EMQs
1 Acute pelvic pain
a. Acute pelvic inflammatory disease
b. Ectopic pregnancy
c. Appendicitis
d. Torsion of ovarian cyst
e. Urinary tract infection
f. Miscarriage
g. Pancreatitis
h. Constipation
i. Endometriosis
j. Vulvovaginal thrush
k. Diverticulitis
The women below all presented with acute pelvic pain.
Choose the most appropriate diagnosis from the above
list.
1. A 25 - year - old is admitted as an emergency with a
2 - day history of right - sided lower abdominal pain
and vomiting. On examination, she has a
temperature of 37.5 ° C and a pulse of 86 beats/
minute. She also has tenderness and guarding in her
right iliac fossa. Her haemoglobin level is normal
but she has a raised white blood cell count.
2. A 32 - year - old presents with 36 hours of lower
abdominal pain, dysuria and urinary frequency. She
has a temperature of 38 ° C and her pulse is 78 beats/
minute. She is slightly tender in her left loin.
3. A 26 - year - old with a past history of Chlamydia,
complains of right - sided lower abdominal pain,
brown vaginal discharge and has a positive
pregnancy test.
4. A 20 - year - old complains of 3 days of lower
abdominal pain and tenderness. On further
questioning she admits to a yellow vaginal discharge.
On examination, she looks slightly flushed and has a
low grade pyrexia. She has lower abdominal
tenderness and cervical excitation on examination.
She has a raised white blood cell count and
C - reactive protein (CRP).
5. A 30 - year - old para 1 presents with cramping lower
abdominal pain. She has heavy vaginal bleeding and
notices fresh clots. Her last menstrual period (LMP)
was 10 weeks ago and she has a positive pregnancy
test.
6. A 24 - year - old presents with 24 hours of right - sided
abdominal pain. She describes the pain as colicky
and today she vomited with the pain. She denies
being sexually active and her LMP finished 3 days
ago. On examination, she has tenderness and
guarding in her right iliac fossa and bowel sounds
are present. She has a raised white blood cell count.
Ultrasound scan shows a 7 cm mass in the right
adnexa.
Obstetrics and Gynaecology: Clinical Cases Uncovered.
By M. Cruickshank and A. Shetty. Published 2009 by Blackwell
Publishing. ISBN 978-1-4051-8671-1.178 Part 3: Self-assessment
PART 3: SELF-ASSESSMENT
2 Acute vulval pain
a. Syphilis
b. Vulval abscess
c. Bartholin’s cyst
d. Herpes simplex
e. Sebaceous cyst
f. Bartholin’s abscess
g. Vulval haematoma
h. Vulvovaginal thrush
i. Herpes zoster virus
j. Fixed drug eruption
k. Urethral caruncle
From the list of options given above, select the most likely
diagnosis for each of the clinical scenarios given below.
Each option may be used once, more than once or not at
all.
1. A 30 - year - old para 2 has a normal vaginal delivery
at 39 weeks ’ gestation. Her first stage lasts 4 hours
and the second stage lasts 4 minutes. She has active
management of third stage and the midwife records
that she has a small perineal abrasion which does
not need suturing. Twelve hours later, she
complains of severe vulval pain and discomfort. On
examination, she has a large tense purple swelling
distorting her right labia majora.
2. A 21 - year - old para 0 returned from a holiday in
Greece 5 days previously. She complains of intense
vulval pain which has become increasingly severe
over the last 24 hours. She thinks this may be caused
by the chlorine in the hotel swimming pool. On
examination, there is diffuse oedema, swelling and
erythma with small blisters around the vaginal
fourchette.
3. A 27 - year - old para 0 complains of a 2 - day history of
throbbing vulva pain and tenderness on the left side
of her vulva. She can no longer sit down because of
a painful swelling to the left side of her posterior
fourchette. On examination, there is a tense red
swelling on the left side of the introitus which is too
tender to allow further examination.
4. A 40 - year - old woman with a 10 - year history of type
1 diabetes gives a 2 - day history of a painful swelling
on her right labia majora. She had a previous
episode which resolved when the swelling burst in a
hot bath. On examination, she has an erythematous
fluctuant swelling measuring 2 cm in diameter over
her right labia majora.
5. A 59 - year - old para 2 gives a 3 - week history of vulval
tenderness. She feels a very tender area ‘ inside ’ her
vulva. The pain is worse on micturition. She last had
a period at age 50 years and has never used
hormone replacement therapy (HRT). On
examination, there is a ring of polypoid tissue
around the urethral meatus which is tender, red and
pouting.
3 Contraception
a. Progestogen emergency contraception pills
b. Copper intrauterine device
c. Combined oral contraceptive pill
d. Vasectomy
e. Female laparoscopic clip sterilization
f. Progestogen contraceptive implant
g. Male latex condom
h. Female condom
i. Progestogen intrauterine system
j. Depot progestogen injection
k. Diaphragm
From the list of options given above, please select the
most appropriate for the scenarios given below.
