesto
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void.Theepisodesofincontinenceareassociatedwithincreasing
urgencybutarerare.Gynaecologicalexaminationisnormal.A
bladderdiaryshowsfrequency12times/dayfunctionalbladder
capacity300mlaveragevoidedvolume150ml.Cystometryshows:
noincontinencethefirstdesiretovoidoccursat100mlstrong
desireat300mlnoobservedincreaseinbladderpressureduring
filling
PleaseSelect
Incorrect
Thecorrectanswerissensoryurgency
.
A27yearoldwomanhadanemergencycaesareansectionforan
obstructedlabourafteranunsuccessfultrialofforcepsintheatre
withepiduralanalgesia.Sincetheoperation,whichwas3daysago,
shehasbeenhavingproblemswithpassingurineandhasleaked
urinewithminimalsensationtovoid.Thereisnorecordeddamage
orsurgicaldifficultieswiththebladderintheoperationnotes.She
nowhasanindwellingcatheterwithintermittentspigotandrelease
every4hours.Theurinedrainingisclearwithadequateurineoutput
PleaseSelect
Incorrect
Theanswerisatonicbladder.
A72yearoldnulliparouswomanisreferredwithintermittent
episodesofwhatisthoughttobevaginalbleedingforthelast6
monthsmainlywhensheisonthetoilet.Shehasurinaryfrequency
andnocturiatwiceorthreetimesanightandoccasionalleaksof
urine.Shehastype2diabetesandsuffersfromhypertension,and
takesmedicationsforbothconditions.Shesmokes20cigarettesa
dayandoccasionallyleaksurinewhencoughing.Onexamination:
BPis150/90mmHgBMIis34abdominalpalpationisnormal
vaginalexaminationshowsanatrophicvaginal,normalcervixand
pelviswithnobloodseen.Urineanalysisshows:protein2+blood
3+glucose3+anultrasoundscanofthekidneys,bladder,uterus
andovariesisnormal
PleaseSelect
Incorrect
Theanswerisbladdertumour.
A59yearoldwoman,P2,isreferredwithurinaryleakagewhen
coughing,sneezing,lifting,bendingandchangingpositionandshe
hashadtowearincontinencepads.OnexaminationherBMIis30
andthereisevidenceoflowergenitaltractatrophythereisno
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demonstrablestressincontinence.Fillingcystometryshows:an
earlyfirstdesiretovoidat75mlurgencyat140mlassociatedwith
highpressuredetrusorcontraction,whichreached40cm/H20and
resultedincompletedbladderemptying
PleaseSelect
Incorrect
Theanswerisdetrusoroveractivity.Thisaurodynamicdiagnosiswhile
overactivebladderisaclinicaldiagnosis.
A33yearoldwoman,P1,isreferredwithalonghistoryofurinary
frequencyandurgencyandannoyingnocturiathatisdeprivingher
ofsleep.Itisnotassociatedwithleaksorbedwettingbutthereis
lowerabdominalpainwhensheemptiesherbladder.These
symptomsaremuchworseduringmenstruationandthereisalso
somedeeppainexperiencedduringsexualintercourse.Three
monthsagoshehadaMirenaintrauterinedeviceinsertedbyher
GPforcontraceptionandsheconfirmsthathersymptomshave
improvedtosomeextentonthebasisthatsheisnowamenorrhoeic.
Onexamination:BPis135/70mmHgBMIis28abdominalpalpation
isnormalwithsomesuprapubictendernessvaginalexaminationis
normalwithsomevaguetendernessintheposteriorandanterior
fornices.Severalurinecultureshavebeennegativeandan
ultrasoundscanofthekidneys,bladder,uterusandovariesis
normal
PleaseSelect
Incorrect
Theanswerispainfulbladdersyndrome.Seequestion1toseehowthe
clinicalhistoryofpainfulbladdersyndromediffersfromtheurethral
syndrome.
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Variousdomains
Fromthefollowingstatements,choosethesinglemostappropriateartery/veinfromthebloodvesseloptions.Eachanswer
maybeusedonce,morethanonceornotatall.
A:Anteriordivisionoftheinternaliliac
B:Ascendingcervicalbranchofvaginalartery
C:Deepcircumflex
D:Inferiorepigastric
E:Internaliliac
F:Internalpudendal
G:Lateralsacral
H:Middlerectal
I:Obturator
J:Ovarian
K:Posteriordivisionoftheinternaliliac
L:Superiorgluteal
M:Umbilical
N:Uterine
O:Vaginal
Maybedividedwhenopeningtheperitoneumduringalaparotomy
andisalsoknownastheurachus.
