Antenatal Care Extra Questions

1. A 32-year-old nulliparous woman sees you in the antenatal clinic at 22 weeks’ gestation. She has just had a transvaginal scan that showed the cervix to be 22 mm in length. She has a past history of a cone biopsy of the cervix six years previously with normal follow-up smears. Which of the following options would you recommend for her?

2. A 29-year-old woman in her first pregnancy presents to the labour ward with some vaginal discharge at 27 weeks and two days. The pregnancy has been uneventful. Speculum examination reveals the cervix to be partially effaced and dilated 3 cm with bulging amniotic membranes. She is not in pain, and her observations are normal. The cardiotocograph (CTG) is reassuring. Which of the following options is the most appropriate in her management?

3. A 35-year-old healthy woman in her second pregnancy at 27 weeks presents to the labour ward with abdominal pain. She had a normal vaginal delivery at term in her first pregnancy three years previously. All observations are within normal limits. A CTG shows one to two irregular contractions every 10 minutes. The fetal heart trace is normal. Vaginal examination reveals the cervix to be 50% effaced but closed. Which of the following is the most appropriate management option?

4. A 35-year-old healthy woman in her second pregnancy at 30+6 weeks presents to the labour ward with abdominal pain. She had a normal vaginal delivery at term in her first pregnancy three years previously. All observations are within normal limits. A CTG shows one to two irregular contractions every 10 minutes. The fetal heart trace is normal. Vaginal examination reveals the cervix to be 50% effaced but closed. What should you do next?

5. A 26-year-old woman in her first pregnancy presents to the labour ward at 28 weeks and four days gestation with abdominal pain. Maternal observations are all within normal limits. A CTG reveals she is contracting at a rate of three times in 10 minutes, with a normal fetal heart rate. Speculum examination shows the cervix is effaced and dilated 3 cm. The ST3 obstetric trainee wants to know the correct dose of magnesium sulfate for neuroprotection for the baby. Which of the following statements is the most appropriate answer?

6. A 28-year-old primigravida with monochorionic diamniotic (MCDA) twins undergoes an ultrasound scan at 24 weeks. Twin 1 has an estimated weight at the 20th centile with the deepest pool of liquor of 1.6 cm. Twin 2 is growing at the 80th centile with the deepest pool of liquor measuring 9.5 cm. Doppler studies on both twins are normal. The bladders of both twins are visible. Which of the following options is the most likely diagnosis?

7. A 28-year-old primigravida presents to the antenatal clinic with headache. Which of the following headaches in pregnancy is classified as primary headache?

8. A 29-year-old woman in her first pregnancy presents at the antenatal clinic complaining of recurrent attacks of migraine. She is now 20 weeks pregnant and is concerned as she has these attacks once every 10 days. She is enquiring if there is any medication that she can safely use during the pregnancy to stop these attacks. Which of the following medications would you consider most appropriate?

9. A 28-year-old woman is admitted with slight lower abdominal pains and a watery vaginal discharge. A beta-methasone course is prescribed. By how much will this management reduce the risk of neonatal death?

10. A 36-year-old woman with uncontrolled diabetes and who is 29 weeks pregnant is admitted because of threatened preterm labour. What is your advice regarding steroids for lung maturity?

11. A 32-year-old woman who is 36 weeks pregnant comes to the labour ward because of upper abdominal pain and slight vaginal bleeding. Her two previous pregnancies ended in Caesarean section because of placental abruption. She has a normal blood pressure (BP) and a reactive non-stress test. What are her chances of having another placental abruption?

12. A 29-year-old pregnant woman has just booked for her antenatal care. Her first pregnancy ended in a Caesarean section birth because of placenta previa. What are her risks (odds ratio, OR) for a recurrence?

13. A non-sensitized Rh-negative pregnant woman is admitted at 34 weeks with a moderate amount of vaginal bleeding. She is stable and the bleeding has stopped. What specific test should you request?

