Maternal Medicine ( Platinum ) – EMQ

Option List:

A. Labetalol oral
B. Measure blood pressure atleast 4 times a day until inpatient and then on Day 3 and Day 5 after birth and if abnormal on alternate days until normal
C. Magnesium sulphate intramuscular
D. Methyldopa oral to be stopped within 2 working days and start labetalol
E. Labetalol oral along with Aspirin 150mg
F. Labetalol intravenous
G. Monitor three times a day until discharge and follow her up in the community
H. Aspirin 150mg daily at night from 12 weeks
I. Methyldopa to be stopped within 2 workings days and continue monitoring
J. Antenatal corticosteroids
K. Transfer to the community
L. Measure Blood pressure 4 times a day while inpatient and then every 1-2 days for upto 2 weeks transfer to the community care until the woman is off treatment
M. Explain the risk of Pre-eclampsia and offer regular BP monitoring

For each scenario given above, choose the single most appropriate management option. Each option may be used once or more than once or not at all.

1.34 year old G2P1L1 with previous normal delivery developed severe preeclampsia and was on labetalol and nifidepine and labour induced at 37 weeks. She delivered vaginally and her intrapartum period was uneventful. The most appropriate way of monitoring the blood pressure for her would be

2. 30 year old nulliparous woman at booking visit was found to have a blood pressure of 140/86, and repeat blood pressure measure again revealed 142/84. What is the treatment that she should be offered?

3. 40 year old G2P1L1 conceived following IVF, has come for a booking appointment. She gives a history of preeclampsia in the previous pregnancy. What is the recommended advice for this woman to avoid Pre-eclampsia?

4. 35 year old primigravida diagnosed to have gestational hypertension was on methyldopa250mg TID during the antenatal period and at 39 weeks delivered vaginally without any complications. The post-natal period, her blood pressure is 150/100. What is the advice that the woman should be offered?

Option List :

A. Admit, start labetalol, monitor BP frequently and repeat investigations (FBS,LFT,RFT twice a week) and repeat USG every 2 weeks
B.  Urinary reagent strip test 6-8 weeks after birth and further review with their GP or specialist review at 3 months if urine proteinuria is 2+ or more
C. Add labetalol to nifidepine
D. Admit, start labetolol, monitor BP atleast 4 times daily, and blood investigations three times a week and repeat USG every 2 weeks
E. Urinary reagent strip test 6-8 weeks after birth and further review with their GP or specialist review at 3 months if urine proteinuria is 1+ or more
F. Add enalapril to nifidepine
G. Start labetalol, offer outpatient management, and measure blood pressure every 48 hours, repeat urine dipstick every visit and offer blood investigations twice a week and fetal heart rate auscultation every visit
H. Change to amlodipine

5. 25 year old primigravida at 32 weeks of pregnancy was found to have 156/100 at the antenatal visits, and was found to be elevated at the same range when repeated. She was investigated and found to have an albumin: creatinine ratio of 10mg/mmol and also serum alanine transaminase of 74 IU/litre with no signs of nausea, epigastric pain, headache, or vomiting. Physical examination revealed normal findings and ultrasound revealed an adequately grown fetus and CTG was found to be normal. The appropriate management option is.

6. 29 year old G3P1L1 Abortion1 was induced labour at 37 weeks of gestation with mild pre-eclampsia for progressive deterioration of liver function and renal function tests. She delivered vaginally and the intrapartum period was uneventful. The Platelet count, transaminases and serum creatinine 48-72 hours after birth was normal and the blood pressure was normal following delivery. The appropriate follow up care wound be

7. 22 year old woman delivered vaginally, and her antenatal period was complicated by severe pre-eclampsia and following delivery was started on nifidepine. Her blood pressure was not controlled with nifidepine. The next step to control blood pressure is

Option List:

A. Within 10 days postpartum
B. Discussion regarding induction of labour immediately
C. Discussion regarding induction of labour after 37+0 weeks
D. Topical emollients
E. Every week until LFT becomes normal
F. Beyond 10 days- 6 weeks postpartum
G. At the post-natal visit at 8 weeks
H.  Urso deoxycholic acid
I. Dexamethasone

8. 29 year old woman with 36+5 weeks pregnancy was diagnosed to have obstetric cholestasis. LFT done was in the upper limit of the pregnancy specific ranges and the bile acid were found to be more than 20 mmol/litre. She has intractable itching responding to topical emollients. What is the best management option?

