MCQ answers
1 True: c, d. Pregnancy is dated from the last menstrual period. Gravidity is the total number of pregnancies
regardless of how they ended. Domestic violence is an increasing problem and it is recommended that all
women are seen on their own to discuss this potential problem. A family history of pre-eclampsia increases
the risk pre-eclampsia in this pregnancy.
See Chapter 1, Obstetrics by Ten Teachers, 18th edition.
2 True: c, d, e. Cephalic describes presentation and not lie. The shoulder presents with a transverse lie.
See Chapter 1, Obstetrics by Ten Teachers, 18th edition.
3 True: a, b. Maternal death is defined as the death of a woman while pregnant or within 42 days of termination of pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not
from accidental or incidental causes. The commonest indirect cause of maternal death is cardiac disease, with
suicide as the next most common. The commonest cause of maternal death on the last confidential enquiry
was thromboembolic disease.
See Chapter 3, Obstetrics by Ten Teachers, 18th edition.
4 True: d, e. CESDI applies to deaths after 20 weeks’ gestation. The definition of late neonatal is death from 7 to
27 completed days after delivery. The principal cause of fetal death is prematurity and not congenital abnormality. The report classifies cases according to the type of care that they received.
See Chapter 3, Obstetrics by Ten Teachers, 18th edition.
5 True: b, c, e. The primary oocyte is arrested at the metaphase of the second meiotic division and not the interphase of the cycle. Meiosis is not resumed until after the LH surge. The first polar body is extruded prior to
ovulation and the second polar body is extruded after ovulation.
See Chapter 4, Obstetrics by Ten Teachers, 18th edition.
6 True: c. The embryo after fertilization remains in the fallopian tube for 3–4 days. It is endometrial cytokines
not myometrial cytokines that modulate cytotrophoblastic proteolytic activity to control the depth of invasion. Human chorionic gonadotrophin is produced by the trophoblast; therefore, it is a specific indicator of
pregnancy. It can also be utilized in the diagnosis of ectopic pregnancy. The embryonic period starts with the
generation of the embryonic disc during the second week postfertilization.
See Chapter 4, Obstetrics by Ten Teachers, 18th edition.
7 True: a, d, e. The cephalic neuropore closes during the 26th day and the caudal neuropore on the 28th day
after fertilization. Cardiac activity is evident from day 22.
See Chapter 4, Obstetrics by Ten Teachers, 18th edition.
8 True: a, e. The plasma volume increases in pregnancy until around 32 weeks after which time it plateaus. The
increase in the plasma volume is one of the fundamental physiological changes of normal pregnancy. This
change is essential to other physiological changes that occur during pregnancy, which include increased cardiac
output and an increase in renal blood flow. Erythrocyte production is increased in pregnancy; however, there
is marked dilution of red cells in the blood owing to the increased plasma volume. The maternal heart sounds
change during pregnancy: there is an increased loudness in both s1 and s2, 95 per cent of women develop a
systolic murmur that disappears after delivery, and 20 per cent have a transient diastolic murmur.
See Chapter 5, Obstetrics by Ten Teachers, 18th edition.26 Obstetrics
9 True: b, e. During pregnancy, there is a dramatic (60–75 per cent) increase in the renal blood flow. The consequence of this is an increase in the glomerular filtration rate (GFR) of the kidney. The increase in the GFR is
responsible for an increase in the clearance of urea and creatinine. Thus plasma concentrations of urea and
creatinine are reduced during pregnancy. Kidneys increase in length by approximately 1 cm during pregnancy.
See Chapter 5, Obstetrics by Ten Teachers, 18th edition.
10 True: b. The fetal alveoli start to develop after 20 weeks’ gestation. The predominant phospholipid is phosphatidylcholine (lecithin). The production of lecithin is enhanced by cortisol, growth restriction and prolonged rupture of membranes. However, diabetes mellitus delays the production of respiratory lecithin. The
fetal lung is filled with fluid from an early gestation. Its production ceases in the early stages of labour under
the influence of adrenaline.
See Chapter 6, Obstetrics by Ten Teachers, 18th edition.
