Which of the following statement(s) is/are true regarding the clinical implications of altered maternal physiology during pregnancy?

• a)
  

  A pregnant woman lying flat on her back has a higher cardiac output.

  
  
• b)
  

  In blood volume depletion during massive obstetric hemorrhage, hypotension occurs early before the pulse rises.

  
  
• c)
  

  The peak expiratory flow rate is a reliable measure of asthma control in a pregnant woman as it is not altered by pregnancy.

  
  
• d)
  

  Pregnant women with pre-existing diabetes require higher doses of insulin.

  
  
• e)
  

  Venous thromboembolism is more common because of increased protein-S activity and decreased protein-C resistance.

The following statement(s) is/are true regarding the physiological adaptations to pregnancy?

• a)
  

  The increase in maternal heart rate contributes to an increase in cardiac output during pregnancy.

  
  
• b)
  

  Mean arterial blood pressure falls because of a fall in systemic vascular resistance.

  
  
• c)
  

  Anatomical and physiological changes in the lungs allow a pregnant woman to withstand hypoxia better than a non-pregnant woman.

  
  
• d)
  

  The lower bicarbonate levels in pregnant women reflect a state of metabolic acidosis.

  
  
• e)
  

  TSH (thyrotropin) levels fall in the first trimester but returns slowly to normal by term.

With regards to the outcome of critical illness in the obstetric population which of the following is/are true?

• a)
  

  In the UK, for every maternal death, approximately 20 near miss events or Severe Acute Maternal Morbidity occur.

  
  
• b)
  

  A patient requiring intravenous antihypertensive treatment requires Level 1 care.

  
  
• c)
  

  In under-resourced countries, the maternal mortality rate can exceed 500 per 100,000 live births.

  
  
• d)
  

  Perinatal mortality associated with maternal critical illness occurs in approximately one in five cases.

  
  
• e)
  

  Approximately 20% of obstetric admissions to critical care are for less than 24 hours.

Regarding liver function tests (LFTs) in pregnancy and HELLP syndrome, the following is/are true?

• a)
  

  Diagnosis of HELLP Syndrome requires presence of all 3 lab criteria-haemolysis, raised transaminases and thrombocytopenia.

  
  
• b)
  

  Delivery is the only definitive therapy for HELLP Syndrome.

  
  
• c)
  

  Hypertension and proteinuria are present in 85%of the cases.

  
  
• d)
  

  The risk of recurrence of pre-eclampsia in future pregnancies is 25–50%.

  
  
• e)
  

  Abnormal liver function tests occur in 3–5% of all pregnancies.

Regarding Inflammatory bowel disease in pregnancy; which of the following drugs is/are considered safe for use in pregnancy?

• a)
  

  Sulfasalazine

  
  
• b)
  

  Azathioprine

  
  
• c)
  

  Cyclosporin

  
  
• d)
  

  Infliximab

  
  
• e)
  

  Corticosteroids

The following is/are true regarding pre-eclampsia:

• a)
  

  1 in 20 (5%) stillbirths in infants without congenital abnormality occur in women with pre-eclampsia

  
  
• b)
  

  20-25% of preterm births are due to pre-eclampsia

  
  
• c)
  

  Low molecular weight heparin is used to prevent hypertensive disorders during pregnancy

  
  
• d)
  

  Supplementation with the antioxidant vitamin C prevents hypertensive disorders during pregnancy

  
  
• e)
  

  Supplementation with the antioxidant vitamin E prevents hypertensive disorders during pregnancy

The following is/are true regarding obstetric cholestasis (OC):

• a)
  

  Women who have had OC should be advised to avoid oral contraceptive containing oestrogen.

  
  
• b)
  

  Pruritus in the third trimester should prompt a request for liver function tests.

  
  
• c)
  

  Pregnancy specific reference ranges for LFTs should be used to diagnose OC.

  
  
• d)
  

  The risk of recurrence in future pregnancies is at least 50%.

  
  
• e)
  

  UDCA is not licensed for use in pregnancy although there is no evidence of adverse effects in the fetus.