14. A 33-year-old woman who is 34 weeks pregnant and under community care is referred to the antenatal clinic because of recurrent mild vaginal spotting over the last week. Her antenatal care has been uneventful. She has a normal fundal placenta. Her history and your clinical examination of her did not reveal any abnormality. Your speculum examination revealed a small ectropion. Her last cervical smear 18 months previously showed mild dyskaryosis. She has screened negative for human papilloma virus (HPV). How will you conduct the rest of her antenatal care and delivery?

15. A 33-year-old woman who is 33 weeks pregnant is admitted with severe abruption and an estimated blood loss of 1500 mL. An emergency ultrasound scan showed a large retro-placental haematoma. Fetal heart pulsations were not seen on the ultrasound scan. She is stabilized with intravenous saline infusions and prepared for an emergency Caesarean section. What is your first line empirical treatment while waiting for the coagulation profile results?

16. A 23-year-old para 2 woman presented with vague abdominal pains when she was 29 weeks pregnant. General and abdominal examination did not reveal any abnormality. She had a normal BP. Fetal Doppler and CTG could not demonstrate the fetal heart. A real-time ultrasound scan augmented with colour Doppler of the fetal heart and umbilical artery confirmed intrauterine fetal demise. It also showed collapse of the fetal skull with overlapping bones. These findings were confirmed by a second scan. She insisted she still feels fetal movements. How will you handle the situation?

17. A 36-year-old woman comes to the labour ward with absent fetal movements for the last six hours. She is 36 weeks pregnant. All investigations confirmed intrauterine death. She has had two previous vaginal births. After counselling, she was still undecided about the period of waiting before active intervention. What is the incidence of the most serious complication if she waits for four or more weeks?

18. A 31-year-old woman presents to the antenatal clinic when she is 22 weeks pregnant. She has had normal antenatal care until her last visit two weeks previously with no medical history or medications. At this visit, her BP is 145/98 mmHg with significant proteinuria. What is your management?

19. You are admitting a 33-year-old woman with a BP of 170/115 mmHg. Her urine dipstick showed 1+ proteinuria. What is the quickest and most convenient method to quantify her proteinuria?

20. A 29-year-old primiparous woman complains of pruritus in the palm of the hands and soles of the feet when 32 weeks pregnant. What is the risk of perinatal mortality because of this obstetric cholestasis?

21. A 38-year-old primigravida undergoes first trimester screening and the result shows a low placental-associated plasma protein (PAPP-A) of <0.4 MoM (multiples of the median). What is the implication of this result?

22. A 32-year-old pregnant woman had a history of a previous small-for-gestational-age baby. Her uterine artery Doppler shows notching at 22 weeks’ gestation, which normalizes when repeated two weeks later. How will you continue her antenatal care?

23. You are caring for a 33-year-old pregnant woman who is diagnosed with a small-forgestational- age fetus. At 31 weeks she showed an umbilical flow plasticity index of >+2 standard deviations (SDs) above the mean for gestational age. What indices should you use to time delivery?

24. A young couple comes to see you at the antenatal clinic. She is 29 years old and 23 weeks pregnant. They have to travel to a ZIKA virus endemic area. She shows you a National Health Service (NHS) advice about how to avoid mosquito bites, but asks you if you have any further advice. What else will you tell her?

25. A 25-year-old, G1 P0 woman attends the antenatal clinic for her 12-week scan. She accepted the offer of undergoing a combined test. However, she has queried the accuracy of the test. Which of the followings best describes the detection rate (DR) and the screen positive rate (SPR) of a combined test?

26. A 37-year-old pregnant woman has been diagnosed with monochorionic diamniotic (MCDA) twins. She agreed to screening for Down syndrome at 13+4 weeks. Which of the following screenings best describes her available option?

27. A 25-year-old has just had her 20-week scan. The fetus is found to have holoprosencephaly and bilateral cleft palate. The cardiac ultrasound scan shows a ventricular septal defect. Which of the following is most likely to be associated with these ultrasound scan findings?

28. A woman has just had her dating ultrasound scan. The sonographer has clearly documented two gestational sacs (T-sign) and confirmed 10-week MCDA viable twins. The woman asks you for further information about MCDA twins. Which of the following statements can you quote in your counselling?

