Clinical Management test (Part 1)
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1) According to the RCOG Green‐top guidelines on prevention and management of post‐partum haemorrhage (PPH) which of the following statements is true?
Explanation: Most cases of PPH have NO identifiable risk factors Prophylactic oxytocics reduce the risk of PPH by about 60% Misoprostol is not as effective as oxytocin but may be used if Oxytocin is not available e.g. home birth Recommended doses of Oxytocin For vaginal deliveries: 5 iu or 10 iu by intramuscular injection For C‐section: 5 iu by IV injection
2) A 25 year old women has a medically managed miscarriage. Assuming she has no complications what would you advise regarding further pregnancy te
Explanation: According to the NICE guidelines women should be advised to take a urine pregnancy test 3 weeks after miscarriage unless they experience worsening symptoms in which case they need earlier review
3) Testing for PKU is done via blood assay for Phenylalanine (Guthrie inhibition assay) When should this be done?
Explanation: The Guthrie inhibition assay is accurate when taken from 12 hours. With McCamon‐Robins fluorometric assay tests they will need to be repeated if taken earlier than 24 hours
4) Which of the following conditions would prevent prescription of a POP to a women or warrant referral to a specialist contraceptive provider?
Explanation: When prescribing a POP the UKMEC criteria should be considered: UKMEC 3 condition should prompt expert opinion or referral to a specialist contraceptive provider. UKMEC 4 condition poses an unacceptable health risk and contraceptive shouldn't be prescribed. NOTE: For POP contraception the only UKMEC 4 condition is active Breast Cancer (within the past 5 years) The following list are the UKMEC 3 conditions relating to POP use: Current ischaemic heart disease (Continuation) Stroke (history of cerebrovascular accident) (Continuation) Headaches migraine with aura, at any age (Continuation)
Gestational trophoblastic neoplasia (GTN) (includes hydatidiform mole, invasive mole, placental site trophoblastic tumour) hCG abnormal Breast cancer (past and no evidence of current disease for 5 years) Viral hepatitis active Cirrhosis severe (decompensated) Liver tumours Drugs that affect liver enzymes
5) A 27 year old women who is 26 weeks pregnant attends clinic with a classical chickenpox rash. The lesions are fairly sparse and she is systemically well. According to the Greentop Guidelines which of the following is appropriate?
Explanation: Varicella Zoster Varicella Zoster is the virus responsible for Chicken pox and shingles. If Chickenpox occurs during pregnancy the Green Top Guidelines advise the following:
VZIG has no therapeutic benefit once chickenpox has developed and should therefore not be used in pregnant women who have developed a chickenpox rash. Intravenous aciclovir should be given to all pregnant women with severe chickenpox
Oral aciclovir should be prescribed for pregnant women with chickenpox if they present within 24 hours of the onset of the rash and if they are 20+0 weeks of gestation or beyond. Use of aciclovir before 20+0 weeks should also be considered
6) When consenting someone for laparoscopy you discuss the risk of vascular injury. The incidence of vascular injury during laparoscopy according to the Green‐top guidelines is?
Explanation: Major vessel injury is the most important potential complication when undertaking laparoscopy. It's incidence is 0.2/1000. Bowel Injury is more common at 0.4/1000
7) A patient attends for a routine diagnostic outpatient hysteroscopy. Which of the following statement are true?
Explanation: Greentop guideline 59 sets out some best practice points for hysteroscopy Hysteroscopy Key Points Miniature hysteroscopes (2.7 mm with a 3‐3.5 mm sheath) should be used for diagnostic outpatient hysteroscopy AVOID routine use of opiates NSAIDs 1 hour pre‐procedure are advised Cervical preparation is not advised as studies do not support reduced incidence of trauma with preparation. Uterine distension with saline provides superior images than with CO2 Vaginoscopy should be the standard technique for outpatient hysteroscopy
8) An 18 year old patient comes to see you in clinic. Her BMI is 25.0 and her BP is 122/80. She is a non‐smoker and there is no personal or family history of VTE or migraine. She would like to start the pill for her acne. She has used topical Zineryt in the past but still has moderate acne. What is the most appropriate option?