1. A couple both aged 39 have two children aged 16
and 14 years. They are certain that their family is
complete. Both are healthy and she has no
menstrual problems. Which would be their most
effective contraceptive option.
2. An 18 - year - old comes to the family planning clinic.
She had sex 11 hours ago and is worried as her
partner commented that the condom burst. On
closer questioning she admits to another condom
accident 8 days before. Her last period began 15
days ago. She should be offered this type of
contraception initially.
3. A 35 - year - old woman has two children aged 8 and 5
years. She is not sure if she wants a third child. She
smokes 15 cigarettes a day. She is overweight (body
mass index [BMI] 30) and is troubled by heavy but
regular periods. This method of contraception
would offer her most benefit.
4. A 35 - year - old woman with no children and no
current regular partner wishes to discuss
contraception. She had a deep vein thrombosis after
a long haul flight 2 years ago but no coagulopathy
was diagnosed. This method of contraception is
contraindicated for this woman.EMQs 179
PART 3: SELF-ASSESSMENT
5. A 22 - year - old woman is happy with her progestogen
implant for contraception. She has developed a latex
allergy confirmed by patch testing. This additional
method of barrier contraception could protect her
from sexually transmitted infections.
4 Genitourinary medicine
a. Candida
b. Bacterial vaginosis
c. Cytomegalovirus
d. Trichomonas vaginalis
e. Gonorrhoea
f. Physiological discharge
g. Herpes simplex
h. Syphilis
i. Genital warts
j. Chlamydia
k. Herpes zoster
For each of the scenarios given above, select the most
likely cause from the list of options.
1. An 18 - year - old woman with a 4 - month history of
noticing several small rough lumps around the
entrance to her vagina. She has no symptoms.
2. A 43 - year - old woman who has noticed a watery
‘ fishy ’ smelling discharge which is often worse after
a period. She has not been sexually active for 2 years
and her last smear test was normal.
3. A 19 - year - old woman has developed postcoital
bleeding recently. She has a contraceptive implant
fitted 2 years ago and her periods tend to be light
and intermittent. She started a new sexual
relationship 3 months ago.
4. A 14 - year - old girl complains of vaginal discharge
which marks her underwear. It is non - offensive and
she has no itch or irritation. She notices that it is
sometimes clear but sometimes slightly yellow and
cloudy.
5. A 24 - year - old woman develops several painful
shallow ulcers on her labia minora and around the
fourchette. She had sex with a casual partner 8 days
ago.
5 Infertility
a. Hypothalamic ammenorrhoea
b. Polycystic ovarian syndrome
c. Turner’s syndrome
d. Tubal factor infertility
e. Premature menopause
f. Oligospermia
g. Endometriosis
h. Hypothyroidism
i. Unexplained infertility
j. Type 1 diabetes
k. Hyperthyroidism
For each of the following couples who present for the
investigation of subfertility, select the single most likely
diagnosis from the list of options given above.
1. A 29 - year - old woman with a history of irregular
bleeding and increased BMI (36) presents with a
2 - year history of primary infertility. Her partner ’ s
semen analysis is normal.
2. A 25 - year - old athlete presents with secondary
amenorrhoea for 6 months and primary infertility.
Her BMI is 18. Her partner ’ s semen analysis is
normal.
3. A 32 - year - old woman presents with a 2 - year history
of primary infertility. She stopped the combined
oral contraceptive pill 2 years ago. Since then she
has experienced very heavy and painful but regular
periods. She also complains of deep dysparunia. Her
partner ’ s semen analysis is normal.
4. A 28 - year - old women presents with an 18 - month
history of primary infertility and dull lower
abdominal pain. She has regular menstrual cycles
and her partner ’ s semen analysis is normal. She was
diagnosed with Chlamydia 5 years previously and
following a course of doxycycline her Chlamydia test
was negative.180 Part 3: Self-assessment
PART 3: SELF-ASSESSMENT
6 Therapeutic options for specific indications in
pregnancy
1. Syntometrine
2. Oxytocin
3. Benzyl penicillin
4. Erythromycin
5. Vaginal prostaglandin E2
6. Atosiban
7. Folic acid
8. Magnesium sulphate
9. 0.9% normal saline infusion
10. Prophylactic dalteparin
For the list of therapeutic options given above, select the
single most appropriate clinical condition below. Each
option may be used once, more than once, or not at all.
a. A 23 - year - old para 2 with confirmed prelabour
rupture of membranes at 30 weeks ’ gestation and no
signs of chorioamnionitis or fetal concerns.
