Maternal Medicine Extra Quesions Batch B – MCQ

1. Ms XY is a primigravida who is 30 weeks pregnant. She presents to A + E with acute onset of shortness of breath and chest pain. She has just travelled via a long haul flight (12 h) to the UK. She has been commenced on therapeutic LMWH (Enoxaparin) pending investigations to rule out a PE. Her booking weight is 66 kg and she currently weighs 76 kg.

What is the correct dose of Enoxaparin she should receive?

2. Ms XY is a primigravida who is 38 weeks pregnant. She presents to A+E with acute onset of shortness of breath and chest pain. She has just travelled via a long haul flight (12 h) to the UK. She has been commenced on unfractionated heparin-pending investigations to rule out a PE. She has received the bolus dose of unfractionated heparin and is currently on 18 units/kg/h. Her APTT ratio 6 h after the bolus dose is 1.3. What is the most appropriate step to correctly titrate her heparin dose prior to her next APTT measurement?

3. Ms XY is a primigravida, 32 weeks pregnant. Her BP on 2 occasions today (at the GP surgery) is 140/92 and 142/95 mm of Hg with ++ protein in the urine. She is asymptomatic for pre-eclampsia. Her FBC, U + Es, LFTS and uric acid are normal. Her reflexes are normal. What is the most appropriate management for her?

4. All of the following are advantages of unfractionated heparin (UH) except:

5. A 26-year-old primigravida is discussing her fears of pregnancy complications with you at the booking visit. She has heard that pregnancy and childbirth increase the risk of thromboembolism. You will be correct to tell her that the incidence of VTE in pregnancy and puerperium is:

6. Which of the following statements regarding contemporary management of patients with beta-thalassemia major is true?

7. A woman with chronic essential hypertension was converted from Lisinopril to methyldopa in a preconception counselling clinic. The pregnancy was uncomplicated and she delivered spontaneously at term.

At what stage postnatally should the antihypertensive medication be switched back to Lisinopril?

58. A 32-year-old woman primigravida who is 34 weeks pregnant attends the antenatal clinic complaining of severe itching. Serum bile acids are found to be elevated and she is diagnosed with obstetric cholestasis. What is the most effective medication to improve her itching?

9. What is the main contraindication to the use of antenatal corticosteroids?

10. In the recent MBRRACE-UK report (2014), what was the leading overall single cause of maternal death?

11. An anaesthetist is asked to assist with the insertion of an intra- venous cannula prior to the commencement of a Syntocinon infusion in labour. The cannula is inserted successfully, but shortly after it was flushed through as the woman starts to have convulsions and becomes hypotensive and bradycardic. The syringes on the trolley are unlabelled and the anaesthetist suspects he may have flushed the cannula with a local anaesthetic solution. What is the appropriate management of her collapse?

12. A 32-year-old woman with known HIV-1 infection is being seen in antenatal clinic in her first pregnancy. Her viral load is <50copies/ml at 36 weeks gestation and she wishes to have further pregnancies in the future. What is the most significant intervention to reduce mother to child transmission?

13. Prior to the development of highly active antiretroviral therapy (HAART), elective caesarean section was the standard mode of delivery to reduce intrapartum mother to child transmission of HIV. At what viral load should caesarean section be considered with present HAART management?

14. With the present multidisciplinary management of HIV in pregnancy using HAART, what is the rate of mother to child transmission of HIV in the United Kingdom?

15. A woman who is HIV positive attends antenatal clinic at 36 weeks gestation. She has an uncomplicated pregnancy. At what plasma viral load could vaginal delivery be recommended?

16. A29-year-oldprimigravidaattendsherbookingvisitat12+2days. An ultrasound scan has confirmed a live fetus appropriate for the period of gestation. She is known to be HIV positive and is not in need of treatment for her own health, with a viral load of >35,000 copies/ml and is very keen for a vaginal delivery. What is the most appropriate intervention with regards to reducing the risk of neonatal transmission of HIV?

17. A 29-year-old gravida 2 para 1 is admitted with history of preterm prelabour rupture of membranes at 31+5weeks gestation of 4 hours duration. She is a known HIV patient with a low viral load and had been commenced on HAART at 22 weeks. Her viral load at 28 weeks was <50 copies/ml. On admission, she is apyrexial, vital signs are within normal limits and the CTG is reassuring. What is the most appropriate immediate management with regard to delivery?