Explanation: The question isn't as straight forward as it seems. Considerations to make are that the patient hasn't trialled oral antibacterials or standard COCPs and has moderate acne. NICE CKS guidance advises consider prescribing a standard COCP in moderate acne. Norethisterone has androgenic properties so preparations containing this should be avoided. Cerazette is a POP so shouldn't be used. Although there are 2 options here that at first glance appear sensible i.e.Dianette & Yasmin you should consider their licences.Dianette's licence is for use in severe acne that has failed to respond to oral antibacterials and for moderately severe hirsutism. Neither of those apply here. Yasmin contains drosperinone which has antiandrogenic effects so would also be a reasonable choice but again it is not licensed for acne. The pragmatic approach would be to use a standard COCP initially with their lower risk of VTE reserving Dianette or Yasmin for those with treatment failure. If hirsutism is present then Dianette or Yasmin would be the obvious 1st line choices.
9) A 26 year old women presents for her 12 week scan. She has been pregnant once before but had a 1st trimester miscarriage. She reports no problems with this pregnancy and has had no vaginal bleeding or spotting. The scan shows no fetal cardiac activity and a small gestational sac. What is the likely diagnosis?
Explanation: As there has been no bleeding or expulsion of the products of conception this is a missed miscarriage
10) A 26 year old patient sustains a 4th degree perineal tear following delivery of her 1st baby. Your consultant agrees to supervise you repair the tear. From the list below what is the most appropriate suture option for repairing the anal mucosa?
Explanation: The RCOG suggests 3.0 polyglactin for repair of the AM (either interrupted or continuous)
11) You are asked to review a patient in the first stage of labour as the midwife is concerned about her progress. This is her first pregnancy. She has dilated from 4cm to 6cm in 4 hours. At your initial assessment she is 6cm dilated with membranes intact. You review her again 2 hours later and the cervix is now 6.5cm dilated with membranes in tact. What is the most appropriate management?
Explanation: In first labours delay is typically diagnosed if cervical dilatation is less than 2 cm dilatation in 4 hours so this patients progress at initial assessment is borderline. If delay is suspected NICE guidance advises a women should have a repeat vaginal examination 2 hours later and delay should be diagnosed if there is less than 1cm progress. In this case it fits the criteria of delay as she has only dilated 0.5cm in 2 hours. Amniotomy should be advised if delay is confirmed as is the case here. There is little evidence for amniotomy (AKA ARM - Artificial Rupture of Membranes) in any other circumstance apart from delayed labour progress. It shouldn't be used routinely in labour that is progressing well. The evidence behind its use in placental abruption is weak. Contraindications to ARM: High presenting part (risk of cord prolapse) Preterm labour Known HIV carrier Caution is taken with polyhydramnios or any malposition or malpresentation Placenta praevia Vasa praevia
12) You are performing a diagnostic laparoscopy on a patient. What is the appropriate distension pressure upon completion of trocar insertion?
Explanation: Pressures: Intra-abdominal pressure 20-25 mmHg for gas insufflation prior to primary trocar. Distension pressure 12-15 mmHg once trocar insertion complete
13) Which of the following has been shown to improve pruritus and liver function in patients with obstetric cholestasis?
Explanation: Dexamethasone is not an establihed treatment with conflicting trial evidence Vitamin K can be used if prothrombin time is prolonged but shouldn't be used for pruritus control
14) You are performing a diagnostic laparoscopy on a patient. What is the appropriate distension pressure upon completion of trocar insertion?