11 True: a, c. The Naegele rule states that the EDD is calculated by adding 7 days to the LMP and then taking
away 3 months. However, this rule assumes a 28-day cycle and ovulation on day 14, and finally an accurate
recollection of the LMP. Although only a small number of women are diagnosed with syphilis during pregnancy, the vertical transmission to the fetus has serious consequences. This transmission to the fetus can easily be prevented by treatment of the mother with antibiotics. There are several classifications of antenatal
care; if the women have community care, then the lead clinician would be the community midwife.
See Chapter 7, Obstetrics by Ten Teachers, 18th edition.
12 True: a, c, d, e. The routine dating scan is unable to detect placenta praevia. Placenta praevia can be detected
by ultrasound but not until the third trimester.
See Chapter 7, Obstetrics by Ten Teachers, 18th edition.
13 True: d. The technique of ultrasound utilizes high-frequency, low-intensity sound waves to generate an
image. Fetal age can be assessed accurately prior to 12 weeks by measuring the crown–rump length and from
12 to 20 weeks gestation can be determined from biparental diameter. The chorionicity of twin pregnancy is
best determined in the first trimester; this should ideally occur at approximately 12 weeks. Nuchal translucency has been shown to be a screening test for Down’s syndrome, other chromosomal abnormalities and
cardiac defects. Serious fetal structural abnormalities are diagnosed in 3 per cent of all pregnancies.
See Chapter 8, Obstetrics by Ten Teachers, 18th edition.
14 True: b. Abnormal uterine artery Doppler indices are used as indicators for an increased risk of pre-eclampsia
and intrauterine fetal growth restriction. Fetal anaemia is associated with a hyperdynamic circulation, whereas
fetal hypoxaemia is associated with blood redistribution. Abnormal flow in the ductus venosus is a pre-terminal
observation and does not precede arterial changes.
See Chapter 8, Obstetrics by Ten Teachers, 18th edition.
15 True: b, c. The normal fetal heart rate at term is 110–150 beats per minute, whilst prior to term 160 beats per
minute is taken as the upper limit of normal. Normal baseline variability reflects a normal fetal autonomic
nervous system. Baseline variability is considered abnormal when less than 10 beats per minute. The presence of two or more accelerations on 20–30-minute cardiotocogram defines a reactive trace.
See Chapter 8, Obstetrics by Ten Teachers, 18th edition.
16 True: a, d. Serum biochemistry has a sensitivity of 60–70 per cent, compared to 30–40 per cent for maternal
age alone. The measurement of serum alpha-fetoprotein is a screening test for neural tube defects and not a
diagnostic test. Chorionic villus biopsy is usually performed between 11 weeks’ and 20 weeks’ gestation.
See Chapter 9, Obstetrics by Ten Teachers, 18th edition.
17 True: b, c, e. Neural tube defects (NTDs) are amongst the common major abnormalities. The aetiology is multifactorial with well-defined environmental, genetic, pharmacological and geographical factors implicated.
Around 70–80 per cent of neural tube defects are anencephaly or encephaloceles. When a parent or previous
sibling has had an NTD, the risk of recurrence is 5–10 per cent. Preconception folate supplementation of theMCQ answers 27
maternal diet reduces the risk of developing these defects by about half. The dosage of folic acid is 400 g for
primary prevention and 4mg for women wishing to prevent a recurrence of an NTD.
See Chapter 9, Obstetrics by Ten Teachers, 18th edition.
18 True: b, c. Second trimester miscarriage normally presents with backache, contractions and vaginal bleeding.
Rupture of the fetal membranes can also be a feature. Antibiotics are only given if there is strong evidence
there is infection.
See Chapter 10, Obstetrics by Ten Teachers, 18th edition.
19 True: b, c, e. Tracheo-oesophageal fistula and anecephaly are both associated with polyhydramnios due to
lack of fetal swallowing.
See Chapter 11, Obstetrics by Ten Teachers, 18th edition.
20 True: a, b, e. Postmaturity is associated with oligohydramnios.
See Chapter 11 Obstetrics by Ten Teachers, 18th edition.
21 True: b, c, e. It has been shown that the fetal mortality and morbidity are greatest in the second twin. The
labour is of normal length.