9. 26 year old woman had delivered vaginally following induction of labour for severe obstetric cholestasis nearing term. When should she be offered measurement of liver function tests?

10. 35 year old G2P1L1, has come with intense itching all over the body including palms and soles. She was prescribed emollients by her GP, which did not have any effect. Itching is so intense that it is disturbing her sleep. The best treatment option for to reduce itching and to improve liver function test for her is

Option List:

A. V/Q scan
B. Lung ventilation scan
C. Pulmonary angiography
D. ECG
E. Lung perfusion scan
F. Arterial blood gases
G. Chest X-ray
H. Lower limb Doppler ultrasound scan
I. D-dimers
J. CTPA
K. Spirometry
L. Lower limb venogram

Instructions: For each of the scenarios below, select the single most appropriate subsequent investigation from the above list. Each option may be used once, more than once, or not at all.

11. A healthy 28 year old woman presents at 35 weeks gestation with sudden onset of shortness of breath and chest pain. She has a pulse of 120 / min, BP 120/80 and SO2 = 94% on air. She is administered a therapeutic dose of low molecular weight heparin. Chest X-ray and lower limb Doppler’s are normal. Following counselling, the woman prefers the investigation that exposes her foetus to the lowest level of radiation.

12. A healthy 32 year old woman presents at 36 weeks gestation with sudden onset of shortness of breath and pleuritic chest pain. She has a pulse of 110 / min, BP 120/80 and SO2 = 95% on air. She is administered a therapeutic dose of low molecular weight heparin. Chest X-ray and lower limb Dopplers are normal. Her mother suffered from breast cancer at age of 55years. She wants to decrease any fetal exposure to radiation.

Option List:

A. Commence intravenous prophylactic unfractionated heparin
B. Commence prophylactic low molecular weight heparin
C. Remove catheter 8 hours after giving the last dose of heparin
D. Change to prophylactic intravenous unfractionated heparin
E. Remove catheter 12 hours after giving the last dose of heparin
F. Change to heparinoid (danaparoid sodium)
G. Remove catheter 24 hours after giving the last dose of heparin
H. Check for antiphopholipid antibodies and Commence prophylactic low molecular weight heparin
I. Change to low-molecular weight heparin (LMWH)
J. Withhold heparin for 12 hours before giving spinal anaesthesia
K. Commence prophylactic low molecular weight heparin
L. Withhold heparin for 24 hours before giving spinal anaesthesia
M. Commence dalteparin
N. Withhold heparin for 6 hours before giving epidural anaesthesia
O. Monitor anti-Xa levels
P. Withhold heparin for 12 hours before giving epidural anaesthesia
Q. Stop LMWH and control bleeding, may require change to UFH.
R. Remove catheter 3 hours after giving heparin
S. There should be gap of 4 hours between LMWH and removal of epidural catheter.

13. A 40-year-old woman, para 1, presents to the obstetric day assessment unit at 28 weeks of gestation with 3 episodes for reduced fetal movements (normal cardiotocograph [CTG] and colour Doppler). Her notes indicate that she had DVT at 20 weeks of gestation during her current pregnancy and is on 80 mg LMWH twice daily. Her booking blood results were normal. However, her recent blood test reveals a platelet count of 60 x 109/L.

14. A 35-year-old woman, gravid 3, para 2, is admitted to the antenatal ward for an elective caesarean section for breech presentation. She had pulmonary embolism during this pregnancy and has been on a therapeutic dose of LMWH (90 mg twice daily) for the last three months. She took her last dose just before coming into the ward.

15. A 43-year-old woman, para 3, presents to the EPAU at 12 weeks of gestation with mild vaginal bleeding. She gives a history of unprovoked deep venous thrombosis (DVT) 1 year prior to this pregnancy and was treated with warfarin for 6 months. In both last pregnancies she developed pre- eclampsia. Currently, the general practitioner has started her on aspirin in view of a previous history of pre-eclampsia.