Explanation: Nulliparous women active 2nd stage labour: Suspect delay if progress inadequate after 1 hour Diagnose delay if progress inadequate after 2 hours If delay is suspected amniotomy should be offered if membranes are intact If delay diagnosed then preparations should be made for C‐section Multiparous women active 2nd stage labour: Suspect delay if progress inadequate after 30 minutes Diagnose delay if progress inadequate after 1 hour If delay is suspected amniotomy should be offered if membranes are intact If delay diagnosed then preparations should be made for C‐section
15) A 26 year old primigravida woman attends A&E due to worsening vomiting. She is currently 10 weeks pregnant. For the past 4 weeks she has had moning sickness but for the last 4 days she has been unable to tolerate any oral fluids without vomiting and thinks she has lost weight. On questioning she has no significant past medical history prior to this pregnancy. She is currently taking the following medication:
Folic acid 400 mcg OD Vitamin D 10 mcg OD Her observations are as follows: Blood pressure: 96/62 Heart rate: 96 Respiration rate: 15 Temperature: 37.1 oC Urinalysis: Protein + Ketones ++ Leucocytes negative Nitrates negative Fingerpick glucose: 6.1 What is the likely diagnosis?
Explanation: This patient has severe nausea and vomiting with ketosis and evidence of dehydration (low BP and tachycardia) in the early part of pregnancy. There is no history of diabetes and the blood glucose doesn't indicate hyperglycaemia. This is consistent with hyperemesis gravidarum (HG).
16) According to the RCOG Green‐top guidelines on prevention and management of post‐partum haemorrhage (PPH) which of the following statements is true?
Explanation: This patient has declined 1st line treatment. As she is >35 and a smoker UKMEC rules make the COCP unsuitable. Mefenamic acid is the next most appropriate option. 1st Line Levonorgestrel‐releasing intrauterine system (IUS eg Mirena) 2nd Line Tranexamic Acid, Mefenamic Acid, NSAIDs, COCP 3rd Line Norethisterone (15 mg) daily from days 5 to 26 of the menstrual cycle, or injected long‐ acting progestogens
17) A patient attends the maternity unit as her waters have broken but she hasn't had contractions. She is 39+6 weeks gestation. Speculum examination confirms prelabour rupture of membranes (PROM). According to NICE guidelines after what time period should induction be offered?
Explanation: Induction of labour is appropriate approximately 24 hours after rupture of the membranes.
A 28 year old primigravida women was admitted from A&E yesterday after attending due to severe nausea and vomiting and started on IV saline with potassium, IV pabrinex and IV cyclizine. She is currently 11 weeks pregnant. For the previous 3 weeks she has been nauseated with occasional vomiting but had really struggled to keep any fluids down for 3 days prior to admission. Her U&Es in A&E were as follows:
Na+ 119 mmol/l K+ 3.1 mmol/l Urea 14.0 mmol/l Creatinine 99 µmol/l You are asked to review her on the ward as she is dysarthric and disorientated. You repeat her U&Es which are as follows: Na+ 139 mmol/l K+ 3.6 mmol/l Urea 5.0 mmol/l Creatinine 55 µmol/l What is the likely diagnosis?
Explanation: This patient was admitted with hyperemesis gravidarum. Although the components of her treatment regime were appropriate, this patient had significant hyponatraemia on admission (normal sodium range 133‐146mmol/l) and her serum sodium level has changed by 20mmol/l in 1 day. Clinicians need to be aware that too rapid a correction of hyponatraemia can lead to demyelination of the central nervous system. In such patients the sodium level should be closely monitored with the concentration change being limited to a maximum of 8‐10mmol/l
19) A 33 year old women with known stage III cervical cancer presents to A&E with lower abdominal and unilateral flank pain. From the following list what is the likely diagnosis?
Explanation: About one third of patients with stage IIIB cancer will develop ureteric obstruction.
20) A 25 year old women who is 20 weeks pregnant is seen in A&E with a 36 hour of feeling nauseated, shivery and having loin pain. Her observations are as follows:
Blood Pressure 88/56. Pulse Rate 110 Temperature 38.8oC Urine dip shows leucocytes +++ and protein +++ You take bloods. What serum lactate level is indicative of tissue hypo‐perfusion?
