EBCOG Part 1-Maternal Medicine-Day 4(SBA)

1.You see a 36 year old woman with a BMI of 38 kg/m2in your day assessment unit.She is 32 weeks into her 4th ongoing pregnancy & describes sudden onset shortness of breath with no cough or chest pain.She does ,however have right leg pain & swelling.Physical exam shows a pulse rate of 100 bpm,BP 110/70 mmHg,temp 31c & RR of 18/min.Chest ausculatation is unremarkable.Her chest X Ray & ECG are normal.You suspect PE & start LMWH.What is your next most appropriate step?

2.A 28 year old with anti-phospholipid syndrome & a previous venous thromboembolism while on oral contraceptive pills is planning to conceive & seeks your advise.Which one of the options is the most appropriate with regards to her thromboprophylaxis in pregnancy?

3.A nullipara had a thrombophilia screen requested by her GP because of the family history of VTE in her mother & sister.Which one of the thrombophilia defects is associated with the highest risk of VTE in pregnancy?

4.A 24 year old woman with 12 weeks pregnancy presents with confirmed venous thromboembolism. What would you advise her regarding her treatment?

5.A 28 year old woman with a BMI of 25 kg/m2 books into the antenatal clinic at 12 weeks.Two years previously she had a confirmed unprovoked iliofemoral thrombosis in her left leg.Your advise regarding thromboprophylaxis during this pregnancy is.

6.A 28 year old woman with a BMI of 25 kg/m2 books into the antenatal clinic at 12 weeks.2 years previously she had a confirmed iliofemoral thrombosis in her left leg after major knee surgery. What will be your advise regarding thromboprophylaxis?

7.What is the incidence of post thrombotic syndrome following a DVT in pregnancy?

8.What are the categories of body weight that require routine measurement of peak anti-Xa activity for women who are under treatment with LMWH for acute VTE in pregnancy?

9.Mrs Anne is a primi who is 30 weeks pregnant.She presents to A&E with acute onset of shortness of breath & chest pain.She has just travelled via a long haul flight(12 hr) to the UK.She has been commenced on therapeutic LMWH-dalteparin pending investigations to rule out a PE.Her booking weight is 66 kg & she currently weighs 76 kg.What is the correct dose of dalteparin she should receive?

10.Ms Marie is a primi who is 30 weeks pregnant .She presents to A&E with acute onset of shortness of breath & chest pain.She has just travelled via a long haul flight (12H) to the UK.Which of the following investigations is not appropriate in the investigation of a suspected PE in pregnancy?

11. A couple attend for pre-pregnancy counselling owing to the woman’s medical history of systemic lupus erythematosus (SLE). She was diagnosed 5 years ago when she had been investigated for severe fatigue, skin rashes, cold fingers and achy joints. She is known to have SLE with high-titre antinuclear factor and double-stranded DNA-antibodies. Renal biopsy has shown stage 4 lupus nephritis. For the last 2 years, the woman has been in good health, taking prednisolone 7.5 mg, hydroxycholoroquine 200 mg, candesartan 32 mg, ferrous sulphate 200 mg and Adcal D3 one tablet daily.Which of her medications needs to be altered before or during pregnancy?

12.A 35-year-old woman was diagnosed with systemic lupus erythematosus 5 years ago. She is in her fifth pregnancy. She is a heavy smoker with BMI of 40 and is non-compliant with her medications. She has had recurrent flares with joint and skin symptoms and is on prednisolone 5 mg three-times daily, hydroxychloroquine 200 mg twice daily and azathioprine 50 mg once daily.Recently, she started taking thromboprophylaxis with 60 mg subcutaneous enoxaparin. She presents 1 month later at 28 weeks of gestation to the assessment unit with aphasia, unilateralmotor weakness.Her blood pressure is 150/100 mmHg and urine analysis shows ++ protein.Which investigation would be diagnostic to help plan further management?

13. A woman has suffered from psoriasis since she was 15 years old. Initially, her disease predominantly caused skin manifestations, which was managed with a variety of creams. Sinceher mid-20s she has had arthritis with painful joints, despite local injections of steroids and prolonged treatment with methotrexate. Approximately 4 years ago her rheumatologist started once-weekly injections with etanercept 50 mg. This relieved her symptoms significantly and her quality of life was dramatically improved.The woman tried to manage without etanercept in early pregnancy; however, her symptoms flared and so, following discussion with her rheumatologist and the obstetric consultant, she restarted etanercept 50 mg weekly by subcutaneous injection. She had an elective caesarean delivery for breech presentation. She was taking prednisolone and etanercept antenatally. The etanercept was stopped 2 weeks before the caesarean delivery.Which of the following medications should the woman avoid whilst she is breastfeeding?

14. A woman with Ehlers-Danlos syndrome hypermobility type (type III) has easily dislocatable hips and knees, hypermobile fingers, bruises easily and has been treated for inguinal and umbilical hernias as a teenager. Previously, she had a miscarriage at 8 weeks of gestation and is now at the antenatal clinic where a scan confirms a viable singleton fetus of 12 weeks of gestation.Which of the following investigations and/or assessments are necessary to prevent serious complications in her pregnancy and labour?

15. A 27-year-old woman was diagnosed with rheumatoid arthritis 6 months after the birth of her first child. She was started on sulfasalazine and has taken this for several years, with good control of her symptoms. However, she stopped the medication during her subsequent pregnancy and found that her hands and feet were not painful or stiff any more. What would be the best initial treatment for her if she experiences a postpartum flare of her rheumatoid symptoms (e.g. painful, swollen wrists and fingers), such that she is unable to care for her newborn child?

16.A 28 year old P1 with SLE presents for a growth scan at 28 weeks gestation.Fetal Heart was 80-90 bpm & a fetal ECHO confirmed a 2nd degree congenital heart block.which one of the following autoantibodies is asso with CHB in women with SLE?

17.A pregnant woman attends antenatal clinic at 12 weeks.She has SLE .Her disease is well controlled & she has not had a flare for 6 months.She asks about her risk of a flare of SLE in pregnancy.You tell her that

18.A pregnant woman attends the antenatal clinic at 12 weeks.she has SLE.she is currently in remission.She asks about live birth rates in women with SLE.you tell that the chances of a live birth are

19. A primi who has anti-Ro antibodies attends antenatal clinic.She asks you about the risk of her baby having congenital heart block(CHB).you tell her the risk is

20.A 26 year old woman with RA attends antenatal clinic at 10 weeks.she is concerned about a flare up of her RA during pregnancy.you tell her that during pregnancythe risk of a disease flare up is

21. A 26 year old woman consults you because she is contemplating a pregnancy.she has RA & is taking methotrexate.your advise regarding MTX & pregnancy is

22. A woman with RA has delivered normally 1 week previously & is now experiencing a flare of her disease.her rheumatologist advises a course of prednisolone,starting at 20 mg daily.she is breast feeding & is concerned about the risks to her baby.with regard to steroid therapy & breastfeeding