16. A 26 -year-old woman, para 1 (delivered 6 hours ago), gives a history of previous thrombophilia. Her mode of delivery was caesarean section for a prolonged second stage of labour. She had a massive postpartum haemorrhage and her current haemoglobin level is 8 g/dL. The midwife comes to inform you about the minimal soakage of the caesarean section wound dressing.

17. A 36-year-old woman, para 3, is reviewed by the senior house officer in the postnatal ward. She had a caesarean section for failure to progress and has been using an epidural for pain relief for the last 4 hours following caesarean section. The midwife wants to give her the dose of prophylactic LMWH. What advice is given to midwife?

Option List:

A. Stop heparin
B. Thrombophilia screen
C. Convert warfarin to low molecular weight heparin
D. Stop warfarin
E. Advise against pregnancy
F. Warfarin as soon as possible
G. Convert low molecular weight heparin to warfarin
H. Close observation for additional risk factors
I. Graduated elastic compression stockings
J. Low molecular weight heparin as soon as possible
K. Low molecular weight heparin from 12 weeks

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

18. A 28 year old woman attends the antenatal clinic at 16 weeks gestation. She suffered a DVT at the age of 20 in the axillary vein.

19. A 32 year old woman attends the antenatal clinic at 8 weeks gestation. She suffered a DVT at the age of 18 but does not recall the specific circumstances. Her sister suffered from pulmonary embolism at the age of 42.

20. A 32 year old woman attends the antenatal clinic at 22 weeks gestation. She is known to be a carrier of the factor V Leiden mutation but has never had a thromboembolic event. Her BMI is 24.

Option List :

A. Administer regional analgesia if APTT is normal
B. Administer regional analgesia if APTT and PT are normal
C. Administer protamine sulphate then regional analgesia
D. Administer prophylactic dose of LMWH
E. Check anti-Xa levels then administer regional analgesia if normal
F. Advice that regional analgesia is contra-indicated
G. Request accepted and administer regional analgesia
H. Remove epidural catheter
I. Check APTT then remove epidural catheter if result is normal
J. Advise against removal of epidural catheter
K. Wait for 2 hours then administer LMWH

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

21. A 24 year old woman with a previous DVT and has been treated with a prophylactic dose of low molecular weight heparin during pregnancy. She presents in spontaneous labour at 37 weeks gestation and requests epidural analgesia. Her last dose of heparin was 16 h earlier.

22. A 26 year old woman with a previous DVT and has been treated with a prophylactic dose of low molecular weight heparin during pregnancy. She presents in spontaneous labour at 37 weeks gestation and receives epidural analgesia, as her last dose of heparin was 14 h earlier. Her epidural catheter is removed about 2 hours ago. When can she be given her next dose of LMWH?

23 . A 25 year old woman with a BMI of 36 has an emergency caesarean section at full dilatation under spinal anaesthesia because of foetal distress. The procedure was uncomplicated with blood loss of 700ml. She is now post-surgery and your attention is drawn to instructions on post-partum thromboprophylaxis.

Option List:

A. Chlorpropamide
B. Glibenclamide
C. Gliclazide
D. Insulin aspart
E. Insulin detemir
F. Insulin glargine
G. Insulin lispro
H. No treatment required
I. Isophane insulin (NPH insulin)
J. Metformin
K. Phenformin
L. Sitagliptin
M. Pioglitazone
N. Rosiglitazone
O. Tolbutamide
P. Troglitazone

For each of the following clinical scenarios, choose the single most appropriate medication from the list of options above. Each option may be used once, more than once or not at all.

24. A woman with a BMI of 33 kg/m2 and persistent glycosuria underwent a glucose tolerance test at 26 weeks of gestation.
Her results are as follows:
Fasting glucose
7.3 mmol/l
2-Hour glucose
10.1 mmol/l
What immediate treatment is recommended?

25. A 36-year-old woman is newly diagnosed with gestational diabetes at 27 weeks of gestation. She has modified her diet and undertaken an exercise regime but her plasma glucose levels remain slightly elevated after 2 weeks of this new regime. She was advised to start medication, but she wish to take oral drug than insulin. What is the most appropriate treatment for her?