Answer for Clinical Cases Uncovered

 MCQs answers

1. e

2. d

3. a

4. a

5. c

6. c

7. d

8. b

9. a

10. d

11. d

12. c

13. a

14. d

15. d

16. b

17. e

18. d

19. c

20. c

21. b

22. a

23. b

24. b

25. b

26. a

27. e

28. d

29. e

30. d

EMQs answers

Obstetrics and Gynaecology: Clinical Cases Uncovered.

By M. Cruickshank and A. Shetty. Published 2009 by Blackwell

Publishing. ISBN 978-1-4051-8671-1.

1

1. c

2. e

3. b

4. a

5. f

6. d

2

1. g

2. d

3. f

4. b

5. k

3

1. d

2. b

3. i

4. c

5. h

4

1. i

2. b

3. j

4. f

5. g

5

1. b

2. a

3. g

4. d

6

1. c

2. d

3. i

4. a

5. e

6. b

7. h

8. j

9. f

10. g

7

1. e

2. l

3. d

4. j

5. g

6. i

7. k

8. b

9. a

10. c

8

1. c

2. h

3. g

4. j

5. d

6. e

7. i

8. b

9. a

10. f

9

1. i

2. b

3. j

4. c

5. h

6. f

7. e

8. a, e

9. d

10. k

10

1. i

2. h

3. e

4. g

5. k

6. c

7. a

8. b

9. f

10. d

SAQs answers

1 Pelvic mass

a. Serum CA125

Ultrasound scan of abdomen and pelvis

CT scan of abdomen and pelvis

Ascitic tap for cytology

(3 marks)

b. The results will be used to calculate her risk of

malignancy index. If this is raised she needs to be

referred urgently to a gynaecology oncologist

(2 marks)

c. Obtain tissue for histological diagnosis

Debulk tumour as much as possible

Relieve symptoms, e.g. from pressure or bowel

obstruction

Perform total abdominal hysterectomy and bilateral

salpingo - oopherectomy (TAH/BSO)/

omentectomy/peritoneal washing

(4 marks)

d. Chemotherapy. Platinum as a single agent or in

combination with taxol (2 marks)

e. Positive cytology from pleural fluid means she has

stage 4 disease and the 5 - year survival is less than

5% (2 marks)

2 Prolapse

a. (i) Other urinary symptoms that she has not

mentioned to complete your history

• Nocturia (getting up once at night is considered

normal)

• Dysuria or haematuria (you need to consider

urinary tract infection [UTI])

• Urinary frequency (4 – 6 times per day is

considered normal)

• Urge incontinence (as she has only mentioned

urgency)

• Voiding problems (e.g. she may have difficulty

initiating micturition or need to double void, she

may need to push her prolapses back to void)

• Degree of incontinence (does she need to wear

pads or change her clothes, how much urine does

she lose, how often is she wet?)

(ii) Any lump felt or seen vaginally (prolapse)

(iii) Is she on hormone replacement therapy (HRT)

and what type?

(iv) Cough or chest symptoms/asthma/smoking

Weight gain/BMI

Ask her if she works and what job she does.

Does it involve lifting or other stress?

(v) It is important to know if her symptoms affect

her work or other usual activities such as hobbies

and sexual function

(vi) Difficult labour or prolonged second stage

Large babies

(6 marks)

b. Cytocoele and stress incontinence. This provisional

diagnosis has been made from her history and the

findings of cystocoele on examination (2 marks)

c. Mid - stream specimen of urine (MSSU). It is

important to exclude UTI in any women with

urinary symptoms (1 mark)

d. Weight loss (increased pressure on the pelvic floor

will exacerbate her problems)

Advice on how to stop smoking

Pelvic floor exercises with bladder retraining (these

are recommended as a combined approach for

women with urinary incontinence)

Practice double voiding

(4 marks)

e. Ring pessary

Surgery

(2 marks)

f. Cystometry may be useful to identify if the

incontinence is caused by detrusor overactivity or

urethral sphincter weakness. This will identify those

Obstetrics and Gynaecology: Clinical Cases Uncovered.