Explanation: Serum lactate should be measured within six hours of the suspicion of severe sepsis in order to guide management. Serum lactate 4 mmol/l is indicative of tissue hypoperfusion
21) What guidelines apply specifically to contraceptive advice and treatment in under 16's?
Explanation: The Fraser guidelines set out the advice concerning contraception to under 16s. The term Gillick arises from a Legal case where Victoria Gillick took her local health authority (West Norfolk and Wisbech Area Health Authority ) to court to stop drs giving contraceptive advice and treatment to under 16's without parental knowledge. The judge rejected the case brought by Gillick. The decision was appealed and eventually went before the house of Lords. This set the term Gillick competence where a child (16 years or younger) is able to consent to his or her own medical treatment, without the need for parental permission or knowledge. The Fraser guidelines were issued by Lord Fraser following the decision by the house of Lords to uphold The courts original decision against Gillick
22) You review a 28 year old patient in the fertility clinic. She has a diagnosis of PCOS. She has been trying to conceive for 2 years. Her BMI is 26 kg/m2. She is a non‐smoker. She has been taking Clomiphene and metformin for the past 6 months. What is the next most appropriate treatment?
Explanation: Clomiphene shouldn't be continued for more than 6 months. The second line options are Gonadotrophins or tubal drilling.
23) You are called to see a 19 year old primigravida woman in A&E who is 11 weeks pregnant, has severe vomiting and is unable to keep fluids down. For the previous 3 weeks she has been nauseated with occasional vomiting but this has gradually deteriorated over the past 5 days.
BP: 102/60 HR: 96 RR: 16 Sats: 98%OA Urinalysis: Ketones ++, protein+, leucocytes negative, nitrites negative, glucose negative Na+ 131 mmol/l K+ 3.3 mmol/l Urea 14.0 mmol/l Creatinine 99 µmol/l Which of the following is an appropriate part of her initial treatment? Her observations and U&Es are as follows:
Explanation: This patient has Hyperemesis gravidarum (HG). Treatment should consist of: 1. Rehydration with electrolyte correction 2. Antiemetics 3. Nutrition/vitamin replacement 4. Thromboprophylaxis This patient is under 20. Metoclopramide should not be given to under 20's due to the risk of oculogyric crisis. Stemetil or cyclizine are 1st line.
Patients with HG are at risk of vitamin B1 deficiency and subsequent Wernicke's encephalopathy. Dextrose solutions can exacerbate Wernicke's so are not appropriate here. In addition the patient is mildly hyponatraemic. Hartmann's or Saline solution with potassium supplementation would be appropriate but this is not listed. Some hospitals use aggressive regimes with 2L given over 4 hrs but the patients condition and response to initial fluid should be closely monitored. Pyridoxine (B6) supplementation is not recommended by NICE and doesn't come in an IV formulation. Thiamine should be supplemented in HG patients. Either 50mg thiamine tablets taken orally if tolerated or IV pabrinex are appropriate. This will reduce the risk of Wernicke's.
24) You are asked to review a 44 year old patient with her partner in fertility clinic. She reports her last period was 5 months ago and the one prior to that 4 months earlier. She hasn't taken contraception of any form for 4 years. Her BMI is 29 kg/m2. She is a non‐smoker. The results of initial investigations are below:
Partners semen analysis: All parameters within normal fertile range on 2 samples Sexual health screen: Negative for HIV, syphilis, gonorrhoea and chlamydia Ultrasound: left ovary measures 1.9 x 1.8 cm. The right ovary wasn't clearly seen. FSH 36 IU/L (Reference Range 5‐25 IU/L female ovulation) LH 44 IU/L (Reference Range Mid‐cycle: 20‐105 mIU/mL) HBA1C 39 mmol/mol (Refernece range: <42mmol/mol) Progesterone 3 nmol/l (Reference range: Day 21 >16 nmol/l) Prolactin 11 ng/ml (reference range: 2 ‐ 29 ng/ml)
What is the best option for her regarding fertility treatment?