29. A 28-year-old low-risk pregnant woman attends the antenatal clinic for the 18–20- week ultrasound anomaly scan. She asks about the chance of finding a structural abnormality. Which of the following describes best the risk of structural abnormalities in all pregnancies?

30. A 17-year-old woman attends the antenatal clinic for her 20-week scan. The sonographer has confirmed the presence of an isolated large gastroschisis. The woman is committed to her pregnancy. What is your next step?

31. A woman attends the antenatal clinic for her 18–20-week scan. The sonographer has demonstrated ‘lemon and banana’ sign and the baby is diagnosed with Arnold–Chiari syndrome. What is the ‘banana’ sign?

32. A pregnant woman has just had her 20-week anomaly scan. Her baby is diagnosed with ventricular septal defect and its femur length is at the 5th centile. What is the most appropriate next step?

33. A pregnant woman complaining of reduced fetal movements at 26 weeks is referred for an ultrasound scan. The scan shows fetal hydrothorax, ascites and massive skin oedema. She is rhesus positive and all her antibody tests are negative. What is the proportion of this condition as a cause of perinatal mortality?

34. A pregnant woman has just had her 12-week ultrasound scan. The scan shows a live severely hydropic baby. What is the most appropriate investigation you would like to offer next?

35. A woman has booked her pregnancy at 27 weeks’ gestation. She has an ultrasound scan that shows multiple congenital abnormalities. She is offered amniocentesis and the baby is diagnosed with Edward syndrome (Trisomy 18). She asks for termination of the pregnancy. Based on the 1967 United Kingdom Abortion (amended in 1990), which ground will support her request?

36. A pregnant woman has just had her 12-week scan. She is diagnosed with a dichorionic diamniotic (DCDA) twin pregnancy. She queries the chance of having them prematurely. What proportion of all twins deliver before 37 weeks?

37. A pregnant woman with MCDA twins has just had a scan at 21 weeks in the fetal medicine unit. Twin 1’s estimated weight is 40% less than the estimated weight for twin 2, and is diagnosed with sacral agenesis and right diaphragmatic hernia. No obvious anomaly is seen in twin 2 and it’s growth and amniotic fluid are normal. What is the management option you would like to offer her?

38. A woman has had her scan at 24 weeks as the symphysiofundal height (SFH) height measures more than for the estimated date. The scan demonstrates severe polyhydramnios. The sonographer could not see one of the fetal organs. What is the most likely missing organ/s in the scan?

39. A woman has had her first trimester combined risk calculated as 1:50. Chorionic villus sampling is offered and accepted. An uncomplicated procedure is performed and she is informed that the first result will be within 72 hours. What type of test is usually used to give the first cytogenetic result?

40. A 36-year-old woman with a BMI of 19 kg/m2 has become pregnant following successful second attempt at in vitro fertilization. She is healthy but smokes 5–10 cigarettes a day. The 19-week anomaly scan did not show any obvious abnormality. What further management would you like to recommend?

41. A 26-week pregnant woman is referred for an ultrasound scan after she presented with an episode of reduced fetal movements. The fetal Doppler assessment shows middle cerebral artery peak velocity multiple of the mean (MoM) at 2 and mild fetal ascites. You noted that her booked blood results show anti-K antibodies level of 2 IU/mL. What is the most appropriate management?

42. A pregnant woman has just had her 20-week anomaly scan. There is no obvious fetal anomaly seen on the scan but the umbilical cord contains only two blood vessels. What further management would you like to recommend?

43. The airport authorities are on the phone. A woman has refused to go through the airport body scanner as she is seven weeks pregnant and worried about fetal radiation exposure. What would be your advice?

44. A woman presents at 34 weeks gestation with a sudden onset of severe headache and altered consciousness following an episode of vomiting and diarrhoea. What is the most appropriate imaging technique?

45. A woman attends for a dating ultrasound scan at 12 weeks gestation. Doppler ultrasound identifies tricuspid regurgitation and a reversed A-wave in the ductus venosus (DV). She is at increased risk of which condition?

46. A woman is referred by the community midwife with suspected small for dates pregnancy at 33 weeks gestation. Ultrasound assessment confirms a small for gestation (SGA) fetus with reduced liquor volume and reversed end diastolic flow on umbilical artery (UA) Doppler. Cardiotocograph (CTG) is normal. What is the most appropriate management?

