C h a p t e r 2
Multiple choice questions
History and examination 15
Maternal and perinatal mortality: the
confidential enquiry 15
Conception, implantation and embryology 16
Physiological changes in pregnancy 16
Normal fetal development 17
Antenatal care 17
Antenatal imaging and fetal assessment 17
Prenatal diagnosis 18
Second trimester miscarriage 18
Antenatal obstetric complications 18
Twins and higher order multiple gestations 18
Disorders of placentation 19
Preterm labour 19
Medical diseases of pregnancy 19
Perinatal infections 21
Labour 21
Operative interventions in obstetrics 23
Obstetric emergencies 24
The puerperium 24
Psychiatric disorders in pregnancy and
the puerperium 24
Neonatology 24
ANSWERS 25
History and examination
1 With regard to the obstetric history:
a) Pregnancy is dated from conception.
b) Parity is the total number of pregnancies regardless of how they ended.
c) It is recommended that women should be seen on their own at least once.
d) A family history of pre-eclampsia should trigger increased antenatal surveillance.
e) The last menstrual period is reliable if the cycles are irregular.
2 The following terms are appropriate:
a) Lie: cephalic.
b) Position: flexed.
c) Station: at the level of the spines.
d) Engagement: two-fifths.
e) Presenting part: shoulder.
Maternal and perinatal mortality: the confidential enquiry
3 Maternal mortality:
a) Includes death caused by an ectopic pregnancy.
b) Is subjected to a confidential enquiry.
c) Must be reported to the Coroner.
d) Epilepsy is the commonest cause of indirect maternal death.
e) Is most often caused by sepsis.16 Obstetrics
4 Confidential Enquiry into Stillbirths and Deaths in Infancy (CESDI):
a) Includes only deaths after 24 weeks.
b) Late neonatal deaths occur after the first month of life.
c) The principal cause of death in the last CESDI was congenital abnormality.
d) Was set up to investigate suboptimal medical care.
e) Perinatal death: all stillbirths plus deaths in the first week of life.
Conception, implantation and embryology
5 During development of the ovarian follicles:
a) The primary oocyte is arrested at the interphase of the second meiotic division.
b) Granulosa cells in the corpus luteum are responsible for steroidogenesis.
c) Theca cells produce testosterone from cholesterol.
d) Meiosis is resumed prior to the luteinizing hormone (LH) surge.
e) The first polar body is extruded prior to ovulation.
6 After a successful conception the following statements are true:
a) The embryo remains in the fallopian tube for 6–8 days.
b) Myometrial cytokines modulate cytotrophoblastic proteolytic activity.
c) At 11 days the implantation site can be seen as a red spot on the endometrial mucosa.
d) Human chorionic gonadotrophin is produced by the corpus luteum.
e) The embryonic disc is formed after the third week postfertilization.
7 Considering embryo development:
a) During the third week, the bilaminar embryo generates the mesoderm.
b) At day 28, the cephalic neuropore closes.
c) Cardiac activity is evident from day 26.
d) The lower respiratory system appears as septation of the foregut.
e) The fetus is recognizably human at 12 weeks’ gestation.
Physiological changes in pregnancy
8 In normal pregnancy:
a) Blood pressure falls in the second trimester.
b) Plasma volume decreases throughout gestation.
c) There is a reduction in erythrocyte production.
d) 50 per cent of women have a transient diastolic murmur.
e) There is an increase in the number of polymorphonuclear leucocytes.
9 Maternal effects on the physiology of the kidney include:
a) There is a 40 per cent increase in renal blood flow.
b) There is an increase in the glomerular filtration rate.
c) The urea and creatinine are higher than the non-pregnant state.
d) The upper limit of protein excretion in pregnancy is 0.6 g per day.
e) The kidneys increase in size.Multiple choice questions 17
Normal fetal development
10 During lung development:
a) Alveolar development occurs after 20 weeks.
b) The predominant phospholipid is phosphatidylcholine.
c) Fetal lung fluid production ceases in the second stage of labour.
d) Fetal breathing movement occurs for 30 per cent in the second trimester.
e) The production of lecithin is enhanced by cortisol and diabetes.
Antenatal care
11 With regard to routine antenatal care:
a) There is no evidence in low-risk pregnancies that reduction in antenatal visits increase maternal or fetal
mortality.
b) The Naegele rule states that the expected date of delivery (EDD) is calculated by adding 7 days to the last
menstrual period (LMP) and then taking away 4 months.
c) Syphilis testing forms part of the routine booking visit.
d) Routine urine testing reduces preterm labour.
e) Every patient should have a named consultant.