Explanation: This patient has radiological (post‐menopausal ovarian volumes will reduce to around 2 cubic cm in most women with established menopause*) and biochemical (low progesterone/high FSH and LH) evidence of early menopause/ovarian failure. This is Group III ovulation disorder. The treatment of choice would be IVF with donor eggs
*Pavlik EJ et al. Ovarian volume related to age. Gynecol Oncol. 2000 Jun;77(3):410‐2.
25) A 45 year old women is seen in clinic following hysteroscopy and biopsy due to irregular menstrual bleeding. Her BMI is 34 kg/m2. This shows atypical hyperplasia. Which of the following is the most appropriate 1st line management?
Explanation: There is high risk of progression to cancer with atypical hyperplasia. and hysterectomy is indicated. Although weight loss would be beneficial this shouldn't delay surgical management.
26) A 22 year old patient who is 18 weeks pregnant presents with vaginal discharge. Swabs are taken which show heavy growth of neisseria gonorrhoea. Which of the following is the most appropriate treatment regime?
Explanation: The following regimes are recommended for Gonococcal infections by BASHH:
Gonococcal infection in Pregnancy Ceftriaxone 500 mg intramuscularly as a single dose with azithromycin 1 g oral as a single dose Spectinomycin 2 g intramuscularly as a single dose with azithromycin 1 g oral as a single dose Gonococcal PID Ceftriaxone 500 mg intramuscularly immediately followed by oral doxycycline 100mg twice daily plus metronidazole 400 mg twice daily for 14 days Spectinomycin 2 g intramuscularly as a single dose with azithromycin 1 g oral as a single dose Uncomplicated/Asymptomatic Adult Ceftriaxone 500 mg intramuscularly as a single dose with azithromycin 1 g oral as a single dose
27) Fraser guidelines apply to which of the following situations?
Explanation: A person under 16 should be Gillick competent for valid consent Fraser guidelines apply to contraceptive advice for under 16's
28) Regarding PCOS (PolyCystic Ovary Syndrome) which of the following criteria are recognized as the current gold standard for diagnosis of PCOS
Explanation: ESHRE/ASRM ( Society for Human Reproduction and Embryology and American Society for Reproductive Medicine) or Rotterdam criteria are the current gold standard for PCOS diagnosis The NICHD criteria predate the Rotterdam criteria whereas Androgen Excess Society (AES) Guidelines brought out in 2006 are are not considered gold standard. ROME 3 criteria are used to classify functional GI disorders whilst Revised American Society for Reproductive Medicine score are criteria used in endometriosis assessment
29) A patient is in the 1st stage of labour at full term and is planning for vaginal delivery. In her previous pregnancy she sustained a 3b perineal tear. Which of the following is the most appropriate measure to minimise perineal trauma?
Explanation: Episiotomy shouldn't be performed routinely even following 3rd or 4th degree tears. NICE also advises perineal massage shouldn't be performed and lidocaine spray should not be used.
30) According to the RCOG Green‐top guideline on management of PPH, up to what volume of blood loss (in the absence of clinical shock signs) is it appropriate to continue basic measures rather than full resuscitation protocols
Explanation: The RCOG suggests in cases of estimated blood losses of up to 1000ml that basic measures are appropriate. Basic measures include: Close monitoring IV access Bloods (FBC and Group&Save/Screen)
31) You are discussing laparoscopy risks with the patient. What of the following statements regarding entry techniques is true?
Explanation: You may be given different information on this topic. Some studies have suggested an increased risk of vascular injury with the Varess entry technique but these are generally not of statistical significance. Other studies have contrasting results with regard to bowel, both groups having a higher risk depending on the study read. The latest cochrane* review published in September 2015 showed no statistically significant difference in visceral or vascular injuries in the 2 groups. The level 1a evidence from green top guideline 49 also supports this view. *http://www.cochrane.org/CD006583/MENSTRlaparoscopic‐entry‐techniques
A 39 year old women is seen in clinic following hysteroscopy and biopsy due to irregular menstrual bleeding. Her BMI is 25 kg/m2. This shows hyperplasia without atypia. Which of the following is the most appropriate management option? What is the likely diagnosis?