47. What proportion of pre-eclampsia can be predicted by risk assessment from maternal history alone in the first trimester of pregnancy?

48. When aspirin is used to reduce risk of pre-eclampsia in woman at high risk, at what gestation should it be commenced for maximum efficacy?

49. When calcium supplementation is used to reduce the risk of pre-eclampsia in women at high risk, at what gestation should it be commenced?

50. What proportion of pregnant women in the United Kingdom is estimated to take the recommended dose of periconceptual folic acid supplementation?

51. What is the incidence of red cell antibodies in pregnancy?

52. In the presence of anti-c red cell antibodies in pregnancy, which additional red cell antibody increases the risk of fetal anaemia?

53. A woman attends the antenatal clinic following a scan at 36 weeks gestation in her fourth pregnancy, which identifies an anterior placenta previa. She has had three previous caesarean births. What is the risk of placenta accreta?

54. What proportion of pregnant women in paid employment require time off work due to nausea and vomiting of pregnancy (NVP)?

55. What is the incidence of acute appendicitis in pregnancy?

56. A 21-year-old woman is admitted at 22 weeks gestation in her first pregnancy with suspected appendicitis. She has a low grade pyrexia with a leucocytosis and a mildly elevated C reactive protein level. Abdominal ultrasound is inconclusive. What imaging technique is the most appropriate subsequent investigation?

57. What is the risk of serious neonatal infection associated with prelabour rupture of membranes (PROM) at term?

58. A women in her first trimester scores more than 3 in the 2-item Generalized Anxiety Disorder scale (GAD-2) used to identify anxiety disorders in pregnancy. What is the best plan of care?

59. Women suffer from various anxieties in pregnancy. What is tokophobia?

60. What vitamin should women be advised to be taken throughout pregnancy and also while breastfeeding?

61. An 18-year-old woman books into the antenatal clinic at 12 weeks of gestation. She is fit and well but is noted to have an increased body mass index (BMI) but no other risk factors for diabetes. What BMI and above should she be offered screening for diabetes?

62. An anxious woman attends the antenatal clinic. She is planning an afternoon picnic and has a list of her favourite foods including UHT milk, cottage cheese sandwiches, vegetable pate, lambs kidneys and baked oily fish. Which of these food products is not recommended in pregnancy due to the risk of listeriosis?

63. A woman is advised to avoid drinking all alcohol in pregnancy but she declines. She enjoys wine but no more than 250 ml per week. She is keen to understand the safe limits of alcohol intake. What is acceptable with regard to alcohol intake during pregnancy?

64. A woman presents with vaginal candidiasis at 23 weeks pregnancy. What treatment should you offer her?

65. You have been asked to review a full blood test results of a woman at 28 weeks of gestation. At what threshold level of haemoglobin concentration would you define anaemia at this gestation?

66. A pregnant woman undergoes a routine anomaly ultrasound scan at 18 weeks of gestation. No ultrasound soft markers are present. At what nuchal translucency measurement is it recommended to refer the woman to fetal medicine services?

67. A woman is noted to have a low-lying placenta at her 20-week anomaly scan. At what gestational age should you arrange the next scan to assess placental localisation?

68. A woman declines an induction of labour at 42 weeks of gestation, the indication being ‘post-dates’. What is the recommended for assessment of ‘fetal wellbeing’ in this situation?

69. A woman at 36 weeks of gestation presents with an uncomplicated breech presentation and consents to undergo an external cephalic version (ECV) after consultation. Unfortunately, due to logistics, this service will not be available when she is 37 weeks. What management is most appropriate?

70. A pregnant woman at 34 weeks gestation is complaining of severe chronic sleep problem. What would be the most appropriate pharmacological intervention?

71. A woman undergoes a successful external cephalic version at 37 weeks gestation. What is the chance of spontaneous reversion to breech?

72. Which tocolytic agent has been proven to increase the success of an ECV?

73. A Gravida 3, Para 2 (both full term normal deliveries) is diagnosed with breech presentation at 35+1 weeks of gestation and is keen to have an external cephalic version. At what gestation is external cephalic version recommended for this mother?