See Chapter 12, Obstetrics by Ten Teachers, 18th edition.
22 True: a, c, d, e. The greater placental area makes placenta praevia more likely. Acute pyelonephritis, IUGR,
hypertension, polyhydramnios, malpresentation and prematurity are more common in multiple pregnancies.
See Chapter 12, Obstetrics by Ten Teachers, 18th edition.
23 True: a, b, c, e. It receives the highest flow of any fetal organ and towards the end of pregnancy, competes with
the fetus for maternal substrate, consuming the major fraction of glucose and oxygen taken up by the gravid
uterus. The functional unit of the placenta is the cotyledon, and the mature human placenta has about 20
cotyledons. The septa, which divide the placenta into its cotyledons, appear at the end of the third month of
development. Three microscopic tissue layers separate the maternal and fetal blood: the trophoblast tissue,
connective tissue and the endothelium.
See Chapter 13, Obstetrics by Ten Teachers, 18th edition.
24 True: c, e. Pre-eclampsia is more common in primagravid women, women with diabetes mellitus (not diabetes insipidus) and in women with pre-existing renal disease.
See Chapter 13, Obstetrics by Ten Teachers, 18th edition.
25 True: b, c, d, e. Hospital admission is not a treatment for the condition; however, it allows the severity of the
condition to be quantified via continuous assessment of the blood pressure and serial haematological and biochemical parameters. Delivery will cure the condition. In pre-eclampsia, the plasma volume is reduced; therefore, frusemide will not help and may make matters worse.
See Chapter 13, Obstetrics by Ten Teachers, 18th edition.
26 True: a, c, e. Ritodrine is a sympathomimetic and causes uterine relaxation. Nifedipine can be used to arrest
preterm delivery as it acts to inhibit intracellular calcium. Atosiban is a specific oxytocin receptor antagonist
and, therefore, reduces uterine contractions. Labetolol is an alpha- and beta-receptor agonist used in the
reduction of blood pressure. Pethidine sedates the mother and the fetus but does not affect the contractions.
See Chapter 14, Obstetrics by Ten Teachers, 18th edition.
27 True: a, b, d. The risks are premature labour, malpresentation, cord prolapse and ascending infections. Any
women delivering after preterm rupture of the fetal membranes is at risk of postpartum haemorrhage and
endometritis.
See Chapter 14, Obstetrics by Ten Teachers, 18th edition.
28 True: a, b, c, e. The incidence of congenital heart disease in the general population is 8 per 1000 live births.
However, if the parent is affected, the incidence raises to 5 per 100 live births; therefore, all pregnant women28 Obstetrics
with congenital heart disease should have a detailed fetal cardiology scan. The haemodynamic changes of
pregnancy increase the strain on the heart. Anaemia exacerbates this situation. Dysrhythmias occur in less
than 3 per cent of women. However, they require urgent treatment. Prophylactic antibiotics should be given
to any women with congenital heart defects.
See Chapter 15, Obstetrics by Ten Teachers, 18th edition.
29 None are true. The treatment of hyperthyroidism in pregnancy is drug treatment. Radioactive iodine is completely contraindicated owing to its effect on the fetal thyroid gland. Surgical treatment may be rarely indicated
where there is no response to medical therapy. During pregnancy, there is an increase in the levels of total T4
and T3; however, there is no increase in the levels of the free hormones. Therefore, the diagnosis requires
increased levels of free T4 and T3, and reduced levels of thyroid-stimulating hormone. Approximately 90 per
cent are due to Graves’ disease. The main complications for the fetus include fetal growth restriction, stillbirth,
fetal tachycardia and premature delivery.
See Chapter 15, Obstetrics by Ten Teachers, 18th edition.
30 True: a, e. Most cases of heart disease are diagnosed prior to pregnancy. Mitral stenosis is the commonest
acquired cardiac lesion, accounting for 90 per cent of rheumatic problems. Mitral valvotomy can be performed during pregnancy, if necessary.
See Chapter 15, Obstetrics by Ten Teachers, 18th edition.