Explanation: Hysterectomy is not first‐line treatment for hyperplasia without atypia. Hysterectomy is first line treatment in atypical hyperplasia (and postmenopausal women should be offered hysterectomy with bilateral salpingo‐oophorectomy) In hyperplasia without atypia progestogen therapy induces histological and symptomatic remission in the majority of women & avoids morbidity associated with surgery. IUS has superior regression rate compared to oral progesterone.
A 41 year old women has abdominal hysterectomy for fibroids. You are asked to review her 76 hours post‐operatively as she is complaining of left sided flank pain and has a fever (Temperature 38.0 oC). BP is 140/90 Heart rate 88. Bloods show creatinine 110mmol/l (pre‐op 70mmol/l). Urine dip shows blood ++ nitrites negative. What is the likely diagnosis?
Explanation: Risk of ureteral injury following gynecologic surgery of any type is approximately 1%. Previous surgery, adhesions, past cancer treatment and endometriosis are some conditions that increase the risk. Abdominal hysterectomies and partial vaginectomies are the highest risk procedures.More than 70% of the time, unilateral ureteral injury is noticed postoperatively, when the patient
may present with: Flank pain Haematuria Ileus Fever Urine discharge vaginally or via wound Hypertension Elevated serum creatinine levels. In cases of bilateral ureteral injury anuria is the first clinical sign.
34) Early amniocentesis has a higher fetal loss rate and increased incidence of fetal talipes and respiratory morbidity compared with other CVS. When is the earliest appropriate gestational age to perform amniocentesis?
Explanation: Green‐top guideline No 8 states Amniocentesis should be performed after 15 (15+0) weeks of gestation. Amniocentesis before 14 (14+0) weeks of gestation (early amniocentesis) has a higher fetal loss rate and increased incidence of fetal talipes and respiratory morbidity compared with other procedures.
A 25 year old women who is 20 weeks pregnant is seen in A&E with a 36 hour of feeling nauseated, shivery and having loin pain. Her observations are as follows: Blood Pressure 88/56. Pulse Rate 110 Temperature 38.8oC Urine dip: leucocytes +++, protein +++, nitrites positive, blood negative, glucose negative Which of the following is an appropriate measure according to the RCOG guidelines?
Explanation: This patient has signs of sepsis The RCOG guidelines advise the below tasks be performed within 6 hours Obtain blood cultures prior to antibiotic administration Administer broad-spectrum antibiotic within one hour of recognition of severe sepsis Measure serum lactate In the event of hypotension and/or a serum lactate >4mmol/l deliver an initial minimum 20ml/kg of crystalloid or an equivalent. Apply vasopressors for hypotension that is not responding to initial fluid resuscitation to maintain mean arterial pressure (MAP) >65mmHg In the event of persistent hypotension despite fluid resuscitation (septic shock) and/or lactate >4mmol/l. Aim to: Achieve a central venous pressure (CVP) of 8mmHg Achieve a central venous oxygen saturation (ScvO2) 70% or mixed venous oxygen saturation
36) You consultant asks you to close following a planned Caesarian section (CS) delivery. Which of the following statements is true regarding CS?
Explanation: NICE advise broad spectrum antibiotics should be given prior to skin incision and these should cover organisms causing endometritis, wound infection and UTI as these occur in 8% of patients having CS. NICE however states co‐amoxiclav should not be used. The SOGC suggest 1st choice antibiotic for CS should be a first‐generation cephalosporin. If the patient is penicillin allergic, clindamycin or erythromycin is appropriate. This should be given 15‐60 minutes before skin incision. Diamorphine is advised for intra and post op analgesia. Oxytocin is advised to reduce blood loss.
37) At what gestation does a mother typically first become aware of fetal movements?