74. A primigravida aged 26 is admitted with threatened preterm labour at 30 weeks and seeks counselling with regards to antenatal corticosteroids. What are the three recognised fetal benefits associated with antenatal corticosteroid administration in the case of premature delivery?

75. A woman who had a previous second trimester miscarriage is currently undergoing a serial ultrasound assessment of cervical length. With what cervical ultrasound feature would cervical cerlage be recommended?

76. A woman at 32 weeks gestation is admitted with severe falciparum malaria. What is the pharmacological treatment of choice?

77. A woman who is in the second trimester of pregnancy is planning to travel to an area endemic for chloroquine-resistant malaria. What would you recommend as the drug of choice for prophylaxis?

78. The velocimetry measurement of blood vessels can be used to improve perinatal outcomes in high-risk pregnancies. Which vessel is assessed?

79. A gravida 2 Para 0+1 molar pregnancy is diagnosed with Rhesus isoimmunisation. Doppler assessment of which vessel is used to monitor fetal anaemia during pregnancy

80. A woman presents at 26+5 weeks of gestation in her first pregnant with reduced fetal movements. What is the most appropriate initial investigation to carry out?

81. Domestic violence during pregnancy increases the risk of maternal mortality. What is the increase in homicide risk when there is domestic violence during pregnancy?

82. A woman who is 28 weeks pregnant in her first pregnancy attends the antenatal clinic. She has no medical problems, but on routine questioning, she discloses domestic abuse. She insists that this information has not been disclosed to anyone else. What is the first action that should be undertaken?

83. A course of antenatal corticosteroids is associated with a significant reduction in neonatal morbidity and mortality in women who are at risk of preterm birth. What is the reduction in risk of intraventricular haemorrhage?

84. What proportion of twin pregnancies have monochorionic placentation?

85. What proportion of monchorionic twin pregnancies are complicated by twin to twin transfusion syndrome (TTTS)?

86. A woman with a monchorionic diamniotic twin pregnancy at 25 weeks gestation is assessed at the regional fetal medicine service. She is found to have severe TTTS (Quintero stage III). What is the optimal treatment?

87. A 30-year-old primagravida with a BMI of 28 is seen in the antenatal clinic at 36 weeks gestation following referral from the community midwife with suspected ‘large-for dates’. An ultrasound scan is arranged, which confirms the fetus to be large for gestational age. An oral glucose tolerance test is arranged a few days later, which is normal. What is the correct management?

88. A healthy 35-year-old woman attends the antenatal clinic at 37 weeks gestation in her third pregnancy. She has had two previous caesarean sections for breech presentation, but the current pregnancy has a cephalic presentation and she would like to have a vaginal birth after caesarean (VBAC). What would be the risk of uterine rupture if she labours with such a history?

89. A 41-year-old woman with a BMI of 36 kg/m2, but otherwise healthy, attends the antenatal clinic at 14 weeks gestation and is found to have a dichorionic diamniotic twin pregnancy. What supplementation would you advise to reduce her risk of developing pre-eclampsia?

90. During pregnancy, how much calcium is accumulated by the fetus?

91. A 26-year-old primagravida with a singleton pregnancy at 23 weeks gestation attends for an ultrasound scan following a small amount of vaginal bleeding. It is noted that the cervical length is 21mm. What is the appropriate management?

92. Which protein is the most important biomarker for the detection of PPROM (Preterm Prelabour Rupture of Membranes)?

93. What is the usual method of diagnosing placental abruption?

94. A primigravida with a low-risk pregnancy is admitted at 30 weeks with an antepartum haemorrhage (APH). A diagnosis of placental abruption has been made. The bleeding settled with conservative management and she is discharged home. What is the most appropriate plan for her further antenatal care?

95. A 35-year-old primigravida is seen in the antenatal clinic for booking. She had been diagnosed with breast cancer at the age of 32 and received adjuvant chemotherapy with doxorubicin following surgery. What is the most appropriate management?

