If a pregnant woman has a Hb of 9.5 g/dL at eight weeks of gestation the flowing is/are true:

• a)

  She carries an increased risk of delivering a low birth weight baby.

• b)

  High protein food supplements are indicated.

• c)

  Daily oral iron supplements should be commenced as soon as possible in non-malarial areas.

• d)

  Weekly oral iron supplements should be commenced as soon as possible in areas of high malarial endemicity.

• e)

  The anthelmintic mebendazole is indicated.

Iron deficiency at eight weeks gestation

• a)

  Is confirmed if the serum ferritin is 4 μg/L.

• b)

  Is excluded if the serum ferritin is 24 μg/L.

• c)

  Is excluded if the haemoglobin concentration is 11.5 g/dL.

• d)

  Is excluded if the mean corpuscular volume is 92 fl.

• e)

  Is best managed with a weekly oral supplement containing 60 mg of elemental iron.

Regarding oral iron supplements the following is/are true:

• a)

  It is ideally administered after a meal for maximum efficacy.

• b)

  It should be taken with coffee or tea, in preference to orange juice or water.

• c)

  It should not be taken concurrently with calcium.

• d)

  It should not be administered to a woman with Immune thrombocytopenia.

• e)

  It should not be administered to a woman with recurrent pyelonephritis.

If the Hb is 9.0 g/dL at 36 weeks gestation in a woman who was not anaemic at her booking visit at eight weeks,

• a)

  There is no increased risk of adverse effects in her new born.

• b)

  There is an increased risk of maternal mortality if not treated adequately.

• c)

  She should not be treated with oral iron supplements.

• d)

  She needs an urgent packed cell transfusion.

• e)

  She needs recombinant human erythropoetin if she declines consent for a packed cell transfusion.

Which of the following couples have a risk of having a baby with Sickle Cell Disease

• a)

  Mother is AS (sickle trait) and father is AS (sickle trait)

• b)

  Mother is SS (homozygous sickle cell disease) and father is AA

• c)

  Mother is AS (sickle trait) and father is AA

• d)

  Mother is AS (sickle trait) and father is AC (HbC trait)

• e)

  Mother is AS (sickle trait) and father is b thalassaemia trait

A 32 year old woman with SCD who is 28 weeks pregnant presents with an acute painful sickle crisis. Which initial treatment is appropriate?

• a)

  Fluid replacement

• b)

  Blood transfusion

• c)

  Analgesia

• d)

  Steroids

• e)

  Hydroxycarbamide

Which of the following statement(s) about pregnant women with SCD is/are true?

• a)

  Over 90% of women with SCD will experience a painful sickle cell crisis during pregnancy

• b)

  Blood for transfusion of pregnant women with SCD should be matched for full rhesus CDE status and Kell status.

• c)

  Pre-eclampsia is more common in women with SCD

• d)

  Prophylactic heparin should be given to all women with SCD throughout pregnancy

• e)

  Intra-uterine growth restriction is more common in pregnant women with SCD

The following conditions are associated with SCD:

• a)

  Pulmonary hypertension

• b)

  Proteinuria and renal dysfunction

• c)

  Retinopathy

• d)

  Leg ulcers

• e)

  Cholecystitis

A fit and well, 32-year-old primigravida is referred at 8 weeks’ gestation. At 24 years of age, she had a calf deep-vein thrombosis (DVT) and broken fibula after a skiing accident. She was not on the contraceptive pill. Her sister, who lives abroad, had a DVT in pregnancy at 36 weeks’ gestation and was found to have antithrombin deficiency. The following is/are appropriate management options:

• a)

  Reassure her that her thrombosis was provoked, not by oestrogen, but factors that no longer apply (trauma and immobilisation).

• b)

  Organise an urgent thrombophilia screen.

• c)

  Start her on standard thrombo-prophylaxis as she may also be at risk of DVT in pregnancy.

• d)

  Offer her thrombo-prophylaxis for 6 weeks postpartum as she has family history of thrombosis.

• e)

  Offer her thrombo-prophylaxis for 6 weeks postpartum as she has personal history of thrombosis.