Explanation: Typically metal movements become apparent by 18‐20 weeks
38) You review a patient in the fertility clinic. The ultrasound and biochemical profile are consistent with PCOS. She has been trying to conceive for 2 years. Her BMI is 26 kg/m2. She is a non‐ smoker. You plan to initiate Clomiphene. According to NICE guidance how long should treatment continue for (assuming patient remains non‐pregnant)?
Explanation: Treatment with Clomiphene should not exceed 6 months* *New addition to NICE guidance CG156 in 2013
39) A patient has been seeing you due to itching during pregnancy and you have diagnosed cholestatic jaundice. What is the most appropriate advice regarding testing LFTs postnatally?
Explanation: LFTs should be deferred for at least 10 days according to greentop guideline 43
40) Which vitamin deficiency leads to Wernicke's encephalopathy?
Explanation: Vitamin B1 deficiency can lead to Wernicke's encephalopathy. Alcoholics are at particular risk. In obstetrics all women with hyperemesis gravidarum should receive thiamine supplementation to prevent Wernicke's.
41) A 45 year old women is seen in clinic following hysteroscopy and biopsy due to irregular menstrual bleeding. Her BMI is 34 kg/m2. This shows hyperplasia without atypia. Following a discussion the patient declines any treatment but agrees she will try and lose weight. Which of the following is the most appropriate regarding follow up?
Explanation: Endometrial surveillance should occur at least every 6 months and discharge should only take place a
42) What guidelines apply specifically to contraceptive advice and treatment in under 16's?
Explanation: The Fraser guidelines set out the advice concerning contraception to under 16s. The term Gillick arises from a Legal case where Victoria Gillick took her local health authority (West Norfolk and Wisbech Area Health Authority ) to court to stop drs giving contraceptive advice and treatment to under 16's without parental knowledge. The judge rejected the case brought by Gillick. The decision was appealed and eventually went before the house of Lords. This set the term Gillick competence where a child (16 years or younger) is able to consent to his or her own medical treatment, without the need for parental permission or knowledge.
A 27 year old women has a miscarriage at 8 weeks. Her observations the following day are: -Temperatue 36.5 oC Blood Pressure 90/60 Heart Rate 95 She has a FBC taken and the results are: Hb: 67 g/l WCC: 7.6 x10*9/l PLT 175 x 10*9/l What is the most appropriate course of management?
Explanation: The RCOG has produced guidelines on transfusion but it must be remembered these are only guidelines. Useful things to consider when considering a transfusion are: Patient Wishes Haemodynamic stability Hb level (and other results e.g. low platelets/evidence DIC) In this patient she is hypotensive and bordering on tachycardia. There is also risk of further bleeding. What the RCOG guidelines say:
44) According to the green top guidelines all of the following complications of laparoscopy should be discussed with the patient EXCEPT which one?
Explanation: Laparascopy Greentop guideline 49 states: Women must be informed of the risks and potential complications associated with laparoscopy. This should include discussion of the risks of the entry technique used: specifically, injury to the bowel, urinary tract and major blood vessels, and later complications associated with the entry ports: specifically, hernia formation
You are asked to review a 44 year old patient with her partner in fertility clinic. She reports her last period was 5 months ago and the one prior to that 4 months earlier. She hasn't taken contraception of any form for 4 years. Her BMI is 29 kg/m2. She is a non-smoker. The results of initial investigations are below: Partners semen analysis: All parameters within normal fertile range on 2 samples Sexual health screen: Negative for HIV, syphilis, gonorrhoea and chlamydia Ultrasound: left ovary measures 1.9 x 1.8 cm. The right ovary wasn't clearly seen. FSH 36 IU/L (Reference Range 5-25 IU/L female ovulation) LH 44 IU/L (Reference Range Mid-cycle: 20-105 mIU/mL) HBA1C 39 mmol/mol (Refernece range: <42mmol/mol) Progesterone 3 nmol/l (Reference range: Day 21 >16 nmol/l) Prolactin 4 ng/ml (reference range: 2 - 29 ng/ml) What is the likely diagnosis?
