EMQ answers
1 Maternal and perinatal mortality: the confidential enquiry
1 A 2 F 3 H 4 C
Fetal death occurring between 20 0 weeks and 23 6 completed weeks. If the gestation is not sure, all births of at least 300 g are reported. This is the definition of a late fetal loss and, as such, does not fit with any of the answers given above.
See Chapter 3, Obstetrics by Ten Teachers, 18th edition.
2 Conception, implantation and embryology
1 A 2 F 3 H 4 C
The pararmesonephric or Mullerian ducts develop into the uterus, uterine cervix and the fallopian tubes along with the upper third of the vagina. The somites are a series of mesoderm tissue blocks that are found on each side of the neural tube. The gastrointestinal tract is the main organ system derived from endodermal layer. The primitive streak determines symmetry and defines the caudal and cephalic poles of the embryo.
See Chapter 4, Obstetrics by Ten Teachers, 18th edition.
3 Physiological changes in pregnancy: uterus and cervix
1 E 2 G 3 D 4 E
Human chrionic gonadotrophin (hCG) is the peptide that is incorporated into triple test. The alpha-subunit of hCG differs only slightly from the alpha-subunits of luteinizing hormone (LH), follicle-stimulating hormone (FSH) and thyroid-stimulating hormone (TSH), and can interact with these receptors. Insulin and insulin-like growth factors (IGFs) are important for fetal growth. Both IGF-I and II are produced within the uterus. From mid-pregnancy, the trophoblast is capable of producing corticotrophin-releasing factor (CRF) and this stimulates the fetal pituitary to increase fetal adrenocorticotrophic hormone.
See Chapter 5, Obstetrics by Ten Teachers, 18th edition.
4 Normal fetal development: the fetal heart
1 J 2 H 3 G 4 A
The foramen ovale shunts blood from the right to the left atrium. With the closure of the foremen ovale at birth, blood drains from the inferior and superior vena cava into the right atrium and is directed across the tricuspid value into the right ventricle.
See Chapter 6, Obstetrics by Ten Teachers, 18th edition.
5 Antenatal care
1 A 2 E 3 G
The triple test is a biochemical-screening test for Down’s syndrome. The dating scan has several specific aims, which include fetal viability, dating, diagnosis and chorionicity of twins. Quantification of protein in combination with blood pressure determination is the main screening test for pre-eclampsia.
See Chapter 7, Obstetrics by Ten Teachers, 18th edition.12 Obstetrics
6 Antenatal imaging and fetal assessment
1 D 2 I 3 J 4 E
Although variable, early and late decelerations all have a component in their definition that describes transient reductions in the fetal heart rate of 15 beats per minute or more, lasting for more than 15 seconds, their definitions require information as to whether the deceleration occurs with or after a contraction. A transient increase in the fetal heart rate of 15 beats per minute or more, lasting for more than 15 seconds, is the definition of fetal heart rate acceleration. It requires no timing with a contraction for its definition.
See Chapter 8, Obstetrics by Ten Teachers, 18th edition.
7 Prenatal diagnosis
1 A 2 B 3 H 4 F
The most common presenting signs of spina bifida on ultrasound examination are the lemon-shaped skulls and the banana-shaped cerebellum.
See Chapter 9, Obstetrics by Ten Teachers, 18th edition.
8 Second trimester miscarriage
1 G 2 F 3 A 4 E
Abdominal discomfort and suprapubic pain are common symptoms that present to obstetricians. However, the pyrexia and leucocytes within the urine would suggest that this is a urinary tract infection, which should be treated with antibiotics. The presentation of ruptured membranes and pyrexia would suggest chorionamnionitis, which should be treated with high-dose antibiotics and possibly termination of the pregnancy for maternal health. The ultrasound examination that demonstrated cervical dilatation and funnelling is suggestive of an incompetent cervix. This could be treated by the insertion of a cervical cerclarage.
See Chapter 10, Obstetrics by Ten Teachers, 18th edition.
9 Antenatal obstetric complications
1 A 2 E 3 D 4 B
The most likely diagnosis for a twin pregnancy presenting with painless vaginal bleeding is a placenta praevia. The twin pregnancy increases the surface area of the placenta and, therefore, increases the chances of it being low within the uterine cavity. The most likely diagnosis for a woman with a previous history of pelvic inflammatory disease and iliac fossa pain is an ectopic pregnancy. Although pelvic inflammatory disease is associated with Fallopian tube damage and increased risk of tubal pregnancy, it does not occur in all women with ectopic pregnancy. Therefore, it may be in the history of a woman with a threatened miscarriage.
See Chapter 11, Obstetrics by Ten Teachers, 18th edition.
10 Twins and higher order multiple gestations
1 B 2 J 3 K 4 D
The chance that at least one of a diazygotic twin pair being affected by a chromosomal defect is twice as high as for a singleton pregnancy. It should be noted that at least 10 per cent of diachorionic diamniotic twins develop from a single zygote and, therefore, have a risk of Down’s syndrome based on maternal age only.