12 The routine dating scan:
a) Allows accurate dating of the pregnancy and a reduction in induction of labour for prolonged pregnancy.
b) Allows the detection of placenta praevia.
c) Allows early detection of twin pregnancies.
d) Allows detection of a failed pregnancy.
e) Allows detection of uterine abnormalities.
Antenatal imaging and fetal assessment
13 Regarding diagnostic ultrasound:
a) It employs the use of low-frequency, high-intensity sound waves.
b) Between 12 and 20 weeks, the crown–rump length and femur length are the most reproducible assessment
of gestational age.
c) It can be used to determine chorionicity accurately in twin pregnancy at the 20-week scan.
d) It has shown that an increased nuchal translucency is associated with cardiac defects.
e) In 6 per cent of pregnancies, there will be a serious fetal structural abnormality.
14 Considering Doppler ultrasound:
a) Abnormal uterine Doppler flow indicates fetal hypoxaemia.
b) Abnormal umbilical artery flow indicates poor placental perfusion.
c) Fetal anaemia is associated with redistribution of blood flow.
d) Fetal hypoxaemia is associated with hyperdynamic circulation.
e) Abnormal ductus venosus blood flow occurs prior to arterial changes.
15 In relation to normal cardiotocograms at term:
a) The baseline at term is usually 120–160 beats per minute.
b) The baseline variability is considered abnormal when it is 10 beats per minute.
c) An acceleration is a baseline increase of 15 beats per minute for 15 seconds.
d) A reactive trace would have one acceleration in 20 minutes.
e) The tocograph trace indicates the strength of the contractions.18 Obstetrics
Prenatal diagnosis
16 The following statements are true for prenatal tests:
a) Serum biochemistry is superior to maternal age as a screening test for Down’s syndrome.
b) Maternal serum alpha-fetoprotein is a diagnostic test for neural tube defects.
c) Amniocentesis has a higher pregnancy loss rate than chorionic villus sampling.
d) Tests using DNA technology can be performed on amniocentesis specimens.
e) Chorionic villus sampling can only be performed before 12 weeks’ gestation.
17 Considering neural tube defects:
a) These occur as a result of poor preconception maternal diet.
b) The majority of these defects occur at the cranial end of the spine.
c) The prognosis for spina bifida depends on the level of the lesion.
d) With a previously affected sibling, the recurrence risk is 1 per cent.
e) A supplement of 4 mg folic acid significantly reduces the risk of recurrence.
Second trimester miscarriage
18 Second trimester miscarriage:
a) Is typically painless.
b) Occurs between 12 and 24 weeks’ gestation.
c) Can be associated with rupture of the fetal membranes.
d) Is diagnosed after exclusion of infection, haemorrhage and multiple pregnancy.
e) Antibiotic prophylaxis is usually given.
Antenatal obstetric complications
19 Oligohydramnios is associated with the following fetal conditions:
a) Tracheo-oesophageal fistula.
b) Talipes.
c) Intrauterine growth restriction.
d) Anecephaly.
e) Premature rupture of the fetal membranes.
20 Polyhydramnios is associated with the following:
a) Maternal diabetes.
b) Neuromuscular fetal conditions.
c) Maternal non-steroidal anti-inflammatory drugs.
d) Postmaturity.
e) Chorioangioma of the placenta.
Twins and higher order multiple gestations
21 In twin delivery:
a) The first twin is at greater risk then the second.
b) Cephalic–cephalic presentation is the most common.
c) Labour usually occurs prior to term.
d) Labour is extended.
e) There is a risk of postpartum haemorrhage.Multiple choice questions 19
22 Multiple pregnancies predispose to:
a) Placenta praevia.
b) Diabetes mellitus.
c) Pre-eclampsia.
d) Malpresentation.
e) Intrauterine growth restriction (IUGR).
Disorders of placentation
23 With regard to the placenta:
a) It receives the highest blood flow of any fetal organ.
b) It has approximately 20 cotelydons.
c) The maternal and fetal blood are separated by one layer.
d) It is a major endocrine organ.
e) Each cotelydon contains a primary stem villus.
24 Pre-eclampsia is more common in:
a) Multigravid women.
b) Women with congenital cardiac disease.
c) Multiple pregnancy.
d) Women with diabetes insipidus.
e) Women with pre-existing renal disease.
25 The treatment of pre-eclampsia includes:
a) Hospital admission.
b) Labetolol.
c) Early delivery.
d) Frusemide.
e) Magnesium sulphate.
Preterm labour
26 The following drugs have been shown to be effective in the treatment of preterm labour:
a) Atosiban.
b) Pethidine.
c) Nifedipine.
d) Labetolol.
e) Ritodrine.