18. A 29-year-old gravida 2 para 1 is seen in an antenatal clinic at 37 weeks for the first time. She has transferred her booking from another region, where she had been diagnosed as HIV positive. Her viral load is 1000 copies/ml. She does not need treatment for her own health and was started on zidovudine monotherapy at the previous hospital. Her previous delivery was spontaneous vaginal delivery with no complications.

What is the most appropriate management plan for delivery?

19. A young primigravida attends assessment unit at 32 weeks gestation following an assessment of raised blood pressure by the community midwife. Urine protein: creatinine ratio is 32 mg/mmol and her blood pressure is 152/102 mmHg.

20. A primigravida with a BMI of 34 kg/m2 presents at 21 weeks gestation with severe throbbing headache and vomiting. She gives a history of similar headaches in the past. On examination, her blood pressure is found to be normal with no proteinuria and the deep tendon reflexes are normal. A neurological review is arranged as there are no localising neurological signs except mild bilateral sixth nerve paresis.

What is the most likely diagnosis?

21. A primigravida has been brought to the Accident and Emergency department following a road traffic accident at 32 weeks gestation. The obstetric registrar is summoned urgently. On arrival she learns that CPR had been commenced 3 minutes earlier following a diagnosis of cardiac arrest and pulseless electrical activity.

What is the most appropriate initial action for an ST5 trainee?

22. A primigravida aged 30 attends antenatal clinic at 34 weeks gestation. She is known to have mild bipolar disorder but has not required any medication prior to pregnancy. Her mother suffers from bipolar disorder and takes lithium. During the visit she reports increasing anxiety, depression and self-neglect. To which health professional should this patient be referred?

23. A 39-year-old Type 2 diabetic of Asian origin presents with an acute onset of epigastric pain, chest pain and breathlessness at 30 weeks gestation. She is gravida 5 Para 4 (four normal vaginal

deliveries), and has a BMI of 41 kg/m . This was an unplanned pregnancy. Her diabetes is poorly controlled and her haemoglobin was 85 g/1 at 28 weeks. She is on oral iron and there is history of familial hyperlipidemia.
What is the most likely working diagnosis for this mother?

24. A 32-year-old primigravida is admitted in spontaneous early labour at 39 + 2 weeks. She is a known asthmatic and has had repeated admissions in this pregnancy with acute exacerbations of asthma. The previous admission had been at 36 weeks gestation when she was commenced on oral prednisolone 7.5mg/day in view of persistent poor asthmatic control.

What is the most appropriate intervention to maintain asthma control in labour?

25. A 29-year-old primigravida with a low-risk pregnancy attends the obstetric assessment unit with generalised pruritus at 34 weeks gestation. Laboratory results reveal bile acids of 16 mmol/l with normal Liver Function Tests (LFT) and you have established a diagnosis of Obstetric Cholestasis.

What is considered to be the best practice with regard to further antenatal care?

26. An 18-year-old primigravida is seen in the antenatal clinic for booking at 8 weeks gestation. She is known to have sickle cell disease and her partner is known to have normal haemoglobin. She has recently arrived from Nigeria and has not taken any vitamin supplements so far. What is the most important vitamin supplement during pregnancy?

27. An 18-year-old primigravida, a recent immigrant from West Africa is admitted at 30 weeks gestation with severe pain in her hips. A diagnosis of acute painful sickle cell crisis has been made.

What is the most important immediate management?

28. A 31-year-old primigravida presents for booking at 10 weeks. She is known to be hypothyroid and is on Levothyroxine 75 μg. She is complaining of feeling tired and lethargic and her TSH is 6.5 mU/ml. What would be the target TSH level at this gestation to indicate optimal control?

29. An 18-year-old primigravida, a recent immigrant from West Africa is admitted at 30 weeks gestation with severe pain in her hips. A diagnosis of acute painful sickle cell crisis has been made.

What is the most important immediate management?