96. You receive a telephone call from a community midwife. A 22-year- old primigravida, currently 15 weeks pregnant, has developed chickenpox and the rash had developed 72 hours ago. The mother is very anxious and the midwife requests advice with regard to further management. What would you advise?

97. A 22- year- old Sudanese Asylum seeker is seen for booking in the antenatal clinic at 12 weeks. She is a primigravida and an ultrasound scan revealed a singleton pregnancy appropriate for gestation. She has history of female genital mutilation (FGM) and examination reveals Type II FGM. What would be the he most appropriate management?

98. A gravida 2 Para 1+0 attends the antenatal clinic for booking at 14 weeks. Her previous pregnancy was an emergency caesarean section for abruption at 38 weeks. Dating scan confirms a live fetus with a low risk for Down’s syndrome. Routine bloods indicate her to have blood group B Rh negative and the antibody titre performed 2 weeks prior to the appointment reveals the anti-D level to be 5 IU/ml. With regards to hemolytic disease of the fetus and newborn (HDFN), what is the optimal management?

99. A primigravida complains of recurrent herpes at 32 weeks gestation. She has been treated with Aciclovir at 20 weeks for a primary episode of genital herpes. She would opt for caesarean section if Herpes lesions are detected at the onset of labour. What would you advise?

100. A primigravida is seen for booking. She is 40 years and has conceived through IVF. Ultrasound scan has confirmed a twin pregnancy. Her BMI is 36 kg/m2. What treatment would you advise to reduce the risk of pre-eclampsia?

101. A community midwife requests advice with regard to induction of labour for a woman who is currently 40 weeks gestation. She has had 2 previous vaginal deliveries at 38 and 39 weeks. The pregnancy has been uncomplicated. What would you advise?

102. A gravida 2 Para 1, booked for low-risk midwifery care presents at 38 weeks with diminished fetal movements for 48 hours. The fetal heart rate was undetectable and sadly, intrauterine fetal death was confirmed with an ultrasound scan. The mother would prefer to go home and return 24 hours later for induction after arranging childcare for her other child. Her blood group is B RhD negative. What would you advise?

103. A British born primigravida with an uncomplicated pregnancy at 22 weeks gestation, needs to travel to sub-Saharan Africa for a family emergency and is expected to spend up to a month in Nigeria. She wishes to know about the risk of contracting malaria. What is her risk during a 1-month stay without chemoprophylaxis?

104. A primigravida is seen in the antenatal clinic. A routine mid trimester anomaly scan at 20 weeks reveals an anterior placenta covering the os. What is the most appropriate management?

105. A gravida 3 Para 2 is diagnosed with an anterior placenta reaching to the os at 20 weeks. She has had 2 previous caesarean sections. What further investigation would you arrange?

106. A 29-year-old primigravida with a low-risk pregnancy attends the obstetric assessment unit with generalised pruritus at 34 weeks. What is the most important investigation to establish a diagnosis of obstetric cholestasis?

107. A multiparous woman is admitted to a delivery suite at 37 weeks gestation. She has been feeling unwell for the last 48 hours. She gives history of flu-like symptoms with cough, abdominal pain and watery vaginal discharge. Her temperature is 38, pulse 110per minute, Respiratory rate 24perminute. You have made a diagnosis of sepsis and antibiotics have been commenced after blood culture. Her serum lactate is 4 mmol/l. What would be recommended for immediate intravenous fluid resuscitation?

108. A primigravida aged 37 is seen at booking. This is a pregnancy following assisted conception. Her BMI is 19 and the ultrasound scan has confirmed a singleton fetus appropriate for the period of gestation. What is the recommended investigation to identify fetus at risk of SGA age?

109. A 40-year-old primigravida is seen in the antenatal clinic with a twin pregnancy conceived through IVF. Gestation is 11+6 days and the ultrasound scan has confirmed DCDA twins appropriate for the gestation with normal nuchal thickening. What is the appropriate monitoring to detect growth discordance?

110. A 38-year-old gravida 3 Para 2 is admitted at 32 week gestation feeling unwell. She has been gradually becoming more anxious through the day with cough and chest pain, which was worse during inspiration. Observations are as follows:
Temperature 37.2 ∘C, Pulse 110 per minute, BP 98/60, RR 24 per minute and blood gases reveal mild respiratory alkalosis.
What is the most appropriate management plan?