Medical diseases of pregnancy
27 The risks of premature preterm rupture of the fetal membranes include:
a) Premature labour.
b) Cord prolapse.
c) Pre-eclampsia.
d) Maternal septicaemia.
e) Antepartum haemorrhage.20 Obstetrics
28 Women with congenital heart disease:
a) Should have a detailed fetal cardiology scan.
b) Should avoid becoming anaemic.
c) Should have prophylactic antibiotics for operative deliveries.
d) Commonly develop dysrhythmias.
e) Should have a shortened second stage of labour.
29 Hyperthyroidism in pregnancy:
a) Should be treated surgically rather than with carbimazole.
b) Can be diagnosed by total T4 measurements.
c) 50 per cent are secondary to Graves’ disease.
d) The main complications for the fetus include growth restriction and fetal bradycardia.
e) Therapy should maintain free T4 and T3 levels in the low normal range.
30 Patients diagnosed as having mitral stenosis:
a) Usually have been diagnosed prior to pregnancy.
b) Account for 50 per cent of rheumatic heart problems.
c) Should have an elective Caesarean section at 38–39 weeks.
d) Should be considered for mitral valvotomy during pregnancy.
e) Should not be given ergometrine routinely for the third stage.
31 The infant of a diabetic mother is at increased risk of:
a) Polycythemia.
b) Hypermagnesaemia.
c) Traumatic delivery.
d) Neonatal jaundice.
e) Hypoglycaemia.
32 Addison’s disease:
a) Is usually an autoimmune process.
b) Is not an indication for Caesarean section.
c) Has no effect on the fetus.
d) Carries a good prognosis in pregnancy.
e) Diagnosis in pregnancy is difficult owing to high oestrogen levels.
33 Considering cystic fibrosis in pregnancy:
a) The partner does not need genetic testing.
b) This is an autosomal recessive disorder.
c) The woman should have an oral glucose tolerance test.
d) Caesarean section is mandatory owing to poor lung function.
e) Fetal growth should be monitored with serial ultrasound scanning.
34 With reference to iron deficiency anaemia in pregnancy:
a) Iron demand in pregnancy increases to 4 mg per day.
b) High levels of serum ferritin confirm the diagnosis.
c) It is more common in multiple pregnancy.
d) It is usually be treated with oral iron.
e) Blood transfusion should be avoided.Multiple choice questions 21
35 Regarding thalassaemias:
a) They represent the commonest genetic disorder.
b) They result from an amino-acid substitution.
c) Alpha-thalassaemia major is incompatible with intrauterine life.
d) It is important to screen the partner.
e) Beta-thalassaemia minor is not a problem antenatally.
36 Intrahepatic cholestasis in pregnancy is associated with:
a) Elevation of total bile salts in the blood.
b) A positive direct Coombs’ test in the neonate.
c) Neonatal jaundice.
d) Intrapartum fetal distress.
e) Marked geographical variations.
37 In relation to women who embark on pregnancy with a diagnosis of epilepsy:
a) Carbamazepine is associated with neural tube defects.
b) Postpartum antiepileptic drugs may need to be reduced.
c) Vitamin K should be commenced from 30 weeks’ gestation.
d) Women on multiple therapy should be converted to monotherapy.
e) Intravenous magnesium sulphate is the best treatment of a status epilepticus during labour.
Perinatal infections
38 With regard to congenital infection with cytomegalovirus:
a) It is characterized by intracerebral calcification.
b) It is a recognized cause of microcephaly.
c) It can be detected by culture of the infant’s urine.
d) It is a cause of developmental delay.
e) 90 per cent of infections are asymptomatic.
39 Congenital malformation can be attributed to maternal infection with:
a) Poliomyelitis.
b) Toxoplasmosis.
c) Measles.
d) Parvovirus.
e) Syphilis.
40 Considering human immunodeficiency virus:
a) It is a retrovirus.
b) The antibody test may take 1 month to become positive after exposure.
c) The vertical transmission rate is approximately 15 per cent.
d) Stopping breast feeding is an effective way of preventing vertical transmission.
e) With intervention, the vertical transmission rate can be reduced to 3 per cent.
Labour
41 With regard to anatomy of the maternal pelvis:
a) The pudendal nerve passes in front of the ischial spine.
b) The anterior–posterior diameter of the pelvic inlet is 11 cm.
c) The anterior–posterior diameter of the pelvic outlet is 11 cm.
d) The levator ani muscles form the pelvic floor.
e) The angle of the inlet to the horizontal can be up to 90°.22 Obstetrics
42 Considering the fetal skull:
a) The anterior fontenelle is diamond shaped.
b) The sutures of the vault are ossified.
c) The vertex presentation longitudinal diameter is the subocciptal–frontal diameter.
d) The occipito-mental diameter is normally too large to pass through the maternal pelvis.
e) Moulding of the fetal skull is a normal physiological process.