Factors affecting the incidence of admission for obstetric intensive care include:

• a)
  

  Availability of a high dependency unit

  
  
• b)
  

  Workload of a unit

  
  
• c)
  

  The number of anaesthetists involved in intensive care

  
  
• d)
  

  Level of the obstetric unit

  
  
• e)
  

  Presence of multi-organ dysfunction

The following is/are recognised as limitations of maternal mortality data as a tool for quality assurance in high resource countries:

• a)
  

  Difficulty in case identification

  
  
• b)
  

  Difficulty in getting to know the truth about what happened

  
  
• c)
  

  The cases may not be generalisable

  
  
• d)
  

  Cases are few and far between and may not generate quality data

  
  
• e)
  

  It has been described as one of the worst-performing indicators

The following is/are true regarding Severe acute maternal morbidity (SAMM) in the developed world:

• a)
  

  The Peripartum hysterectomy rate is 0.5%

  
  
• b)
  

  SAMM is encountered in 2% of all maternities

  
  
• c)
  

  The obstetric intensive care admission rate is below 5%

  
  
• d)
  

  The commonest reason for admission to obstetric intensive care in the antenatal period is hypertensive disease

  
  
• e)
  

  SAMM data are of limited value in the presence of a robust risk management mechanism

Regarding the epidemiology of SAMM the following is/are true:

• a)
  

  Cardio-vascular system failure is the commonest organ system dysfunction morbidity in SAMM

  
  
• b)
  

  Sepsis is more common in developed countries than developing countries

  
  
• c)
  

  Internal iliac artery ligation is reported more often than peri-partum hysterectomy for postpartum hemorrhage in the literature

  
  
• d)
  

  Data from maternal mortality alone is strong enough to make conclusions on ways of reducing maternal deaths

  
  
• e)
  

  It is relatively easier to define SAMM according to the disease and organ system dysfunction than by other methods

Which of the following is/are true regarding heart failure in the peri-partum phase?

• a)
  

  A woman must show at least three of the following symptoms: dyspnoea on exertion; cough; orthopnea and paroxysmal nocturnal dyspnoea; abdominal discomfort; pleuritic chest pain; palpitations.

  
  
• b)
  

  An abnormal electrograph (ECG) is always present in peripartum heart failure.

  
  
• c)
  

  An echocardiogram is necessary to confirm or exclude peripartum heart failure.

  
  
• d)
  

  A cardiac MRI is necessary to confirm or exclude peripartum heart failure.

  
  
• e)
  

  The diagnosis is more easily missed in the peripartum period compared to the non-pregnant population.

Which of the following is/are true about treatment of heart failure in the antenatal phase?

• a)
  

  No treatment is recommended because of the risk to the fetus.

  
  
• b)
  

  Most heart failure drugs are not licensed for use in pregnancy.

  
  
• c)
  

  Guidelines for treatment should exist in units looking after these women.

  
  
• d)
  

  An interdisciplinary approach to treatment is recommended.

  
  
• e)
  

  Immediate delivery is always necessary to allow optimal treatment of the mother.

Which of the following is/are true regarding peripartum cardiomyopathy (PPCM)?

• a)
  

  Peripartum cardiomyopathy (PPCM) is the major cause of pregnancy-induced heart failure

  
  
• b)
  

  The incidence of PPCM is well defined in Europe and the USA

  
  
• c)
  

  Pro-inflammatory processes are considered likely as the underlying mechanism of PPCM

  
  
• d)
  

  Recent research appears to refute angiogenic imbalance as a likely cause of PPCM

  
  
• e)
  

  Women with a positive family history of cardiomyopathy typically have a more severe course of disease

The following is/are true regarding aortic dissection in pregnancy?

• a)
  

  In women under the age of forty 20% of type A aortic dissection occurs in the obstetric population

  
  
• b)
  

  Maternal mortality is around 80%

  
  
• c)
  

  The underlying vascular pathology consists of degeneration of collagen and elastin of the aortic wall causing intima necrosis

  
  
• d)
  

  Marfan syndrome represents the leading single underlying connective tissue disorder of pregnancy related aortic dissection

  
  
• e)
  

  Hypertension has been observed in up to 90% either as the single underlying disease or in combination with a predisposing disorder

Women during pregnancy and the postpartum period are at increased risk of cerebral venous thrombosis (CVT). Diagnosis of CVT can be proven by which of the following diagnostic test(s)

• a)
  

  D- Dimer level.

  
  
• b)
  

  Transcranial Doppler sonography.

  
  
• c)
  

  A careful history and examination by a neurologist.

  
  
• d)
  

  Magnetic resonance imaging venography.

  
  
• e)
  

  CT of the head with contrast.

Women of childbearing age with known epilepsy who wish to conceive should receive preconception advice from a neurologist. Which of the following would be considered good advice?

• a)
  

  To take the pre-dose serum level of antiepileptic drugs (AEDs) as a baseline for monitoring changes of serum- concentration through pregnancy

  
  
• b)
  

  Considering changing AED regimens to monotherapy and titrate the daily dose to the lowest effective dose

  
  
• c)
  

  The risk of teratogenesis is highest if taking sodium valproate

  
  
• d)
  

  Discontinue all AEDs as they have been shown to be teratogenic

  
  
• e)
  

  Take 5 mg folic acid daily.

With regards to the pathology of sickle cell disease (SCD), which of the following statements is/are true?