A 38-year-old, previously fit and well pregnant woman presents to the obstetric day unit at 4 pm, at 32 weeks’ gestation with a 3-day history of shortness of breath that began suddenly. This is a twin pregnancy, with well-grown babies. She is of slight build with no additional risk factors. The following is/are appropriate management options:

• a)

  Perform a general examination and a chest X ray. As both are normal, you put it down to pregnancy with twins and advise taking it easy.

• b)

  Quickly arrange a duplex scan of both legs, before the ultrasound department closes. If no DVT is seen, it is unlikely to be a pulmonary embolism and she can go home.

• c)

  Discuss with radiology and organise a computer tomography pulmonary angiography as definitive imaging (CTPA).

• d)

  Start prophylactic low-molecular-weight heparin till the next day when definitive investigation can be performed

• e)

  Start therapeutic low-molecular-weight heparin and discuss with radiology whether a perfusion scan could be carried out in the next 24 h.

A 36-year-old multiparous woman who suffered a DVT and pulmonary embolism at 28 weeks gestation, presents to labour ward with mild contractions at 5 am. She is on therapeutic LMWH, the last dose was at 8 pm the previous evening. The current gestation is 35 weeks, and her previous deliveries were both induced for post-maturity. The cervix has effaced, but is not dilated. She tells you that if she labours she really wants an epidural. The following is/are appropriate management options:

• a)

  Check anti-Xa levels. If they are normal she can have an epidural.

• b)

  Advise her that it is fine, and she can have it after 8 am if she labours.

• c)

  Advise her that it would not be safe to insert an epidural until 24 h after the last dose, so not to inject any further and admit and observe her.

• d)

  Admit and change her to an unfractionated heparin infusion.

• e)

  Advise her to have no further heparin till after delivery to reduce the risk of bleeding

A 32-year-old woman, with a body mass index of 36 and type 2 diabetes, underwent an emergency caesarean section at full dilatation after a failed forceps attempt. The blood loss was 1500 ml, and LMWH was withheld until further assessment. Twelve hours after surgery, she collapses. The blood pressure is 50/30 mmHg, P is 130 bpm, and oxygen (O2) saturation is 88% on air. The following is/are appropriate management options:

• a)

  Assume it is a massive pulmonary embolism and send to accident and emergency for thrombolytic drugs and give them as soon as they arrive.

• b)

  Fast bleep the cardiology registrar to carry out a bedside echocardiogram.

• c)

  Conduct an arterial blood gas analysis to assess O2 partial pressure and haemoglobin.

• d)

  Exclude internal bleeding, then start a loading dose of unfractionated heparin

• e)

  Exclude internal bleeding, then start therapeutic LMWH

The risk of allo-immunisation in rhesus-D-negative women is influenced by:

• a)

  The volume of blood transfused.

• b)

  The frequency of feto–maternal transfusion.

• c)

  ABO blood-group status.

• d)

  Individual differences in response.

• e)

  Parity.

In the management of red-cell allo-immunisation the following is/are true:

• a)

  Severe fetal anaemia is uncommon with anti-D levels below 4 IU/ml.

• b)

  Antenatal administration of anti-D immunoglobulin can reduce the risk of immunisation from about 1.5–0.2%.

• c)

  The management is similar in every affected pregnancy.

• d)

  Usually a strong correlation exists between antibody levels and disease severity.

• e)

  In a second affected pregnancy, assessment for fetal anaemia should be started from about 10 weeks prior to a previously affected pregnancy.

Which of the following statement(s) is/are true concerning fetal monitoring in red-cell allo-immunisation?

• a)

  Fetal anaemia can be associated with increased blood-flow velocities in fetal arteries and veins.

• b)

  Hydrops is an important early feature in fetal anaemia.

• c)

  Doppler assessment of middle cerebral artery peak flow velocity is useful in predicting fetal anaemia reliably.

• d)

  A normal fetal heart-rate pattern on cardiotocography excludes the presence of fetal anaemia.

• e)

  Measurement of cardiac chambers (umbilical vein diameter) can predict the presence of fetal anaemia.

In non-D allo-immunisation the following statement(s) is/are true:

• a)

  Antibody levels are a good indication of disease severity.

• b)

  Most non-anti D antibodies are associated with haemolytic disease of the fetus and newborn.

• c)

  Early ultrasound assessment is recommended in cases of anti-c, anti-C and E antibodies.

• d)

  Doppler assessment of middle cerebral peak systolic velocity is unreliable in predicting anaemia in anti-K immunisation.

