and Janesh Gupta2
(1)
Fetal Medicine, Rainbow Hospitals, Hyderabad, Telangana, India
(2)
University of Birmingham Birmingham Women’s Hospital, Birmingham, UK
Options for Questions 1–4
A.
Amniocentesis
B.
Fetal blood sampling
C.
Chorionic villus sampling (CVS)
D.
Maternal Doppler study
E.
Fetal blood sampling
F.
Fetal fibronectin
G.
NT scan
H.
Cervical length by TVS
I.
Fetal ultrasound study
Instruction
Select the most appropriate investigation for the given clinical scenario (each option could be used once, more than once or not at all).
1.
Consanguineous couple, now 11 weeks pregnant. G4 P2L1 A1 with one live child with thalassaemia minor, one previous child who died of thalassaemia major and one termination of pregnancy following fetal diagnosis.
2.
Mrs. X, 34 years of age at 17 weeks’ gestation has a 1 in 16 risk of Down syndrome on the quadruple test and wants to confirm fetal karyotype.
3.
Mrs. Y, G3A2 previous two preterm births of AGA fetuses at 22–24 weeks’ gestation due to cervical incompetence. Now 11 weeks pregnant.
4.
Mrs.Z, 32 years of age, 29 weeks pregnant, has an SGA fetus with reduced amniotic fluid. She is perceiving reduced fetal movements since a day.
Options for Questions 5–8
A.
Maternal IV antibiotics
B.
Fetal antibiotic therapy
C.
Selective feticide
D.
Fetoscopic laser coagulation of placental anastomotic vessels
E.
Amniodrainage
F.
Vesicoamniotic shunt
G.
Fetal blood transfusion
H.
LASER septostomy
I.
Immediate delivery by LSCS
Instruction
Select the most appropriate treatment for the given clinical scenario (each option could be used once, more than once or not at all).
5.
Mrs. A, a primary school teacher, 27 years of age, is 34 weeks pregnant. She contracted parvovirus infection following an outbreak at her school 2 weeks back. Now the ultrasound scan shows fetal hydrops.
6.
Mrs. B has monochorionic diamniotic twins and is now 24 weeks pregnant. The fetal scan shows excessive amniotic fluid with a large fetal urinary bladder in one sac with almost no liquor and non-visualisation of fetal urinary bladder in the other with a growth discrepancy of 35 % between the twins.
7.
Mrs. C has dichorionic diamniotic twins with one anencephalic fetus and a structurally normal co-twin. She is 22 weeks pregnant, and there is polyhydramnios in the sac of the anencephalic fetus. The mother understands that anencephaly is a lethal anomaly and wants to minimise the perinatal risks for the normal co-twin.
8.
Mrs. D has a singleton fetus diagnosed with an omphalocele. Fetal karyotyping was normal and after conferring with the paediatric surgeon, she is planning for postnatal surgical correction of the abdominal wall defect. She is now 29 weeks pregnant and has developed severe polyhydramnios causing maternal respiratory discomfort.
Options for Questions 9–12
A.
Lichen sclerosus
B.
Seborrhoeic dermatitis
C.
Atopic vulvitis
D.
Lichen simplex
E.
Psoriasis
F.
Herpes simplex
G.
Behcet’s disease
H.
Hidradenitis suppurativa
I.
Paget’s disease
J.
Tinea cruris
For each of the following patients with vulval symptoms, please select the most likely diagnosis from the list. Each option may be used once, more than once or not at all.
9.
A 5-year-old girl presents with burning on micturition and vulva I scratching. On examination the vulva is noted to have a well-demarcated white area around the introitus. The overlying skin appears thin with extensive fissuring. The perianal area is not involved.
10.
A 70-year-old postmenopausal woman presents with vulval itching. On examination, she has a narrow introitus. The skin over the labia, the perineal area and the genitocrural folds is thin and dry, with white discoloration and superficial excoriations. A skin biopsy reveals atrophic epidermis with hyperkeratosis and superficial dermal hyalinisation with lymphocytic infiltrates.
11.
A 23-year-old woman presents with vulval itching. On examination there is a well-demarcated symmetrical lesion involving the labia major and minor and extending to the genitocrural folds. The lesions appear beefy red with scaling. A biopsy shows papillomatosis, parakeratosis and neutrophil exocytosis.
12.
A 34-year-old woman presents with a burning sensation in the vulval region. On examination the vulva is erythematous with marked oedema and numerous small superficial ulcerations. The inguinal lymph nodes are enlarged and tender.
Options for Questions 13–15
A.
Average
B.
Historical controlled observational study
C.
Intention to treat analysis
D.
Meta-analysis
E.
Narrative review
F.
Power calculation
G.
Randomised controlled trial
H.
Relative risk
I.
Secondary analysis
J.
Systematic review
For each of the questions below, choose the most appropriate answer from the list of options above. Each option may be used once, more than once or not at all.
13.
The sample size of a study is assessed by which calculation?
14.
Reliable evidence of clinical practice should be derived from which type of evidence?
15.
A chemotherapy trial that includes all the patients who started the trial is described as what type of analysis?
Options for Questions 16–18
A.
Combined oral contraceptive pill
B.
Copper intrauterine contraception device (IUCD)
C.
Depo-Provera
D.
GyneFix IUCD
E.
Nexplanon implant
F.
Laparoscopic sterilisation
G.
Levonelle
H.
Levonorgestrel intrauterine system
I.
Male contraception
J.
Mini-laparotomy and sterilisation
K.
Progestogen-only pill
L.
Sheath/condom
M.
Withdrawal
For each of the scenarios described below, choose the most appropriate contraceptive advice from the list of options above. Each option may be used once, more than once or not at all.
16.