111. A 37-year-old primigravida weighing 102 kg (BMI 40 kg/m2) is seen in an antenatal clinic for booking. She conceived via assisted conception following a long period of subfertility. Ultrasound has confirmed a dichorionic diamniotic twin pregnancy of 11+5 days gestation. What is the best practice with regard to reducing maternal risk of venous thromboembolism?

112. You are seeing a patient at antenatal clinic at 16 weeks’ gestation to make a plan for her antenatal care. T e midwife wants to know if the woman has any major risk factors for an SGA fetus. Which of the following is a major risk factor for this?
Options

113. You see a 34-year-old para 1 with a BMI of 29 in your antenatal clinic. She is at 10 weeks’ gestation with a confirmed intrauterine pregnancy and is taking folic acid 400 mcg daily. In her last pregnancy, 3 years ago, she developed preeclampsia at 37 weeks’ gestation. She was induced and spontaneously delivered a healthy female at 37+2 weighing 2990 g. She has no additional risk factors. Which of the following would be the best initial antenatal management plan?

114. A 35-year-old para 1 at 32 weeks’ gestation is being monitored for an SGA fetus, her midwife plotted symphysis fundal height on a customized growth chart suggested static growth. Her antenatal care has previously been uneventful other than a course of steroids at 26+3 weeks’ gestation during an admission for threatened preterm labour. Her first delivery was 3 years ago at 39 weeks with the delivery of a healthy male infant weighing 2950 g. She has had tuberculosis as a child living in India, but is otherwise fit and well. Ultrasound scan today reveals the fetal abdominal circumference to be around the 7th centile on a customized chart, with an UA pulsatility index greater than 2 standard deviations from the mean for gestational age. End diastolic flow is present.
What would be the best initial follow-up plan for her?

115. A 25-year-old para 0 with a twin pregnancy has just had a 24-week ultrasound scan at the antenatal clinic. T e report shows twin 1 with a DVP of liquor measuring 1.4 cm and twin 2 with a DVP of 10.8 cm. Her 12-week scan report says ‘ sign clearly seen’. What is the most likely diagnosis?

116. A 28-year-old para 1 (SVD 3 years ago) who is RhD negative is found to have an anti-D level of 6 IU/ml at a routine 28-week red cell antibody screen. T e father is homozygous RhD positive. She is o ered weekly ultrasound scans to detect fetal anaemia. What would be the indication for referral to fetal medicine centre for consideration of intrauterine transfusion?
Options

117. A 19-year-old para 0 is found to have anti-K antibodies at a titre of 8 IU/ml a er her 28-week routine antibody screen. She thinks the baby was conceived while on holiday abroad and has no contact with the father. What is the next step in her management?
Options

118. A 41-year-old para 2 has multiple fetal anomalies found at a routine 20-week anomaly ultrasound scan. An amniocentesis is performed and trisomy 13 is diagnosed. A er counselling, she opts for medical termination of pregnancy, which is performed at 21+3 weeks’ gestation. She is found to be Rh negative. A Kleihauer test con rms a fetal maternal haemorrhage of 4 ml. What total dose of anti-D immunoglobulin is required?
Options

119. A 31-year-old para 1 homeless heroin misuser with unknown dates books late and is found to be at approximately 28 weeks’ gestation on ultrasound. She is also found to be Rh negative and receives routine antenatal anti-D immunoglobulin (Ig) prophylaxis of 500 IU, with a plan for a further 500 IU at approximately 34 weeks’ gestation. One week a er her initial anti-D Ig injection, now at around 30 weeks’ gestation, she has an episode of a small amount of postcoital spotting. T e cervix is healthy and closed, and the placenta is not low.
What is the best management with regards to anti-D?
Options

120. A 32-year-old para 0 is seen for antenatal booking at 10 weeks’ gestation. She is a keen outdoor activity enthusiast and asks you about a list of activities she is thinking of doing on her holidays while pregnant.
Which of her planned activities is it most important to strongly advise her against?
Options

121. A 39-year-old para 0 who is 12+2 by last menstrual period attends for dating scan. She is keen to have screening for aneuploidy. T e CRL is found to be 89 mm. What would be the best management with regard to dating the pregnancy and screening for Down syndrome?