Explanation: This patient has radiological (post‐menopausal ovarian volumes will reduce to around 2 cubic cm in most women with established menopause) and biochemical (low progesterone/high FSH and LH) evidence of early menopause/ovarian failure. This is Group III ovulation disorder. The treatment of choice would be IVF with donor eggs Pavlik EJ et al. Ovarian volume related to age. Gynecol Oncol. 2000 Jun;77(3):410‐2.
A 23 year old patient presents to the emergency department with sudden onset of severe lower abdominal and pelvic pain. History reveals she normally has regular 28 day cycles but she missed her last period. Past medical history reveals 2 termination of pregnancy procedures in the past 3 years. The most recent one 6 months ago. She smokes 5 cigarettes per day. On examination she has lower abdominal tenderness and on vaginal exam there is cervical tenderness. Observations are as follows: Temperature: 37.2 oC Blood pressure: 100/60 Heart rate: 110 Respiration rate: 16 Urine sample & blood results: awaited What is the likely diagnosis?
Explanation: This patient is most likely to have a ruptured ectopic pregnancy. The history of multiple TOPs suggests her contraceptive methods are not reliable and her missed period is suggestive she may currently be pregnant. There is no temperature or vaginal discharge to suggest PID though this is of course possible as is appendicitis. The last termination was 6 months ago so endometritis is unlikely.
A 21 year old patient presents to the emergency department with sudden onset of severe lower abdominal and pelvic pain. History reveals she missed her last 2 periods. She normally has regular 28 day cycles. She smokes 5 cigarettes per day. On examination she has lower abdominal tenderness and on vaginal exam there is cervical tenderness. Observations are as follows: Temperature: 37.2 oC Blood pressure: 90/54 Heart rate: 115 Respiration rate: 18 Pregnancy test positive What would be the most appropriate management of this patient?
Explanation: This patient has shock and a pregnancy of unknown location ‐ ectopic should be suspected. There is no role for medical management in the treatment of tubal pregnancy or suspected tubal pregnancy when a patient shows signs of hypovolaemic shock and observation would be inappropriate with a shocked patient.
48) A patient arrives on labour ward she is 37 weeks pregnant. Her last pregnancy ended with delivery via uncomplicated lower segment C‐Section 4 years ago. Contractions are 5 minutes apart and on examination and the cervix is 5cm dilated. She wants to know the risk to the baby of proceeding with vaginal delivery (VBAC). What is the additional risk of perinatal death with VBAC?
Explanation: The Green‐top guidelines regarding Vaginal Birth After C‐section (VBAC) state the following risks with VBAC: 2‐3/10,000 additional risk of birth‐related perinatal death 8 in 10,000 infant developing hypoxic ischaemic encephalopathy 22‐74 in 10,000 Risk of uterine rupture (previous lower segment c‐section) 1% additional risk of either blood transfusion or endometritis VBAC reduces the risk of: Reduces risk the baby will have respiratory problems after birth: rates are 2‐3% with planned VBAC and 3‐4% with ERCS
49) You review a patient in the fertility clinic. The ultrasound and biochemical profile are consistent with PCOS. She has been trying to conceive for 2 years. Her BMI is 26 kg/m2. She is a non‐ smoker. Which of the following is the most appropriate first line treatment?
Explanation: Clomifene and/or Metformin are 1st line agents. Weight loss in the setting of subfertility is advised if BMI >30 kg/m2
A 26 year old patient attends the A&E department. She reports becoming acutely short of breath with chest pain 1 hour prior to attending. She is not on any regular medication. Of note she had an uncomplicated birth by normal vaginal delivery at term 3 weeks ago. Her observations are as follows: Blood pressure: 100/60 Heart Rate: 100 Respiratory Rate: 20 Oxygen sats: 94% on air What is the likely diagnosis?
Explanation: The relative risk of VTE in the puerperium compared to non‐pregnant women is up to 20 fold. This patient has lower than expected oxygen saturations and borderline tachypnoea and tachycardia. Pulmonary embolism is the most likely diagnosis.
Your score is