31 True: a, c ,d , e. The infant of a diabetic mother is at increased risk of various metabolic and traumatic
insults. The fetus is at increased risk of hypoglycaemia, hypocalcaemia, hypomagnesaemia.
See Chapter 15, Obstetrics by Ten Teachers, 18th edition.
32 True: a, b, c, d. The diagnosis can be difficult in pregnancy because of cortisol levels; instead of being characteristically reduced, they may be in the low normal range.
See Chapter 15, Obstetrics by Ten Teachers, 18th edition.
33 True: b, c, e. It is important to test the partner for carrier status so that an accurate assessment of fetal risk
can be made. The couple should be offered genetic counselling regarding the risk of the fetus having cystic
fibrosis or being a carrier. Pancreatic function is affected in women with cystic fibrosis and 8 per cent will
develop gestational diabetes in pregnancy. Ideally, vaginal delivery should be the aim; however, the second
stage may be shortened in the event of maternal exhaustion. The fetal risks include fetal growth restriction.
See Chapter 15, Obstetrics by Ten Teachers, 18th edition.
34 True: a, c, d. Iron demand in pregnancy increases from 2 to 4 mg daily. The diagnosis of iron deficiency is suspected if the mean corpuscular volume (MCV) is below 85 fL. Low levels of serum iron and ferritin help to
confirm the diagnosis. Nutritional status affects the iron stores, and repeated pregnancy and poor social factors
may lead to anaemia as will the increased iron requirements of multiple pregnancy. Blood transfusion should
be avoided, if possible, because of the small risk of antibody production and transfusion reaction.
See Chapter 15, Obstetrics by Ten Teachers, 18th edition.
35 True: a, c, d, e. The genetic defect in thalassaemia causes a reduced production of normal haemoglobin,
whereas sickle cell disease is caused by an amino-acid substitution that results in it precipitating when in its
reduced state. Alpha-thalassaemia major is incompatible with intrauterine life, with the fetus developing
marked hydrops.
See Chapter 15, Obstetrics by Ten Teachers, 18th edition.
36 True: a, d, e. In intrahepatic cholestasis (IHC), the serum shows an increase in conjugated bilirubin and alkaline phosphatase. There is large geographical variation in the incidence of IHC with one of the highest incidences occurring in Chile. The fetal risks for obstetric cholestasis include preterm labour, meconium staining
and, rarely, intrauterine fetal death.
See Chapter 15, Obstetrics by Ten Teachers, 18th edition.MCQ answers 29
37 True : a, b, d. Carbamazepine is classically associated with neural tube defects. However, sodium valproate is
associated with NTDs, genitourinary and cardiac defects, and phenytoin is associated with cardiac and genitourinary defects.Vitamin K supplementation should be recommended from 36 weeks’ gestation. This is because
vitamin K-dependent clotting factors within the newborn may be reduced and lead to haemorrhagic disease.
Although magnesium sulphate is the treatment of choice for an undiagnosed seizure during labour, intravenous benzodiazipines (i.e. lorazepam, carbamazepine) are the recognized treatment for status epilepticus
during labour.
See Chapter 15, Obstetrics by Ten Teachers, 18th edition.
38 All are true. Congenital cytomegalovirus (CMV) is associated with various fetal manifestations. These include
hepatosplenomegaly, microcephaly, intrauterine growth retardation, hyperbilirubinaemia, intracerebral calcification and mental retardation. Only 5–10 per cent of infants will be symptomatic at birth. Congenital
CMV is a cause of fetal hydrops and, as such, polyhydramnios.
See Chapter 16, Obstetrics by Ten Teachers, 18th edition.
39 True: b, e. Toxoplasmosis during the first trimester of pregnancy is mostly likely to cause fetal damage, but
only 10–25 per cent are transmitted to the fetus. In the third trimester, 75–90 per cent of infections are transmitted, but the risk of fetal damage in almost zero at term. Up to 70 per cent of fetuses become infected if the
mother has primary or secondary syphilis during pregnancy; however, the spectrum of congenital disease
varies greatly.
See Chapter 16, Obstetrics by Ten Teachers, 18th edition.