43 Progress in labour is measured by:
a) The frequency of uterine contractions.
b) The force of uterine contractions.
c) Descent of the presenting part.
d) Dilation of the cervix.
e) The length of time since rupture of the membranes.
44 In relation to the mechanism of labour:
a) Engagement is said to have occurred when the widest part of the presenting part has passed through the
false pelvis.
b) Restitution occurs after external rotation.
c) Extension occurs after internal rotation.
d) Extension occurs at ‘crowning’.
e) Descent of the fetal head is needed before flexion, internal rotation and extension can occur.
45 Regarding face presentation:
a) This occurs in 1:250 labours.
b) The presenting diameter is the submento-bregmatic, which is 9.5 cm.
c) It is commonly due to fetal thyroid tumours.
d) The face can deliver vaginally with the chin meno-anterior.
e) Oxytocin should be used to augment slow progress.
46 Considering the Bishop’s score:
a) It includes station of the presenting part.
b) It includes the length of the cervical canal.
c) It includes the gestation of the fetus.
d) It includes parity of the mother.
e) A score of 4 indicates the cervix is unfavourable.
47 Concerning brow presentation:
a) This may be treated in labour by craniotomy.
b) It is the least common malposition.
c) The presenting diameter is mento-vertical.
d) It may be treated in labour by Caesarean section.
e) This is incompatible with vaginal delivery.
48 The following are contraindications to epidural anaesthesia:
a) Previous treatment with coagulants.
b) Multiple pregnancy.
c) Lack of trained staff.
d) Hypertension in pregnancy.
e) Patients receiving narcotics.Multiple choice questions 23
49 Vaginal bleeding in the first stage of labour may be due to:
a) Placental abruption.
b) Cervical fibroids.
c) Ruptured uterus.
d) Vaginal trauma.
e) Vasa praevia.
Operative interventions in obstetrics
50 The advantages of the midline episiotomy are:
a) Less blood loss.
b) Reduced incidence of dyspareunia.
c) Less anal sphincter damage.
d) Less pain in the postpartum period.
e) It is easier to repair.
51 Kjelland’s forceps:
a) Have a pelvic curvature.
b) Have a cephalic curvature.
c) Have a sliding lock.
d) Are used to rotate an occipital-posterior position.
e) Should not be used under pudendal block anaesthesia alone.
52 Indications and prerequisites for delivery with the ventouse include:
a) Delay in the second stage.
b) The cervix is fully dilated.
c) Gestation less than 34 weeks.
d) Fetal distress in the second stage.
e) Fetal membranes are ruptured.
53 During an assisted breech delivery:
a) An episiotomy can be cut once the anus is seen at the fourchette.
b) Pinard’s manoeuvre can be used to deliver legs in the extended position.
c) Mauriceau–Smellie–Veit’s manoeuvre is used to deliver extended arms.
d) Forceps should not be applied to the fetal head.
e) Epidural analgesia is mandatory.
54 The following complications are more likely after Caesarean section than after vaginal delivery:
a) Pulmonary embolism.
b) Secondary postpartum haemorrhage.
c) Postnatal depression.
d) Amniotic fluid embolism.
e) Infection.24 Obstetrics
Obstetric emergencies
55 With regard to shoulder dystocia:
a) It occurs in approximately 1 per cent of labours.
b) It is more common in assisted vaginal delivery.
c) McRobert’s manoeuvre will be effective in 90 per cent of cases.
d) Fundal pressure should be avoided.
e) Avoid lateral flexion of the head on the neck.
The puerperium
56 Human milk has the following advantages over formula milk:
a) Human milk contains more protein.
b) Human milk contains more lactose.
c) Human milk is associated with a reduction in atopic illness.
d) Human milk is a good source of iron.
e) Human milk is a good source of vitamin K.
Psychiatric disorders in pregnancy and the puerperium
57 Postnatal blues:
a) Usually start between days 3 and 5.
b) May be prolonged by anaemia.
c) Are more common in women who have normal deliveries.
d) Are prevented by night sedation.
e) Occur in women who are discharged early for hospital.
Neonatology
58 Neonatal jaundice is a recognized feature of:
a) Sickle cell disease.
b) Glucose-6-phosphate dehydrogenase.
c) Rhesus incompatibility.
d) Beta-thalassaemia.
e) Meningitis.
59 The following are thought to protect against hyaline membrane disease in the neonate:
a) Intrauterine growth restriction.
b) Severe pre-eclampsia.
c) Heroin addiction.
d) Prolonged rupture of the fetal membranes.
e) Diabetes mellitus
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