By M. Cruickshank and A. Shetty. Published 2009 by Blackwell

Publishing. ISBN 978-1-4051-8671-1.SAQs answers 189

PART 3: SELF-ASSESSMENT

women who require a suburethral taping (e.g.tension

free vaginal tape by transvaginal or obturator route )

for their stress incontinence. (2 marks)

3 Heavy menstrual bleeding

a. Dysfunctional uterine bleeding

Endometrial polyp

Endometrial hyperplasia

Endometriosis

Adenomyosis

Endometrial cancer (uncommon in this age group)

(1 mark per item to a maximum of 3)

b. Number of days of bleeding

Duration of cycle

Abnormal bleeding (intermenstrual bleeding,

postcoital bleeding)

How many pads or tampons she uses

Flooding

Clots

Effect of bleeding on lifestyle

Use of contraception

Last cervical smear test

Menarche

(1 mark per item to a maximum of 6)

c. Ultrasound scan

Endometrial biopsy

Hysteroscopy

Full blood count

Ultrasound scan may reveal endometrial polyps or

fibroids

An endometrial biopsy can show hyperplasia or

atypia and can rule out malignancy

Hysteroscopy will enable visualization of the

endometrial cavity and can diagnose endometrial

polyps, submucosal fibroids and endometrial cancer

A full blood count (FBC) can be helpful in cases of

iron deficiency anaemia secondary to heavy

menstrual bleeding

D & C would not be accepted as an answer as it is an

outdated investigation

Thyroid function tests are not useful unless the

patient has symptoms suggestive of a thyroid

disorder

(1 mark per item to a maximum of 3)

d. NSAIDs (e.g. mefenamic acid) should be considered

as first line treatment along with tranexamic acid

which she has already tried (side - effects: indigestion,

diarrhoea, vomiting, aggravation of peptic ulcer

disease)

Mirena IUS is very effective and in this patient could

be left in place until she reaches the menopause

(side - effects: irregular spotting, bleeding, breast

tenderness, acne, headaches, small risk of uterine

perforation at insertion)

Combined oral contraceptive (COC) pill (side -

effects: breast tenderness, nausea, mood changes,

rarely, deep vein thrombosis). COC may be

considered in younger age groups but this patient

is aged 45 years

(2 marks each, i.e. 1 for method and 1 for side - effect)

e. Endometrial ablation:

Less invasive

Less surgical risk

Fast recovery

Day case procedure

Completed family

Side - effects:

Vaginal discharge

Pelvic pain

Infection

Uterine perforation

May need additional surgery, procedure failure

(2 marks for choosing endometrial ablation, 1 for any

of the factors to justify this and 2 for side - effects)

Hysterectomy: (not first choice)

Completed family

Patient may want to be completely free of having

periods

Side - effects: intraoperative or postoperative

haemorrhage, infection (UTI, wound), damage to

bowel or bladder at operation, deep vein

thrombosis, pulmonary embolus

(1 mark for choosing hysterectomy, 1 for any of the

factors to justify this and 2 for side - effects)

f. Abdominal hysterectomy

Vaginal hysterectomy

Laparoscopic - assisted vaginal hysterectomy

Total laparoscopic hysterectomy

(1 mark per item to a maximum of 3)

g. Anaesthetic review is important in obese patients

before deciding on surgery (1 mark)

4 Bleeding in early pregnancy

a. Amount of bleeding

(i) Length of menstrual cycles

(ii) Associated pain

(iii) History of pelvic inflammatory disease/

appendicectomy/previous ectopic pregnancy190 Part 3: Self-assessment

PART 3: SELF-ASSESSMENT

You should suspect from the history that she has

bleeding in early pregnancy and you need to

assess the severity of her bleeding, the duration of

amenorrhoea and gestation (based on her normal

cycle length) and if there are any features that

would increase her risk of ectopic pregnancy.

(4 marks)

b. (i) Pulse rate

(ii) Blood pressure

(iii) Abdominal tenderness

(iv) Speculum examination to look at cervical os

You need to assess her clinical state because she is

actively bleeding. Tenderness suggests an ectopic

pregnancy. Examination of the cervical os will

confirm if a miscarriage is inevitable.