PleaseSelect
Incorrect
Theanswerisumbilical.Knowledgeofthebloodsupplytothepelvisand
anteriorabdominalwallisessential.Radiopaedia.orghasauseful
mnemonictohelpyourememberthebranchesoftheinternaliliacartery.
Maybecomethrombosedinthepuerperiumandisararecauseof
acutelocalisedabdominalpain
PleaseSelect
Incorrect
Theanswerisovarian.
Occasionallymayneedtobeligatedincasesofacutepelvicor
obstetrichaemorrhage
PleaseSelect
Incorrect
Theanswerisanteriordivisionoftheinternaliliac.Notethattheansweris
anteriordivisionoftheinternaliliacratherthaninternaliliacinorderto
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Variousdomains
avoidpostoperativeischaemicpaininthebuttockwhentheposterior
divisionisoccluded.
Needstobesecuredwhenclosingtheanteriorvaginaduringatotal
hysterectomy
PleaseSelect
Incorrect
Theanswerisascendingcervicalbranchofvaginalartery.
Biophysicalbloodflowanalyses(Doppler)maybeusedinthe
secondtrimesterofpregnancytoassesspossibleperinatal
outcomes
PleaseSelect
Incorrect
Theanswerisuterine.
Maybedamagedwheninjectinglocalanaestheticduringaregional
blockforinstrumentaldeliveries
PleaseSelect
Incorrect
Theanswerisinternalpudendal.
Occlusionhasbeenshowntobeaneffectivetreatmentforwomen
withleiomyomata(fibroids)
PleaseSelect
Incorrect
Theanswerisuterine.
Maybedamagedduringinsertionofasecondaccessportduring
laparoscopyandsometimesresultsineitherasubrectus
haematomaorpostoperativehaemorrhage
PleaseSelect
Incorrect
Theanswerisinferiorepigastric.
Biophysicalbloodflowanalyses(Doppler)maybeusedinthethird
trimesterofpregnancytoassesspossibleperinataloutcomes
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Variousdomains
PleaseSelect
Incorrect
Theanswerisumbilical.
Initialsuturingduringasurgicalrepairofarightmediolateral
episiotomywillpreventpostpartumhaemorrhage
PleaseSelect
Incorrect
Theanswerisvaginal.
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Variousinvestigations
ThefollowingclinicalscenariosrelatetoawomanwhopresentstoherlocalAccidentandEmergencyDepartmentwith
severeacuteabdominalpainrequestingurgentmedicalassistance.Choosethesinglemostappropriateinvestigation
necessaryforthediagnosisandmanagementofthispatient.Eachanswermaybeusedonce,morethanonceornotatall.
A:Arterialbloodgasanalyses
B:Bloodcultures
C:Bloodsugar
D:Ca125
E:CervicalswabformicroscopyandGramstain
F:ChestXray
G:Creactiveprotein
H:CTscanofabdomen
I:ErectabdominalXray
J:Fullbloodcount
K:Liverfunctiontests
L:Midstreamurineformicroscopy
M:Pelvicultrasoundscan
N:Serumamylaseandlipase
O:Serumlactate
P:Transabdominalultrasoundscan
Q:Ultrasoundscanofkidneys,uretersandbladder
R:Urea,electrolytesandcreatinine
S:Urinepregnancytest
Ahealthy32yearoldP3hasa12hourhistoryofincreasinglysevere
boutsofcentralabdominalpainwithvomitingduringtheheightof
thepain,whichslowlypassesoff,withlossofappetite.Shegave
birthtoahealthymaleinfant,birthweight3456g,4daysagoandis
breastfeeding.Thelochiaanduterineinvolutionhavebeenrecorded
bythemidwifeasbeingnormal.Thepregnancywasuncomplicated
throughout.Theanomalyultrasoundscanat20weeksofgestation
wasnormalapartfromasimplerightovariancystthatmeasured89
cmdiameter.Sheisanonsmokerandwaswellpriortotheonsetof
thepainandhasneverexperiencedanythinglikethispaininthe
past.
Onexamination:shelooksdistressed,paleanddehydratedthe
abdomenisverytenderinthelowerhalfwithnoperitonism,andthe
uterusisjustpalpablenoothermasses.Vaginalexaminationis
normal.Observationsareasfollows:
Pulserate(bpm)
Bloodpressure(mmHg)
110
Temperature(C)
140/90 Urineanalysis
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blood2+
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ketones3+
protein
trace
Respiratoryrate
(breaths/min)
12
O2Saturationonair
(%)
98
PleaseSelect
Incorrect
Thecorrectansweristransabdominalultrasoundscan.Thekeyto
answeringthesequestionscorrectlyisintheinstructions:"choosethe
singlemostappropriateinvestigationnecessaryforthediagnosisand
managementofthispatient".