• a)
  

  HbS is caused by a single point mutation on the α globin chain gene

  
  
• b)
  

  Patients with homozygous HbSS will not produce any HbA

  
  
• c)
  

  Homozygous HbSS SCD is usually the most clinically severe of the sickling disorders

  
  
• d)
  

  Patients with SCD are usually anaemic with a reduced reticulocyte count and lactate dehydrogenase

  
  
• e)
  

  Patients with SCD should invariably be on iron supplementation during pregnancy

With regards to the management of SCD in pregnancy which of the following statements is/are true?

• a)
  

  All patients with a history of painful crises should be offered regular transfusion during pregnancy as soon as pregnancy is confirmed

  
  
• b)
  

  Aspirin is thought to be beneficial in patients with SCD when pregnant to reduce the increased risk of pre-eclampsia

  
  
• c)
  

  Parenteral morphine should be avoided in the management of painful crises during pregnancy

  
  
• d)
  

  Babies born to women affected with SCD are usually found to be large for dates during the 3rd trimester of pregnancy

  
  
• e)
  

  Vaginal delivery is an acceptable mode of delivery in patients with SCD

A 35 year old primigravida presents in her 1st trimester. She is known to have a history of essential thrombocythemia with no history of venous or arterial thrombosis. She has been treated with aspirin for her disease. Her current platelet count is 700 × 10 ⁹ /L. Which of the following would be appropriate in her management?

• a)
  

  Start warfarin and continue aspirin, titrate INR between 2.0 to 3.0. Continue aspirin and warfarin until 6 weeks post-delivery.

  
  
• b)
  

  Start hydroxycarbamide and stop aspirin.

  
  
• c)
  

  Continue aspirin. Start low molecular weight heparin at prophylactic dose post-delivery; continue until 6 weeks post-partum.

  
  
• d)
  

  She should continue aspirin and be managed as any normal pregnancy as she has no previous thrombotic history.

  
  
• e)
  

  Start interferon-alpha in view of the high platelet count and the risk of increased thrombosis in pregnancy.

With regards to the management of severe pre-eclampsia, which of the following is/are true?

• a)
  

  The use of prophylactic magnesium sulphate should be used to prevent eclampsia

  
  
• b)
  

  Definitive treatment includes delivery of the fetus

  
  
• c)
  

  Aggressive intravenous hydration is crucial to maintain renal perfusion and prevent acute kidney injury

  
  
• d)
  

  A blood pressure target of 140 mHg (systolic) and 90 mmHg (diastolic) is reasonable

  
  
• e)
  

  When systolic blood pressure is extremely high, rapid control of blood pressure (aiming for a target blood pressure within 30 minutes) is necessary to prevent cerebral haemorrhage

With regards to risk factors for puerperal sepsis, which of the following is/are true?

• a)
  

  The single most important risk factor for postpartum infection is PROM

  
  
• b)
  

  The use of prophylactic antibiotics in preventing puerperal sepsis following PROM is well established

  
  
• c)
  

  Maternal sepsis is commonly associated with gram negative infections, reflecting colonization of the uro-genital tract

  
  
• d)
  

  In severe cases of puerperal pyrexia, Group B beta-haemolytic streptococcus should be suspected as the most likely pathogen

  
  
• e)
  

  Repeated vaginal examinations predispose to maternal infection

Regarding the diagnosis of puerperal sepsis, which of the following is/are true?

• a)
  

  Haemodynamic variables as outlined by the surviving sepsis campaign should be applied to all cases of suspected puerperal sepsis

  
  
• b)
  

  Sepsis, as defined by the international Surviving Sepsis Campaign, is the presence of infection (either suspected or proven) along with features of systemic inflammation

  
  
• c)
  

  Serum lactate should be measured, as an elevated level in pregnancy is of clinical significance

  
  
• d)
  

  Source control is definitive management and should always be considered early

  
  
• e)
  

  A central venous saturation (ScvO ₂ ) below 70–75% suggests ongoing tissue hypo-perfusion

A 32 year-old pregnant woman presents with progressive breathlessness and altered mental state over a 3 day period. She has a history of thyrotoxicosis, for which she is compliant to her anti-thyroid therapy. She is currently taking oral carbimazole 10 mg daily. She has no symptoms of upper respiratory tract infection. On examination, the temperature is 38.5C. The blood pressure is 110/60 mmHg and heart rate 125 per minute. The thyroid is generally enlarged with a bruit. There are bi-basal crepitations. There is no clinically significant murmur over the praecordium. There is a gravid uterus corresponding to 32-week of gestation in a cephalic presentation. There is pedal oedema up to mid-shin.

What is/are the most appropriate urgent management steps in her care?