b. A 20 - year - old para 1 who presents at 30 weeks ’
gestation with three moderate uterine contractions
every 10 minutes. Her cervical assessment shows her
to be in early labour with the cervix being 3 cm
dilated and 50% effaced. You wish to administer
steroids for fetal lung maturity
c. A 36 - year - old para 3 who has been well antenatally
and intrapartum, has a spontaneous vaginal delivery
at term. Following delivery of the placenta there is a
500 mL vaginal blood loss and the uterus feels a little
boggy. The placenta is checked and looks complete.
d. A primipara has her labour induced at 39 +3 weeks ’
gestation for the indication of pre - eclampsia and a
growth restricted baby. Her cervix is favourable and
she has an artificial rupture of membranes. There is
no uterine activity.
e. An induction of labour is planned for a primipara at
38 weeks ’ gestation for the indication of cholestasis
of pregnancy. Her cervical Bishop ’ s score is 4.
f. A 32 - year - old para 2 is admitted with hyperemesis
gravidarum at 12 weeks ’ gestation. She has +++
ketonuria.
g. A 40 - year - old para 2 (two previous caesarean
sections) has her third planned caesarean section at
39 weeks ’ gestation. She has a BMI of 39 and is a
smoker.
h. A 26 - year - old woman on carbamazepine for control
of epilepsy is seen for prepregnancy counselling. Her
epilepsy is under good control and she is hoping to
come off contraception and try for a pregnancy soon.
i. A 33 - year - old primipara is in spontaneous labour at
41 +2 weeks ’ gestation. Her cervix is 4 cm dilated,
fully effaced, membranes are intact and she is
having moderately strong uterine contractions about
3 – 4 every 10 minutes. A urine culture at 15 weeks ’
gestation had grown group B streptococci.
j. An 18 - year - old primigravida is in hospital at 35
weeks ’ gestation for pre - eclampsia (BP
150/94 mmHg, +++ proteinuria). She is now
complaining of pain in her epigastrium and is
asking for paracetamol for a headache. Her reflexes
are brisk with clonus.
7 Antenatal tests on mother and fetus
1. Nuchal translucency (NT) measurement in the first
trimester
2. Mid-trimester anomaly ultrasound scan
3. Alpha-fetoprotein elevated on mid-trimester serum
screening
4. Urine for proteinuria
5. Amniocentesis
6. External cephalic version
7. Screening for sickle cell
8. Doppler scan of umbilical blood flow
9. Cardiotocogram (CTG)
10. Mid-stream sample of urine for culture
Match the antenatal test/intervention given in the list
above to the most appropriate option below. Each option
may be used once, more than once or not at all.
a. Reduced fetal movements for 24 hours at 37 weeks ’
gestation
b. A fetal growth scan at 32 weeks ’ gestation showing
abdominal circumference below the 5th centile and
reduced liquor volume
c. Dysuria and suprapubic discomfort at 24 weeks ’
gestation
d. Spina bifida in the fetus
e. Screening test for Down ’ s syndrome
f. Screening for gestational diabetes
g. Diagnostic test for Down ’ s syndrome
h. Diagnostic test for chorioamnionitis
i. Breech presentation at 37 weeks ’ gestation
j. Routine antenatal check at 28 weeks ’ gestation
k. An 18 - year - old Nigerian woman booking at 11
weeks ’ gestation
l. Cleft lip in the fetusEMQs 181
PART 3: SELF-ASSESSMENT
8 Complications associated with pregnancy and their
clinical presentation
1. Placenta praevia
2. Twin–twin transfusion syndrome
3. Chorioamnionitis
4. Scar rupture
5. Placental abruption
6. Cord prolapse
7. Preterm labour
8. Pylelonephritis
9. HELLP syndrome
10. Endometritis
Match the diagnoses given above to the single most likely
clinical scenario given below. Each option may be used
once, more than once, or not at all.
a. A 16 - year - old primigravida complains of some
blurred vision and epigastric pain at 31 weeks ’
gestation. Her blood pressure is 140/90 mmHg and
there is ++++ proteinuria. Her blood results
include: haemoglobin 9 g/dL , low platelet count
95 × 109/L, increased serum urate 0.40 nmol/L and
alanine aminotransferase 186 IU/L, normal serum
bilirubin 10 IU/L, urea 5 nmol/L.
b. A 22 - year - old para 0 has symptoms of nausea,
vomiting, fever and back pain at 36 weeks ’ gestation.