30. A 38-year-old pregnant woman with obesity and Type 2 diabetes presents with chest pain at 28 weeks gestation. Which is the blood marker of choice for diagnosis of AMI in pregnancy

31. Following diagnosis of AMI in pregnancy, which medication should not be used in the acute phase?

32. What is the approximate incidence of overt hypothyroidism in pregnancy?

33. A 41-year-old woman has an oral glucose tolerance test (OGTT) at 28 weeks gestation in her fourth pregnancy. The results are as follows:
Fasting plasma glucose: 5.8 mmol/l
2 hour plasma glucose: 7.4 mmol/l
What is the correct diagnosis?

34. A 30-year-old woman is diagnosed with gestational diabetes following an oral glucose tolerance test (OGGT) at 26 weeks gestation in her first pregnancy. Her fasting blood glucose is 7.2 mmol/l. What is the appropriate management?

35. A 20-year-old woman with Type 1 diabetes presents at 32 weeks gestation in her first pregnancy with regular painful contractions, a closed cervix and a positive fetal fibronectin test. What is the most appropriate management plan?

36. What is the prevalence of asthma in pregnant women?

37. For women with severe asthma, in what proportion does disease further deteriorate during pregnancy?

38. For which group of women is vitamin K supplementation advised in the last month of pregnancy?

39. A woman with a BMI of 40 whose epilepsy is well controlled on anti-epileptic drugs (AEDs) attends for a booking appointment with the community midwife at 10 weeks gestation. Which combination of vitamin supplements should she be advised to take?

40. A woman who is taking antipsychotic medication is contemplating pregnancy.
Why is Lithium not the drug of choice?

41. A  woman is recently diagnosed with gestational diabetes. A programme of exercise and dietary change is initiated. What is the likelihood of her needing further treatment with an oral hypo- glycemic agent or insulin therapy in this pregnancy?

42. A woman attends the perimental health antenatal clinic at 8 weeks of gestation. She wishes to stop her lithium therapy with the sup- port of her psychiatrist and seeks advice.

What should be the recommended action after fully counselling the patient?

43. A woman attends clinic for preconceptual counselling after previously being treated for breast carcinoma. She is planning a pregnancy. How long after completion of the treatment is it recommended to wait before conceiving?

44. A primagravida who is otherwise fit and well, sadly, has a stillbirth at 38 weeks of gestation.
In what proportion of cases is there no identifiable cause?

45. A woman with known sickle cell trait  attends antenatal booking clinic. What antenatal complication is significantly more common com- pared to uncomplicated pregnancies?

46. A woman attends the antenatal clinic in a wheel chair with a known long-term traumatic spinal cord injury. At what level of spinal injury and above would you be concerned about the occurrence of autonomic dysreflexia?

47. A 25-year-old woman presents at 12 weeks gestation. Four years earlier she presented with a deep vein thrombosis after fracturing her femur and undergoing a major orthopaedic operation. Her thrombophilia screen result is negative, she has no family history of thrombosis and she has a body mass index of 23 kg/m . What thromboprophylaxis should be offered to this woman?

48. You are asked to see a 28-year-old woman who is day 2 following a caesarean section for unsuccessful induction of labour at 37 weeks’ gestation. She was diagnosed with mild preeclampsia at 36 weeks’ gestation. Her blood pressure has been 155/100 mm Hg on two occasions today, although she is asymptomatic and her deep tendon reflexes are normal. She is breast feeding. You decide to start her on an antihypertensive agent.

Which of the following antihypertensive agents has insufficient evidence on infant safety to recommend or use in breast feeding mothers?

49. You have been asked to see a 37-year-old para 1 at 25 weeks’ gestation. She had an elective caesarean section for breech presentation at 39 weeks in her first pregnancy. This is her second pregnancy, and she now describes a small painless lump in her right breast, which she has discovered accidentally. There is no history of bleeding per nipple. She is worried as she has a strong family history of breast cancer and you arrange an urgent referral to the specialist breast team.

What is the most appropriate first-line imaging modality?

50. A 33-year-old asylum seeker from Somalia is referred by the community midwife to the antenatal clinic, and you see her with an interpreter. She is 22 weeks into her first ongoing pregnancy and reports that she was subjected to female genital cutting when she turned 12 years of age. She also gives a history of recurrent urinary tract infections. Examination of the vulva shows that the clitoris, labia minora and labia majora are surgically removed.

Which of the following female genital mutilation types describe these findings?