Ahealthy22yearold,P0+1,hasa48hourhistoryofincreasingly
severelowerabdominalpainlocalisingtotherightside.Shehaslost
herappetiteandgenerallyfeelsunwellshewaswellpriortothe
onsetofthepain.Shesmokes1015cigarettesadayandsuffers
withmildasthmaandusesinhalerswhennecessaryshehas
noticedamoreproductivecoughandsomebreathlessness.Her
LMPwas3weeksagoperiodsareregular:34/28days.Sheuses
theprogesteroneimplantforcontraception,whichwasinsertedafter
anuncomplicatedterminationofpregnancy.
Onexamination:shelookspaleanddehydratedtheabdomenis
verytenderinthelowerhalfparticularlyontherightsidewithno
peritonismnomasses.Vaginalexamination:thereissomevague
tendernessotherwiseunremarkable.Observationsareasfollows:
Pulserate(bpm)
Bloodpressure(mmHg)
120
Temperature(C)
38.4
Protein
trace
Nitrites
trace
Ketones+
Respiratoryrate
(breaths/min)
19
O2Saturationonair
(%)
90
PleaseSelect
Incorrect
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ThecorrectanswerischestXray.Rightlowerlobepneumoniamay
presentwithacuteabdominalpainandaproperexaminationofthe
respiratorysystemwillprovidetheprovisionaldiagnosis.
A19yearold,P0+1,hasa72hourhistoryofincreasinglysevere
lowerabdominalpainlocalisingtotherightside.Shehaslosther
appetiteandgenerallyfeelsunwellshewaswellpriortotheonset
ofthepain.Shesmokes10cigarettesaday.HerLMPwas3weeks
agoperiodsareregular:34/28dayswithsomebreakthrough
bleedingfromtimetotime.Shehasusedtheprogesteroneimplant
forcontraceptionfor2years,whichwasinsertedafteratermination
ofpregnancythatwascomplicatedbyapostoperativeuterine
infection.
verytenderinthelowerhalf,particularlyontherightsidewitha
suggestionofsomeperitonismnomasses.Vaginalexamination:
thereissomedarkbrownvaginaldischargenomassesnormal
sizeduterusandcervicalexcitationtenderness.Observationsareas
follows:
Pulserate(bpm)
Bloodpressure(mmHg)
105
Temperature(C)
37.9
Protein
trace
Blood+
Ketones++
Respiratoryrate
(breaths/min)
12
O2saturationonair
(%)
99
PleaseSelect
Incorrect
Thecorrectanswerispelvicultrasoundscan.Seeexplanationtoquestion
1.
Ahealthy38yearoldP3hasa5hourhistoryofsuddenonset
severerightsidedlowerabdominalpainthatcameonaftersexual
intercourse.HerLMPwas24daysagoperiodsareregular:34/28
daysshehasbeensterilised.Shehasapasthistoryofrecurrent
urinarytractinfections,whichisunderinvestigationbyaurologist.
Onexamination:shelookspaleanddistressedtheabdomenisvery
tenderinthelowerhalf,particularlyoverthebladderandontheright
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sidewithreboundperitonismnomasses.Vaginalexamination:
normalsizeduterus,nomassesandcervicalexcitationtenderness
iselicited.Observationsareasfollows:
Pulserate(bpm)
Bloodpressure(mmHg)
115
Temperature(C)
36.0
Protein
trace
Bloodtrace
Respiratoryrate
(breaths/min)
18
O2saturationonair
(%)
96
PleaseSelect
Incorrect
Thecorrectanswerisfullbloodcount.Clinically,thiswomanhasintra
abdominalhaemorrhageandhercardiovascularsystemiscompensating,
probablytoitslimit,sothereisnotimeforascanandaFBCwillconfirm
theclinicaldiagnosisanddefinehowmuchbloodhasbeenlostandhow
muchneedstobereplaced.
Ahealthy38yearoldP3hasa10hourhistoryofsevererightsided
lowerabdominalpainassociatedwithnauseaandvomiting,and
feelsgenerallyunwell.HerLMPwas4weeksagoandisduesoon
periodsareregular:34/28dayssheusesthediaphragmwith
spermicidalcreamforcontraception.Shesmokes10cigarettesa
dayandhasapasthistoryofirritablebowelsyndromeandhasbeen
somewhatconstipatedlately.