122. A 32-year-old para 0 undergoes IVF outside the UK and has a trichorionic triamniotic triplet pregnancy. She is concerned about how she will cope with her pregnancy towards her due date and asks the latest she is likely to be delivered by. When should women with trichorionic triamniotic triplets be o ered elective delivery, in the absence of prior complications or labour?

123. You are asked to update a guideline for your unit on antenatal and postnatal care of women suffering from domestic violence. Approximately what percentage of women receiving antenatal or postnatal care in the UK reports a history of domestic violence?

124. A 29-year-old primigravida is found to be breech at a 36-week midwife antenatal clinic. This is confirmed on ultrasound scan. She declines ECV and you book a planned caesarean section for 39 weeks’ gestation. What are the chances of the baby spontaneously turning to cephalic?

125. You see a couple for preconceptual counselling. They are both fit and well with no medical history. The woman’s father (now deceased) had haemophilia A. What are the chances of the couple having a child affected by haemophilia A?

126. A 29-year-old para 0 at 36+0 weeks’ gestation is referred by a community midwife with a BP of 148/97 mm Hg and 2+ proteinuria at a routine antenatal check. On arrival at hospital her BP is 146/95 mm Hg and repeat is 149/93. The protein : creatinine ratio (PCR) is 37 mg/mmol, but renal function, full blood count, transaminases and bilirubin are normal. T e C G is also normal. What would be the best initial management plan?
Options

127. You are asked to update your unit guidelines on antenatal aspirin. Which of the following patients should have aspirin 75 mg daily from 12 weeks’ gestation?

128. A 25-year-old primigravida develops severe preeclampsia at 27 weeks’ gestation and is delivered by emergency caesarean section. She is concerned about her future pregnancies. What is the chance of her developing preeclampsia in her next pregnancy?

129. A 32-year-old nulliparous woman attends for preconception counselling. She had a laparoscopic gastric band procedure 3 months ago. What is the minimum amount of time pregnancy should be delayed after bariatric surgery?

130. A 32-year-old primigravida at 33+6 weeks’ gestation has been under close surveillance a er a diagnosis of an SGA fetus. She attends for ultrasound in the morning clinic. Fetal abdominal circumference remains less than the 10th centile, DVP of liquor measures 1.2 cm and the UA Doppler shows reversed end diastolic ow. T e C G is normal. A course of antenatal corticosteroids was completed 2 days ago. She had a large breakfast 4 hours ago. T e labour ward is busy, an elective caesarean section has just been commenced, but you have access to open an emergency second operating theatre. She is keen for a vaginal delivery. What would be the best management plan you would advise for her?

131. A primigravida at 20 weeks’ gestation attends obstetric triage feeling short of breath. She has a monochorionic diamniotic twin pregnancy. She has not attended for antenatal care since her dating scan at 14 weeks’ gestation where chorionicity was confirmed, after which she separated from her partner. Chest examination is unremarkable, but her SFH is 32 cm. An ultrasound scan is performed, revealing that both twins are alive. Win 1 has polyhydramnios with a DVP of liquor measuring 9.5 cm and bladder visible. Win 2 has oligohydramnios with a DVP of liquor measuring 0.5 cm. Despite an hour of scanning, it is not possible to identify a bladder in twin 2. Both twins have end diastolic ow present on UA Doppler. A diagnosis of suspect twin–twin transfusion syndrome is made. What Quintero stage would this be classified as?

132. A 28-year-old primigravida with monochorionic diamniotic twin comes for her regular ultrasound and antenatal clinic appointment at 24 weeks. Win 2 has no fetal heart present and Spalding’s sign is present. Win 1 has a fundal height with normal size, liquor volume, UA Doppler and a visible bladder with plenty of fetal movement. An ultrasound 2 weeks ago had been normal. Her BP is normal and there is no proteinuria. After a single fetal death in a monochorionic diamniotic twin pregnancy, what is the overall rate of survival for the co-twin?