See Chapter 12, Obstetrics by Ten Teachers, 18th edition.EMQ answers 13
11 Disorders of placentation
1 G 2 D 3 K 4 B
At 34 weeks’ gestation, the mostly likely diagnosis is pre-eclampsia. However, the diagnosis of pre-eclampsia requires urinary protein quantification. Therefore, the management would be for admission and further investigation. A 31-year-old woman with a booking blood pressure of 145/85 mmHg has chronic hypertension. During pregnancy, the blood pressure initially falls and then rises in the third trimester; therefore, this may be a normal physiological response for this woman and, as such, the blood pressure should be monitored. A blood pressure ranging from 150/100 to 170/119 mmHg with significant proteinuria indicates pre-eclampsia. A woman with a blood pressure within this range needs treatment with intravenous antihypertensives.
See Chapters 13 and 15, Obstetrics by Ten Teachers, 18th edition.
12 Medical diseases of pregnancy
1 E 2 F 3 B 4 I
Ursodeoxycholic acid is used in the symptomatic treatment of obstetric cholestasis. It chelates bile acids and reduces the itching associated with the disorder. Magnesium sulphate has been shown to reduce the chances of a patient having a further seizure related to pre-eclampsia. A woman presenting with tiredness, glycosuria and a fasting blood glucose of 8.1 mmol/L has diabetes and may require insulin to control blood glucose.
See Chapter 15, Obstetrics by Ten Teachers, 18th edition.
13 Perinatal infections
1 E 2 A 3 I 4 F
Listeria monocytogenes is a Gram-positive rod. It is an important cause of a wide spectrum of human diseases. Toxoplasmosis is a protozoan that can produce congenital or postnatal infections in humans. Congenital infections occur when non-immune mothers are infected with the protozoan and are of greater severity. Fifths disease is caused by parvovirus B19.
See Chapter 16, Obstetrics by Ten Teachers, 18th edition.
14 Labour
1 F 2 B 3 H 4 C
The mechanism of labour refers to the series of changes that occur in the position and attitude of the fetus during its passage through the birth canal. The process involves engagement, descent, flexion, internal rotation, extension, restitution, external rotation, and delivery of the shoulders and fetal body. Engagement is side to have occurred when the widest part of the presenting part has passed successfully through the inlet.
See Chapter 17, Obstetrics by Ten Teachers, 18th edition.14 Obstetrics
15 Obstetric emergencies
1 C 2 E 3 D
The history of a sudden onset of occipital headaches with associated vomiting should raise the suspicion of subarachnoid haemorrhage. The associated loss of consciousness would point to the diagnosis of subarachnoid haemorrhage. Although migraine and hypercalcaemia could present with this history, they are not options available. The definitive diagnosis would be confirmed with brain imaging. The combination of hypertension and proteinuria combined with a collapse would be eclampsia until proven otherwise.
See Chapter 19, Obstetrics by Ten Teachers, 18th edition.
16 The puerperium
1 G 2 F 3 C
The most likely diagnosis of an enlarged uterus and associated temperature is retained products of conception. She initially needs blood cultures and intravenous antibiotics. This should be followed by a surgical evacuation of the uterus. The differential diagnosis for a woman who presents after a Caesarean section with a temperature and abdominal pain is a wound infection, uterine infection or urinary tract infection. Caesarean section increases the risk of uterine infection and this is confirmed by the presence of an offensive discharge. This is unlikely to be retained products, as the uterine cavity is checked manually after a Caesarean section. A urinary tract infection would have dysuria and urine analysis would be abnormal. The differential diagnosis of a woman who presents with a temperature and chest signs is a chest infection, pneumonia or pulmonary embolism. The most likely diagnosis with purulent sputum is pneumonia, which should be treated with antibiotics.
See Chapter 20, Obstetrics by Ten Teachers, 18th edition.
17 Psychiatric disorders in pregnancy and the puerperium
1 E 2 F 3 H 4 A
Puerperal psychosis affects approximately 1 in 1000 women. It presents rarely before the third postpartum day, but usually does so before 4 weeks. The onset is characteristically abrupt, with rapidly changing clinical picture. The patient should be referred urgently to a psychiatrist and will require admission to a psychiatric unit. It is common for women in the first 24–48 hours to experience an elevation in mood, a feeling of excitement and some overactivity. This is termed to the postnatal ‘pinks’. Bipolar affective disorder is usually controlled with a combination of mood-stabilizing drugs (lithium), antidepressants and neuroleptics. Lithium carries a risk of causing cardiac defects if used in the first trimester.
See Chapter 21, Obstetrics by Ten Teachers, 18th edition.
18 Neonatology
1 G 2 C 3 A
Damage to the lowest roots of the brachial plexus (C8 and T1) is unusual but includes Klumpke’s palsy due to birth during breech delivery where the arm remains above the head.
See Chapter 22, Obstetrics by Ten Teachers, 18th edition.
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