Onexamination:shelooksunwellanddehydratedtheabdomenis
verytenderinthelowerabdomen,particularlyontherightsideand
loinnomasses.Vaginalexamination:normalsizeduterus,no
massesandnosignificantpelvictendernessandfaecalloadingof
therectum.Observationsareasfollows:
Pulserate(bpm)
Bloodpressure(mmHg)
110
140/70
Temperature(C)
38.1
Urineanalysis
Protein+
Blood+
Ketones+++
Respiratoryrate
(breaths/min)
13
O2saturationonair
(%)
98
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PleaseSelect
Incorrect
Thecorrectanswerismidstreamurinemicroscopy.Seeexplanationto
question1.
A21yearold,P1+1,hasa72hourhistoryofincreasinglysevere
lowerabdominalpainlocalisingtotherightside.Shehaslosther
appetiteandgenerallyfeelsunwellshewaswellpriortotheonset
ofthepain.HerLMPwas3weeksagoperiodsareregular:34/28
dayswithsomebreakthroughbleedingfromtimetotime.Sheuses
theMirenaIUSforcontraception,whichwasinsertedaftera
terminationofpregnancy2monthsago.Shesmokes1015
cigarettesadayandhasapasthistoryofrecurrenturinarytract
infectionsthatiscurrentlyunderinvestigationbyaurologist.
verytenderinthelowerhalf,particularlyontherightsidewitha
suggestionofsomeperitonismnomasses.Vaginalexamination:
thereissomedarkbrownoffensivevaginaldischargenormalsized
uterusandcervicalexcitationtendernessandatenderfullnessin
thepouchofDouglas.Observationsareasfollows:
Pulserate(bpm)
Bloodpressure(mmHg)
115
115/55
Temperature(C)
Urineanalysis
38.5
Proteintrace
Blood+
Ketones++
Respiratoryrate
(breaths/min)
15
O2saturationonair
(%)
95
PleaseSelect
Incorrect
Thecorrectanswerispelvicultrasoundscan.Seeexplanationtoquestion
1.
Ahealthy28yearold,P0+2,hasa7hourhistoryofsuddenonset
severerightsidedlowerabdominalpainherLMPwas6weeksago
periodsarenormallyinfrequentandirregular:34/3556days.She
andherpartnerhaveapasthistoryofsubfertilityandarecurrently
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receivingclomifenecitrate100mgforovulationinductionfor
anovulatoryoligomenorrhoea.Herfirstpregnancywasanearly
miscarriagethesecondwasalefttubalpregnancy.
Onexamination:shelookspaleanddistressedtheabdomenisvery
tenderinthelowerhalfontherightsidewithreboundperitonismno
masses.Vaginalexamination:normalsizeduterus,nomassesand
cervicalexcitationtendernessiselicited.
Observationsareasfollows:
Pulserate(bpm)
Bloodpressure(mmHg)
110
120/50
Temperature(C)
36.0
Urineanalysis
hasnot
passedurine
Respiratoryrate
(breaths/min)
14
O2saturationonair
(%)
96
PleaseSelect
Incorrect
Thecorrectanswerisurinepregnancytest.Seeexplanationtoquestion
1.
A45yearoldP3hasa4dayhistoryofincreasinglyseverelower
abdominalpainassociatedwithnauseaandvomitingandfeeling
generallyunwellwithanorexia.Twoweeksagoshehadavaginal
hysterectomy,whichwascomplicatedbyasymptomaticpost
operativeanaemiathatrequiredatwounitbloodtransfusion.She
wasdischargedfromhospital1weekagoandhasnotfeltwellsince
andhasnoticedanincreasinglyheavybloodstainedvaginal
discharge.Shesmokes10cigarettesadayandhasapasthistoryof
irritablebowelsyndrome.Shehasbeensomewhatconstipatedsince
theoperation.
Onexamination:shelooksunwellanddehydratedtheabdomenis
verytenderinthelowerabdomenandontherightsidethereis
reboundtendernessnomasses.Vaginalexamination:apelvic
fullnesswasnotedwithsignificantpelvictendernessintheright
fornixfaecalloadingoftherectum.Observationsareasfollows:
Pulserate(bpm)
110
Temperature(C)
38.3
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Bloodpressure(mmHg)
140/75
Urineanalysis
Protein+
Blood++
Ketones+
Respiratoryrate
(breaths/min)
14
O2saturationonair
(%)
98
PleaseSelect
Incorrect
ThecorrectanswerisCTscanofabdomen.Withthefaecalloadingand
theclinicalpossibilityofapelvicabscessaCTwillgivemorevaluable
informationthananultrasoundscanespeciallytoseeifbowelisinvolved
andifageneralsurgeonneedstobeinvolvedwithareturntotheatre.
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