A 16-year-old with Eisenmenger’s complex consults you for contraceptive advice.
17.
A 42-year-old multiparous single woman with a BMI of 35 consults you for advice regarding contraception. She had a termination 6 months ago while on the combined oral contraceptive pill.
18.
A 27-year-old nulliparous student is requesting contraception. She refuses any form of hormonal preparation.
Options for Questions 19–21
A.
Ca-125
B.
Cervical smear
C.
Computed tomography (CT) scan
D.
Diagnostic laparoscopy
E.
Endometrial outpatient biopsy
F.
Follicle-stimulating hormone (FSH), luteinising hormone (LH) and oestradiol
G.
Full blood count
H.
Inpatient hysteroscopy
I.
Magnetic resonance imaging (MRI)
J.
Outpatient hysteroscopy
K.
Routine ultrasound scan
L.
Thyroid function tests
M.
Triple swabs
N.
Urgent ultrasound
O.
Urodynamics
For each of the scenarios described below, choose the single most useful investigation from the list of options above. Each option may be used once, more than once or not at all.
19.
A 55-year-old woman presents with postmenopausal bleeding. An ultrasound scan shows a normal uterus and ovaries with an endometrial thickness of 5 mm.
20.
A 42-year-old woman presents with an irregular cycle. Her last cervical smear 1 year ago was normal and she has no menorrhagia.
21.
A 45-year-old woman with human immunodeficiency virus (HIV) infection presents to the gynaecology clinic with intermenstrual bleeding and occasional postcoital bleeding.
Options for Questions 22–23
A.
0.05 %
B.
0.5 %
C.
5 %
D.
10 %
E.
20 %
F.
35 %
G.
50 %
H.
80 %
I.
Reduces incidence of bowel and vascular trauma only
J.
Reduces incidence of vascular trauma only
K.
Reduces incidence of bowel trauma only
Lead in: for each of the questions below, choose the most appropriate answer from the list of options above. Each option may be used once, more than once or not at all.
22.
Bowel adhesions to the anterior abdominal wall are found in what percentage of patients without prior surgery?
23.
What is the advantage of open laparoscopy?
Options for Questions 24–28
Management of labour
A.
Amniotomy (artificial rupture of membranes).
B.
Caesarean section.
C.
Change maternal labour position.
D.
Commence continuous electronic fetal monitoring (CTG).
E.
Commence intermittent fetal heart rate auscultation.
F.
Episiotomy.
G.
Intravaginal prostaglandin.
H.
Intravenous antibiotics.
I.
Intravenous fluids.
J.
Instrumental (forceps or ventouse) delivery.
K.
Fetal blood sampling.
L.
Intravenous oxytocin.
M.
Repeat vaginal examination at suitable time interval.
N.
Subcutaneous terbutaline.
Instructions: for each clinical scenario listed, select the NEXT MOST appropriate clinical management. Unless stated otherwise, all scenarios refer to a 25-year-old woman who is 40 weeks pregnant and is in spontaneous-onset labour. Abbreviations: Cx = cervical dilatation; FHR = fetal heart rate.
24.
CTG variable decelerations for 20 min at Cx 4 cm. CTG normal prior to decelerations. Currently, FHR baseline is 140 bpm. Membranes intact. Uterine contractions are 3–4 every 10 min. Epidural analgesia top-up was given 20 min prior. The woman is in left lateral supine position. Maternal BP 100/60 mmHg.
25.
Progressed from Cx 5 cm to Cx 6 cm in 4 h. Membranes artificially ruptured 8 h ago. Uterine contractions are 2–3 every 10 min. The fetus has severe IUGR at 38 weeks. Continuous fetal CTG monitoring in progress; CTG is normal with normal FHR.
26.
In the second stage of labour. Active pushing for 2 h. CTG shows deep decelerations. Fetal head just visible when labia are parted at peak of maternal expulsive effort. Epidural top-up 1 h ago. Uterine contractions are 4 every 10 min.
27.
Appearance of meconium-stained liquor following amniotomy at Cx 5 cm labour. Spontaneous-onset labour. Low-risk pregnancy. Intermittent FHR monitoring prior to amniotomy showed normal FHR.
28.
Progressed from Cx 5 cm to Cx 9 cm in 4 h. Spontaneous-onset labour with intact membranes. Uterine contractions are 2–3 every 10 min. Low-risk pregnancy. Intermittent FHR monitoring shows normal FHR. No urge to push.
Options for Questions 29–33
Management of Labour
A.
Amniotomy (artificial rupture of membranes).
B.
Caesarean section.
C.
Change maternal labour position.
D.
Commence continuous electronic fetal monitoring (CTG).
E.
Commence intermittent fetal heart rate auscultation.
F.
Episiotomy.
G.
Intravaginal prostaglandin.
H.
Intravenous antibiotics.
I.
Intravenous fluids.
J.
Instrumental (forceps or ventouse) delivery.
K.
Fetal blood sampling.
L.
Intravenous oxytocin.
M.
Repeat vaginal examination at suitable time interval.
N.
Subcutaneous terbutaline.
Instructions
For each clinical scenario listed, select the NEXT MOST appropriate clinical management. Unless stated otherwise, all scenarios refer to a 25-year-old woman who is 40 weeks pregnant and is in spontaneous-onset labour. Abbreviations: Cx = cervical dilatation; FHR = fetal heart rate.
29.
CTG decelerations for 40 min then a prolonged deceleration for 4 min without recovery of the FHR. Currently, FHR is 80 bpm. CTG was normal prior to decelerations. Cx is 5 cm. Membranes ruptured 3 h prior. The woman in left lateral supine position. No epidural analgesia. No oxytocin augmentation. Contractions 2 in 10 min.
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