On examination, she looks flushed and dehydrated
with a temperature of 38.5 ° C and she has right -
sided renal angle tenderness. Her uterus is soft and
non - tender and she is feeling good fetal movements.
c. A para 0 has about 200 mL of fresh painless vaginal
bleeding at 34 weeks ’ gestation. The baby is in an
oblique beech position with a normal CTG tracing.
d. A para 1 at 28 weeks ’ gestation complains of
abdominal pain and small amount of fresh vaginal
bleeding. Her uterus is contracting about 6 in 10
minutes, there is not much uterine relaxation between
contractions and there is fetal tachycardia, reduced
baseline variability and late decelerations on the CTG.
e. A para 4, with a history of insulin - dependent
diabetes, has been admitted to the ward with
polyhydramnios and an unstable lie of the fetus at
37 weeks ’ gestation. On her way to the toilet she
feels a sudden large gush of fluid per vaginum. She
gets back to her bed and presses the emergency
buzzer. When the midwife checks her the uterus is
soft, non - tender, with no uterine contractions and
the fetal heart is found to be 60 beats/minute.
f. A 27 - year - old para 1 has a secondary postpartum
haemorrhage (PPH) of 800 mL, 10 days after
delivery. Her temperature is 37.8 ° C, she has some
tenderness in her lower abdomen, but no guarding
or rigidity, and her uterus seems to be involuting.
On vaginal examination, the cervical os closed and
there is some tenderness over the uterus.
g. A 33 - year - old is being managed conservatively
following confirmed prelabour rupture of
membranes at 30 weeks ’ gestation. At admission her
CRP is <10 and white blood cell count 9 × 109/L. At
31 +2 weeks, her CRP is noted to be at 60 and white
blood cell count 18.8 × 109/L. On examination, she
is found to be slightly tender over the uterus and
there is a fetal tachycardia of 180 beats/minute.
h. A 30 - year - old with monochorionic twins is scanned
at 22 weeks ’ gestation. She complains of a sudden
increase in her abdominal girth. One twin is noted
to have its abdominal circumference at the 10th
centile with 2 cm pools of liquor, with the other
twin at the 90th centile with 9 cm pools of liquor.
i. A 19 - year - old para 0 at 32 weeks ’ gestation, on
antibiotics for a confirmed urinary tract infection,
complains of abdominal tightenings every 3 – 4
minutes with a mucosy discharge per vaginum. The
midwife examines her and finds her cervix to be
1 cm long and 3.5 cm dilated.
j. A 33 - year - old para 1 (previous caesarean section) is
having a trial of vaginal birth. She makes good
progress until 5 cm dilatation, when she complains
of a continuous pain in the suprapubic area. The
midwife notices fresh bleeding per vaginum and
there are decelerations on the CTG.
k. A 28 - year - old para 0 presents with postcoital
painless spotting of blood per vaginum at 35 weeks.
The fetal head is fixed in the pelvis, her uterus is soft
with a normal fetal heart rate. Following a scan, a
speculum examination is performed which shows a
cervical ectropion, with no further bleeding seen.182 Part 3: Self-assessment
PART 3: SELF-ASSESSMENT
9 Clinical features and their associations
1. BP, urine protein
2. Symphysiofundal height
3. Increasing maternal age
4. Intrauterine fetal growth restriction
5. Bicornuate uterus
6. Grand multiparity
7. Fetal macrosomia
8. Folic acid periconception
9. Hyperemesis gravidarum
10. Previous caesarean section
From the list above, which would be the single most
appropriate association from the options below? Each
option may be used once, more than once, or not at all.
a. Prevention of fetal neural tube defects
b. Screening for fetal growth problems
c. Smoking
d. Molar pregnancy
e. Pregnancy in an insulin - dependent diabetic woman
f. Atonic PPH
g. Increased risk of gastroschisis
h. Preterm labour
i. Screening for pre - eclampsia
j. Increasing incidence of trisomy 21
k. Low lying or adherent placenta
10 Indications for interventions in pregnancy
1. Elective caesarean section for delivery
2. Maternal immunization postpartum
3. Neonatal immunization
4. Anti D administration in a rhesus negative mother
5. Betamethasone for fetal lung maturity
6. Vitamin B12 supplementation
7. Hydralazine infusion
8. Continuous CTG monitoring
9. Syntometrine
10. Higher (5mg) dose of periconception folic acid
From the list above, select the single most appropriate
association for the options below. Each option may be
used once, more than once, or not at all.
a. Mean arterial pressure of 134 in a para 0 in labour
with pre - eclampsia.
b. Fresh thick meconium seen in labour.
c. Severe hyperemesis gravidarum.
d. Insulin - dependent diabetes mellitus.
e. Mother diagnosed to have chronic hepatitis B on
antenatal screening.
f. Para 2 with previous history of atonic PPH now in
the third stage of labour.
g. Amniocentesis performed at 16 weeks ’ gestation.
h. Mother non - immune to rubella on antenatal
screening.
i. HIV positive mother on HAART with a viral load of
10100 at 37 weeks.
j. Mother diagnosed to be hepatitis C positive on
antenatal screening.
k. Prelabour preterm rupture of membranes at 28
weeks ’ gestation.
l. A primipara with non - progress of labour.
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