(4 marks)

c. (i) Urinary pregnancy test

(ii) Urine dipstick

(iii) FBC

(iv) Serum β human chorionic gonadotrophin

(HCG)

(4 marks)

d. Ultrasound of the pelvis. This will identify if she has

an intrauterine pregnancy and if it is viable. If the

uterus is empty, you need to consider this along

with the result of the serum βHCG and your clinical

findings (2 marks)

5 Vulval pain

a. Squamous cell cancer of the vulva. The clinical

findings suggest vulval intraepithelial neoplasia

(VIN) with an area which has progressed to a

squamous cell cancer of the vulva. The brief clinical

scenario of itch not relieved by any topical

treatments also suggests VIN although this can be a

feature of lichen sclerosus (2 marks)

b. VIN

Lichen sclerosus

Lichen planus

(6 marks)

c. She needs a diagnostic skin biopsy. This is to

confirm the diagnosis and to determine if there is

any evidence of invasion. This can be performed

under local anaesthetic but you need to ensure that

the biopsy is of sufficient size and depth and the

most suspicious area is biopsied. As invasion is

suspected clinically, you should not perform an

excision biopsy as this may compromise further

surgery if it turns out to be a cancer. (2 marks)

d. She needs to have the area excised to ensure that

there is no invasion in the residual areas. If there is

only VIN, this will also provide her with symptom

relief. In this older age group and with a single

lesion, the risk of recurrence is low (compared to

younger women with multifocal disease) but she

should be seen for follow - up (3 marks)

6 Labour

a. (i) Yes (1 mark)

(ii) Her cervix is fully effaced and dilating (1 mark)

Her contractions are getting regular and increasing

in intensity and frequency (1 mark)

b. TENS (1 mark)

Birthing pool (1 mark)

Morphine/pethidine (1 mark)

Nitrous oxide (Entonox) inhalation (1 mark)

Epidural block (1 mark)

c. (i) Could mean fetal distress or hypoxia (1 mark)

May be a result of fetal postmaturity (1 mark)

(ii) Continuous fetal cardiotocograph (CTG) (1

mark)

d. (i) Poor or inadequate progress of labour (1 mark)

or inco - ordinate uterine activity (1 mark)

(ii) Augmentation of labour with a carefully titrated

oxytocin intravenous infusion (2 marks)

7 Hyperemesis

a. Abdominal pain, heartburn (1 mark)

Urinary symptoms – dysuria, frequency, haematuria,

urine volumes (1 mark)

Diarrhoea (1 mark)

Fever (1 mark)

Jaundice (1 mark)

Trigger factors for vomiting, duration, frequency

(1 mark)

b. Pulse, BP (may be tachycardic, or have postural

hypotension) (1 mark)

Temperature (1 mark)

Signs of dehydration – decreased skin turgor, dry

skin, mouth, eyes (1 mark)

Icterus

c. Urinanalysis for ketones, leucocytes, nitrites, MSSU

for culture/sensitivity (+ for urine pregnancy test if

not already confirmed) (2 marks)

Bloods for FBC, urea and electrolytes, liver function

tests, thyroid function tests (2 marks)SAQs answers 191

PART 3: SELF-ASSESSMENT

Pelvic ultrasound to confirm viable pregnancy

(singleton or multiple) and rule out molar

pregnancy (2 marks)

d. Commence intravenous fluids (not 5% dextrose)

– at least 3 L/day with electrolyte management as

required (e.g. for hyponatraemia, hypokalaemia)

(2 marks)

Regular antiemetics – e.g. promethazine,

metaclopramide, cyclizine (1 mark)

Strict intake/output fluid chart with regular checks

for ketonuria (2 – 3 times a day) (1 mark)

Pulse/BP/temperature chart 4 - hourly (1 mark)

Consider thrombophylaxis (1 mark)

Thiamine replacement (1 mark)

e. Pylenephritis/UTI (1 mark)

Gastroenteritis (1 mark)

Hepatitis (1 mark)

Pancreatitis (1 mark)

Appendicitis (1 mark)

8 Pre-eclampsia

a. Headaches

Visual disturbance

Upper abdominal/epigastric pain

Nausea, vomiting

Increase in swelling (legs, rings getting tighter)

Urine output volumes (normal or reduced)

Has she been feeling good fetal movements?