• a)
  

  Urgent delivery by Caesarean section

  
  
• b)
  

  Thyroid function test and ultrasound of the thyroid

  
  
• c)
  

  Increase the Carbimazole dose to 30 mg daily

  
  
• d)
  

  Beta blockers should be administered early

  
  
• e)
  

  Hydrocortisone IV is the preferred steroid in this setting

A 34 year-old Chinese woman, is admitted for diabetic ketoacidosis at 36 weeks gestation with a relatively short history of lethargy and shortness of breath. She has no prior history of diabetes mellitus, and the oral glucose tolerance test at 28 weeks of gestation was normal. During admission, she is afebrile, blood pressure 120/60 mmHg and pulse rate 100 per minute. The systemic examination is essentially unremarkable. The random blood glucose was 21 mmol/L, positive urine ketone and serum bicarbonate of 15 mmol/L. She was started on intravenous fluids and an insulin infusion. It has been more than 72-hours on her insulin infusion, but the urine ketones remain positive.

Which of the following would be appropriate next step(s)?

• a)
  

  Increase the intravenous insulin infusion

  
  
• b)
  

  Send for serum β-hydroxybutyrate

  
  
• c)
  

  Start oral feeding where tolerable

  
  
• d)
  

  Increase intravenous normal saline

  
  
• e)
  

  Send plasma for a renal panel

A 28 year-old woman presents at 38 weeks gestation with sudden onset of headache and nausea especially over the frontal area. There is no history of photophobia, visual disturbance or hearing impairment and no limb weakness. Her past medical history includes polycystic ovarian syndrome since her teens. She was diagnosed with a macro-prolactinoma 5 years ago for which she received oral cabergoline. Cabergoline was stopped at the beginning of the pregnancy. On examination, she is in distress due to the headache. The blood pressure is 90/60 mmHg and pulse rate 120 per minute with slight neck stiffness. There are no visual signs and the rest of the neurological examination is unremarkable. Cardiac and respiratory examinations are also normal. MRI of the pituitary shows an enlarged, heterogenous sellar mass abutting the optic chiasm, with areas of high signal on T1 image. You make a diagnosis of pituitary apoplexy. Which of the following would be (an) appropriate next step(s)?

• a)
  

  Prompt fetal delivery

  
  
• b)
  

  Start oral cabergoline 0.5 mg stat

  
  
• c)
  

  Intravenous hydrocortisone 100 mg stat

  
  
• d)
  

  Urgent neurosurgical referral for hypophysectomy

  
  
• e)
  

  Intravenous mannitol to reduce brain edema

The following is/are true regarding pregnancy related sepsis?

• a)
  

  Maternal sepsis accounts <1% of maternal deaths in high-income countries

  
  
• b)
  

  Maternal sepsis accounts >10% of maternal deaths in low-income countries

  
  
• c)
  

  The mortality rate associated with maternal sepsis approaches 10% in developed countries

  
  
• d)
  

  The mortality rate associated with maternal sepsis approaches 20% in low-income countries

  
  
• e)
  

  Sepsis is now the most common cause of direct maternal death in the UK

The following is/are true regarding pregnancy related sepsis?

• a)
  

  There has been an increase in deaths related to genital tract sepsis, in keeping with an increase in the overall UK maternal mortality rate.

  
  
• b)
  

  Group A streptococcal disease has been the main contributor to maternal death from sepsis.

  
  
• c)
  

  Maternal sepsis rates have also risen similarly in the USA.

  
  
• d)
  

  Deaths due to sepsis are at least 2-fold higher in Latin America compared to developed countries.

  
  
• e)
  

  There are in excess of 1 million infection-related neonatal deaths in the developing world each year.

Regarding Group A beta-haemolytic streptococcus (GAS), the following is/are true?

• a)
  

  GAS has an attributable mortality greater than many other invasive bacteria

  
  
• b)
  

  Up to 10% of the population are carriers of GAS

  
  
• c)
  

  GAS is easily transmissable via droplet spread

  
  
• d)
  

  GAS infection generally follows a predictable clinical behaviour once diagnosed

  
  
• e)
  

  Invasive GAS is less common than other clinical manifestations of GAS

Regarding morbidity and mortality in sever pre-eclampsia, the following is/are true?

• a)
  

  Up to 90% of mothers with severe pre-eclampsia admitted to the intensive care unit develop multi-organ dysfunction

  
  
• b)
  

  HELLP syndrome occurs in up to 25%

  
  
• c)
  

  Placental abruption occurs in 10%

  
  
• d)
  

  Acute kidney injury (AKI) occurs in up to 5%

  
  
• e)
  

  Severe preeclampsia has an estimated stillbirth rate of around 20 per 1000