40 All are true. Human immunodeficiency virus (HIV) is a retrovirus, with the genetic code in a single strand of
RNA. Vertical transmission occurs in 25–40 per cent of pregnancies where there is no intervention to reduce
the risk. Three interventions have been shown to reduce the vertical transmission of HIV. These are: (1) avoiding breastfeeding; (2) elective Caesarean section; and (3) antiviral medication during the latter half of pregnancy. If all three interventions are undertaken, then the risk of transmission is probably less than 3 per cent.
See Chapter 16, Obstetrics by Ten Teachers, 18th edition.
41 True: b, d, e. The pudendal nerve passes behind and below the ischial spine. The pelvic inlet is defined as the
area bounded in front by the symphysis pubis, on each side by the upper margin of the pubic bone, the
ileopectineal line and the ala of the sacrum, and posteriorly by the promontory of the sacrum. The normal
anterior–posterior (AP) diameter of the pelvic inlet is 11 cm and the transverse diameter is 13.5 cm. The AP
diameter of the pelvic outlet is 13.5 cm, with a transverse diameter of 11 cm. The normal angle of the inlet is
60° to the horizontal, however, in Afro-Caribbean women, this angle may be as much as 90°.
See Chapter 17, Obstetrics by Ten Teachers, 18th edition.
42 True: a, d, e. The anterior fontanelle is diamond shaped and is formed at the junction of the sagittal, frontal
and coronal sutures. The sutures of the vault are soft unossified membranes, whereas the sutures of the face
and the skull base are firmly united. The longitudinal diameter of the vertex presentation is the subocciptal–bregmatic diameter. The occipito-mental diameter is 13 cm and describes the brow presentation. This is
usually too large to pass through the maternal pelvis.
See Chapter 17, Obstetrics by Ten Teachers, 18th edition.
43 True: c, d. Progress is measured by the dilatation of the cervix and the descent of the presenting part. It may
be satisfactory in the absence of strong frequent contractions or may appear unsatisfactory even when the
contractions are strong.
See Chapter 17, Obstetrics by Ten Teachers, 18th edition.
44 True: c, d, e. Engagement is said to have occurred when the widest part of the presenting part has passed
through the pelvic inlet. Restitution occurs directly after delivery of the fetal head, this allows the fetal head
to align itself with the shoulders in the oblique position. In order to deliver, the shoulders then have to rotate30 Obstetrics
from the oblique into the AP plane. During this rotation, the fetal occiput rotates to the transverse and this
is termed external rotation.
See Chapter 17, Obstetrics by Ten Teachers, 18th edition.
45 True: b, d. Face presentation occurs in about 1 in 500 labours. Rarely, extension of the neck can due to a fetal
anomaly, such as a thyroid tumour. If progress in labour is excellent, and the chin remains mento-anterior,
vaginal delivery is possible by flexion. Oxytocin should not be used and, if there are any concerns about fetal
condition, Caesarean section should be carried out.
See Chapter 17, Obstetrics by Ten Teachers, 18th edition.
46 True: a, b, e. Bishop’s score relates to the favourability of the cervix for induction of labour. It scores the station of the presenting part, the cervical consistency, position, dilation and effacement. High scores are associated with an easier shorter induction that is less likely to fail. Low scores are associated with longer inductions
of labour, which are more likely to fail and result in Caesarean section.
See Chapter 17, Obstetrics by Ten Teachers, 18th edition.
47 True: c, d. Brow presentation is the least common malpresentation (1 in 1500) not malposition. Malposition
refers to the abnormal position of the occiput in a vertex presentation. The presenting diameter is mentovertical (measuring 13.5 cm). This is incompatible with a vaginal delivery.
See Chapter 17, Obstetrics by Ten Teachers, 18th edition.
48 True: c. Coagulation disorders are a contraindication to epidural anaesthesia; however, previous use of coagulants is not an indication. Lack of trained staff is a contraindication to the use of epidural analgesia, as it may
place patients at risk.
See Chapter 17, Obstetrics by Ten Teachers, 18th edition.