(1 mark each)

b. Epigastric/right hypochondrial tenderness (over the

liver)

Brisk reflexes/clonus

Significant peripheral swelling

Papilloedema on fundoscopy

(1 mark each)

c. She has severe pre - eclampsia and is at risk of its

complications especially of convulsions/eclampsia

and those associated with high blood pressure (e.g.

intracranial haemorrhage) (1 mark)

d. IV cannula/blood samples for urgent FBC (including

platelet count), serum urate, urea and electrolytes,

liver function tests, group and save

Check fetal heart (CTG)

Hydralazine for control of blood pressure

Magnesium sulphate for prophylaxis against

eclampsia

Transfer to high risk setting on labour ward for

intensive monitoring (BP, pulse, respiration,

neurological state, intake output chart)

Depending on further clinical condition, blood

results and state of her cervix, plan for induction

of labour or caesarean section once acute

condition is under control

(1 mark each)

9 Fetal malposition

a. Ultrasound scan – look for placental position

(whether low lying), confirm lie of the fetus, liquor

volume (especially for polyhydramnios) (2 marks)

b. As she is at term with the baby in an oblique

position, it is advisable she stays in hospital as an

inpatient because of the risk of rupture of

membranes with the cord prolapsing. Cord prolapse

would necessitate an emergency delivery because of

the associated acute fetal risks (1 mark)

The option of external cephalic version (ECV)

should be discussed with her once the scan has

ruled out anything of concern (1 mark)

c. It involves external manipulation of the baby

through the maternal abdomen to turn the baby to a

cephalic position (1 mark)

Uterine tocolysis is recommended as it improves the

success of the procedure (1 mark)

The success rate is about 60% in parous women,

and there is a <5% chance that the baby will turn

back again to a malposition after a successful ECV

(1 mark)

The (uncommon) risks of the procedure include

spontaneous rupture of membranes ,

retroplacental haemorrhage and cord accidents

which may lead to fetal concerns necessitating

emergency delivery (1 mark)

d. Low lying placenta

Polyhydramnios

Uterine abnormality, fibroids in the lower segment

Grand multiparity

(1 mark each)

10 Antenatal screening for Down’s

syndrome

a. Based on her age alone (trisomy 21 has an increasing

incidence with age), her risk would be

approximately 1 : 100 (at age 40 at delivery) (1 mark)

Between 11 and 14 weeks: age + nuchal thickness

alone or in combination with βHCG and PAPP - A

levels in maternal serum (1 mark)192 Part 3: Self-assessment

PART 3: SELF-ASSESSMENT

Between 14 and 20 weeks: mid - trimester triple or

quadruple test on serum screening

(age + βHCG + alpha - fetoprotein + unconjugated

estriol + inhibin A) (1 mark)

11 – 14 weeks+: 14 – 20 weeks screening – the

integrated test (1 mark)

All these tests have false positive and false negative

rates. If the results come back with a high risk of

trisomy 21, a diagnostic test would be

recommended to check the fetal karytotype

(2 marks)

b. The diagnostic tests available include chorionic villus

sampling (CVS) which is usually performed between

10 and 14 weeks. It carries a 2% risk of miscarriage

(2 marks)

Amniocentesis is performed from 15 weeks ’

gestation, it carries a 1% risk of procedure - related

pregnancy loss (2 marks)

There is also a small (1%) risk of failed culture, and

mosaicism (particularly with CVS) which may

require repeat testing

c. FBC

Blood group, rhesus status and red cell antibodies

Immunity status to rubella

Screening for hepatitis B infection

Screening for HIV infection

Screening for syphilis infection

Urine for MSSU for asymptomatic bacteruria

(1 mark each)