EBCOG Part 1 – High Yield Questions – Antenatal care (E.M.Q)

A Abruption of placenta

B Accidental haemorrhage

C Unexplained haemorrhage

D In labour

E Intrauterine death

F Placenta accreta

G Placenta praevia

H Preterm labour

I Primary postpartum haemorrhage

J Secondary postpartum haemorrhage

For each case described below, choose the single most appropriate diagnosis from above list of options. Each option may be used once, more than once, or not at all.

1.A 23-year-old woman is 40 weeks pregnant. She presents to hospital with a history of reduced fetal movements. She says that abdominal contractions are coming every few minutes and she has been having a blood-stained discharge per vagina. On vaginal examination the cervix is 5 cm dilated, with cephalic presentation and station is +1.

 2.A 31-year-old primigravida, who is 30 weeks pregnant, presents to the emergency department with absent fetal movements. She also complains of severe headache, heartburn and blurring of vision for the last few days. On examination, her blood pressure is 170/110 mmHg, a urine dipstick shows ++++ protein, and abdominally her uterus is hard and tender with no visible signs of fetal movement per abdomen.

3.A 32-year-old pregnant woman in her first pregnancy at 36/40 weeks by date presents to the labour ward with a history of painless significant vaginal bleeding after sexual intercourse. On examination the abdomen is soft and not tender. The fetus is presenting by the head and is 5/5th palpable above the symphysis pubis. Cardiotocography (CTG) is normal.

4. A 26-year-old primigravida, who is 40 weeks pregnant, presents to the labour ward with a history of constant abdominal pain for the last few hours. She also gives a history of having lost a cupful of fresh blood per vagina before the pain started. Abdominal examination shows an irritable uterus. CTG was normal.

5.A 35-year-old woman had a vaginal delivery 7 days ago. She presents to her general practitioner with a history of a foul-smelling discharge per vagina. She also gives a history of passing blood clots per vagina for the last 24 hours. On examination her blood pressure is 90/40 mmHg, her pulse is 110 beats/minute and her temperature is 38°C. On abdominal examination uterus is tender on palpation and the uterine fundus is 2 cm above the umbilicus. Speculum examination reveals clots in the vagina.

A Mesenteric vein thrombosis

B Pancreatitis

C Appendicitis

D Ureteric colic

E Pyelonephritis

F Torsion of an ovarian cyst

G Pre-eclampsia

H Red degeneration

I HELLP (haemolytic anaemia, elevated liver enzymes and low platelet count) syndrome

J Acute fatty liver

K Severe constipation

L Abruption

M Preterm labour

N Urinary retention

0 Sickle cell crisis

P Crohn's disease

Q Ulcerative colitis

R None of the above

For each case described below, choose the single most appropriate diagnosis from the above list of options. Each option may be used once, more than once, or not at all

6. A 20-year-old woman in her first pregnancy is admitted with severe abdominal pain at 30 weeks' gestation. She describes the pain to be radiating from her back to her groin. She was treated for an episode of fever with chills a month ago by her general practitioner. Urinalysis showed leucocytes and blood. Her blood test results are as follows: haemoglobin 97 g/L, white blood cell count 19 x 10°/L, platelets 180 x 10°/L, uric acid 0.35 mmol/L, amylase 150 IU/L, aspartate aminotransferase (AST) 22 IU/L and alanine aminotransferase (ALT) 27 IU/L.

7. A 29-year-old woman attends the day assessment unit with abdominal pain. She is 30 weeks pregnant in her fourth pregnancy. She also gives a history of nausea and vomiting since morning. There is no history of tightening, or bleeding per vaginum. She drinks 24 units of alcohol a week. Her blood pressure is 135/85 mmHg and pulse is 105 beats/minute. Urine analysis is negative. Her blood results are: haemoglobin 125 g/L, white blood cell count 13 x 10°/L, C-reactive protein (CRP) 210 mg/L, AST 42 IU/L, gamma-glutamyl transferase (GGT) 55 IU/L, alkaline phosphatase (ALP) 250 IU/L, amylase 700 IU/L and bilirubin 32 umol/L.

8. A 29-year-old woman in her first pregnancy presents to accident and emergency at 34 weeks' gestation with a history of acute abdominal pain. She is agitated, confused, and complains of headache and severe nausea. There is no history of uterine tightening or bleeding per vaginum. Her blood pressure is 135/80 mmHg and urinalysis shows 3+ protein. Her initial blood results are: haemoglobin 115g/L, white blood cell count 9 x 10°/L, CRP 150 mg/L, AST 110 IU/L, GGT 87 IU/L, ALP 660 IU/L, bilirubin 427.60 pmol/L, amylase 65 IU/L and serum albumin 20 g/dL.

9. A 33-year-old primigravid woman presents with lower abdominal pain at 16 weeks' gestation. There is no history of vaginal bleeding or dysuria. She had an episode of vomiting in the morning. On examination her temperature is 37.9°C. There is tenderness in her lower abdomen, particularly the right lower quadrant. Vaginal examination reveals a closed cervix with no bleeding, Blood results are: haemoglobin 135 g/L, white blood cell count 17 x 10°/L, CRP 740 mg/L, AST 32 U/L, GGT 19 IU/L, ALP 155 IU/L, bilirubin 20 umol/L, amylase 55 IU and serum albumin 280 g/L.