49 True: a, c, e. Any cause of antepartum haemorrhage may cause bleeding in the first stage of labour, including a late presenting placenta praevia or an intrapartum abruption. To these must be added conditions usually occurring in the first stage of labour. Vaginal trauma usually occurs in the second stage of labour with
delivery of the fetal head.
See Chapter 17, Obstetrics by Ten Teachers, 18th edition.
50 True: a, b, d, e. The major disadvantage that it carries is a more than six-fold risk of it extending to involve
the anal sphincter.
See Chapter 18, Obstetrics by Ten Teachers, 18th edition.
51 True: b, c, e. Kjelland’s forceps have a cephalic curvature but no pelvic curvature. The sliding lock is used to
correct asynclitsim. They should not be applied to a high head: one that is more than one-fifth palpable
abdominally. The minimum analgesia requirement for delivery by Kjelland’s forceps is an effective epidural
or a spinal block. Kjelland’s forceps should only be used by an experienced operator.
See Chapter 18, Obstetrics by Ten Teachers, 18th edition.
52 True: a, b, d, e. The maternal indication for assisted vaginal delivery are maternal exhaustion, maternal illness,
where the Valsalva manoeuvre is contraindicated, and failure to descend owing to soft tissue resistance. Fetal
indications include any condition that makes it unsafe for the fetus to remain in the uterus during second
stage and a non-reassuring heart rate tracing. The prerequisites for instrumental delivery are adequate analgesia, empty bladder, cervix fully dilated, defined position and station, cephalic presentation and adequate
uterus contraction.
See Chapter 18, Obstetrics by Ten Teachers, 18th edition.
53 True: a, b, An episiotomy should not be performed too early as heavy bleeding may occur but, once the fetal
trunk is delivered, it is difficult to perform. Lovesett’s manoeuvre is used to bring down extended arms.
Mauriceau–Smellie–Veit’s manoeuvre is used to deliver the aftercoming head of the breech in a controlledMCQ answers 31
manner; if this manoeuvre proves difficult, then obstetric forceps need to be applied to aid delivery of the
fetal head.
See Chapter 18, Obstetrics by Ten Teachers, 18th edition.
54 True: a, c, e. Overall, the risks of both early and long-term complications are increased in women delivered
by Caesarean section. The main problems are thromboembolism, infection and haemorrhage. Amniotic
fluid embolism usually occurs during or immediately after labour and is no more common after Caesarean
section. Secondary postpartum haemorrhage is usually due to retained products and is less common after
section. Between 10 and 15 per cent of women will suffer with some form of depression in the first year after
delivery of their baby and it is more common in women who have undergone a Caesarean section.
See Chapter 18, Obstetrics by Ten Teachers, 18th edition.
55 All are true. Difficulty with delivery of the fetal shoulder is termed shoulder dystocia. The incidence varies
from between 0.2 to 1.2 per cent depending on the definition used. Risk factors for shoulder dystocia include
large baby, small mother, maternal obesity, postmaturity and assisted vaginal delivery. Shoulder dystocia
should be managed in a sequence of manoeuvres designed to facilitate delivery without fetal damage. The
first of these manoeuvres is McRobert’s manoeuvre (maximal flex and abduction of the patient’s hips onto
her abdomen) and this will effect safe delivery in approximately 90 per cent of cases. Fundal pressure should
be avoided, as it may lead to rupture of the uterus. Inappropriate traction on the fetal head causing lateral
flexion should be avoided, as this can result in nerve damage and Erd’s palsy.
See Chapter 19, Obstetrics by Ten Teachers, 18th edition.
56 True: b, c. Human milk has a low iron concentration; however, the iron is absorbed more efficiently from
human than from formula milks.
See Chapter 20, Obstetrics by Ten Teachers, 18th edition.
57 True: a, b, d.
58 True: b, c, e. Two-thirds of babies develop jaundice in the first week of life. Any visible jaundice in the first
24 hours must be urgently investigated and assumed to be haemolysis until proven otherwise. Sickle cell and
beta-thalassaemia are not associated with neonatal jaundice.
See Chapter 22, Obstetrics by Ten Teachers, 18th edition.
59 True: a, b, c, d. All these conditions stress the fetus and promote surfactant production. Surfactant production is inhibited in diabetes.
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