A Prescribe oral acyclovir for 7 days     

B Warn to stay away from hospital because of the infectious nature of her condition

C Refer to hospital

D Requires an immediate caesarean section under epidural anaesthesia to avoid the theoretical transmission of the virus from skin lesions to CNS in a spinal anaesthesia

E Administer varicella zoster immunoglobulin (VZIG) as soon as possible

F Prescribe a 10-day course of prophylaxis with zanamivir or oseltamivir as soon as possible

G Investigate with sputum culture and chest radiograph

H Treat empirically for pneumonia, avoiding chest radiograph but with supportive measures including oxygen administration and rehydration and oral antibiotic therapy

I Institute supportive treatment and intravenous acyclovir

 For each case described below, choose the single most appropriate course of action from the above list of options. Each option may be used once, more than once, or not at all.

10. A 28-year-old woman presents at 28 weeks gestation with a 3-day history of a rash and chesty cough and a history of recent exposure to chickenpox. She smokes 20 cigarettes per day. 2

11.  A 29-year-old pregnant woman develops a fever, cough and sore throat 2 days after arrival in the UK from a visit to Zambia.

12.A 19-year-old woman presents to the emergency department with breathlessness, fever and a cough productive of green sputum. On admission she tests positive for pregnancy.

13. A 28-year-old woman presents unwell with symptoms and signs of varicella infection, difficulty breathing and fever at 39 weeks' gestation.

14.A 25-year-old woman is exposed to chickenpox at 16 weeks' gestation. A serum test sent 9 days after exposure is negative for VZIG.

A Amniotic fluid volume and umbilical artery Doppler in 1 week

B Amniotic fluid volume and umbilical artery Doppler in 2 weeks

C Amniotic fluid volume and umbilical artery Doppler twice per week

D Biophysical profile

E Continue low- risk pathway

F Ductus venosus Doppler

G Growth scan in 3–4 weeks

H Growth scan, amniotic fluid volume

I Growth scan, amniotic fluid volume and umbilical artery Doppler

J Growth scan, amniotic fluid volume and umbilical artery Doppler in 2

weeks

K Middle cerebral artery (MCA) Doppler

L Serial growth scans from 28 weeks

M Umbilical vein Doppler

N Uterine artery Doppler at 18 weeks

For the following clinical scenarios, choose the most important ultrasound scan investigation or action to take next. Assume that you are in a hospital where fetal medicine scanning is available. Each option may be used once, more than once or not at all.

15. A 28-year-old woman has a growth scan as her previous baby was born with aweight below the 5th centile. She is now at 28 weeks of gestation. The growth scan for obstetric history shows that the estimated fetal weight (EFW) is on the 50th centile. Amniotic fluid volume and umbilical artery Doppler are normal.

16. A 32-year-old woman in her first pregnancy is seen at 28 weeks of gestation. She has had a growth scan due to a symphysis fundal height measurement belowthe 10th centile. The growth scan shows an EFW of <5th centile with normal amniotic fluid volume and umbilical artery Doppler.

17. A 26-year-old patient is seen in the antenatal clinic. She is at 29 + 5 weeks of gestation and has a symphysis fundal height below the 10th centile. She has an ultrasound scan that shows EFW below the 5th centile and a normal amniotic fluid volume with absent end- diastolic flow in the umbilical artery. The CTG is normal.

18. An 18-year-old woman in her first pregnancy has a growth scan at 28 weeks of gestation due to her high BMI of 37 kg/m2. The growth scan shows an EFW <10th centile. Amniotic fluid volume is normal and the umbilical artery Doppler shows a raised pulsatility index of >2 standard deviations with end- diastolic flow positive

A Arterial blood gas

B Compression duplex ultrasound

C Continue treatment and repeat scan in 7 days

D Computed tomography pulmonary angiography (CTPA)

E D-dimer

F ECG and chest X- ray (CXR)

G Full blood count (FBC), urea and electrolytes (U&E), liver function test (LFT), coagulation test

H Magnetic resonance venography

I Refer back to midwife- led care

J Start prophylactic low-molecular-weight heparin (LMWH)

K Start therapeutic dose LMWH

L Start unfractionated heparin

M Stop treatment and repeat scan in 3 days

N Stop treatment and repeat scan in 7 days

O Thrombophilia screening

P Ventilation/perfusion (V/Q) scan

For each of the following clinical scenarios, select the most appropriate next step in management from the list of options above. Each option may be used once, more than once or not at all.

19. A 34-year-old patient is seen in the obstetric triage unit out of hours at 26 weeks of gestation with acute pain, tenderness and swelling of her left leg. She is otherwise well with no chest pain or shortness of breath.

20. A 38-year-old patient is seen at 22 weeks of gestation with acute swelling and pain in her right calf. She was started on a therapeutic dose of LMWH and has had a Doppler ultrasound scan that is negative for deep vein thrombosis (DVT). She remains symptomatic.