• e)

  Amniotic fluid bilirubin levels are usually markedly raised in anti-K immunisation

Which of the following is/are recognised obstetric complications of antiphospholipid syndrome (APS)?

• a)

  Intrauterine growth restriction

• b)

  Recurrent miscarriage

• c)

  Obstetric cholestasis

• d)

  Pre-eclampsia

• e)

  Gestational diabetes

Which are the following is/are true regarding recurrent miscarriage:

• a)

  It is defined as four or more consecutive pregnancy losses.

• b)

  It affects about 15% of the general population.

• c)

  It is associated with poorly controlled diabetes.

• d)

  It has an unknown cause (idiopathic) in 60% of cases.

• e)

  It should include a thrombophilia screen as part of first-line investigation.

In the following scenarios, when is heparin an appropriate therapeutic intervention?

• a)

  After eight consecutive miscarriages, patient A has recurrent miscarriage screening, and blood tests all return as normal. She enquires about what medication to use in a subsequent pregnancy.

• b)

  Patient B presents to her GP with a positive pregnancy test. She has had two deep vein thromboses in the past 7 years.

• c)

  Patient C is pregnant for the first time. Her sister is positive for APS and has had aspirin and heparin treatment after four pregnancy losses.

• d)

  Patient D is diagnosed with APS and has had three miscarriages. She is now 6 weeks gestation

• e)

  Six-week duration in the postpartum for patient E who is heterozygous for Factor V Leiden.

The following statement(s) relating to the treatment of thrombophilia among women who have had recurrent miscarriages is/are true:

• a)

  Use of corticosteroids have no reported side-effects when confined to the first trimester.

• b)

  If aspirin is deemed an appropriate treatment, 300 mg is the recommended daily dose for the duration of the pregnancy.

• c)

  No cases have been documented to suggest that osteoporosis has developed in a woman as a consequence of heparin use during pregnancy.

• d)

  Low-molecular-weight heparin is more frequently used than unfractionated heparin, as administration is once daily and fewer side-effects are reported.

• e)

  Current research for the use of heparin and aspirin in pregnancy is based on high-quality, level one randomised-controlled trials.

The following statement(s) is/are true about the prenatal diagnosis of thalassaemia:

• a)

  Cardiothoracic ratio is the most sensitive ultrasound marker for fetal haemoglobin Bart’s disease in the first trimester.

• b)

  During the second trimester, middle cerebral artery peak systolic velocity (MCA PSV) is the most sensitive marker for fetal haemoglobin Bart’s disease.

• c)

  During the second trimester, cardiothoracic ratio is the most sensitive marker for fetal beta-thalassaemia major

• d)

  During the second trimester, fetal beta-thalassaemia major can be diagnosed by haemoglobin pattern using blood sampling from cordocentesis.

• e)

  The couple are screened and diagnosed to carry different thalassaemia traits by haemoglobin pattern (α–β couple), and further prenatal diagnosis is not required.

The following statement(s) is/are true about non-invasive prenatal diagnosis of thalassaemia using circulating fetal nucleic acid in maternal plasma:

• a)

  Fetal beta-thalassaemia major is unlikely if paternal inherited beta mutant is absent in maternal plasma.

• b)

  Fetal beta-thalassaemia major is unlikely if paternal inherited normal beta gene is detectable in maternal plasma.

• c)

  Fetal beta-thalassaemia major is unlikely if maternal inherited beta mutant is absent in maternal plasma.

• d)

  Fetal beta-thalassaemia major is confirmed if both the maternal and paternal inherited beta mutant is present in maternal plasma.

• e)

  If a fetus does not have beta-thalassaemia major, the maternal mutant versus wild-type alleles ratio in the maternal plasma is less than 1 as measured by digital polymerase chain reaction method.

The following statement(s) is/are true about pre-implantation genetic diagnosis (PGD) of thalassaemia:

• a)

  PGD is feasible for beta-thalassaemia only.

• b)

  One limitation of cleavage stage (blastomeres) biopsy is allele dropout.

• c)

  Mono-intracytoplasmic sperm injection is essential to avoid paternal contamination.

• d)

  One potential advantage of PGD is that it allows human leukocyte antigen matching for pre-selection of potential donor progeny for the beta-thalassaemia major sibling who requires bone marrow transplantation.

• e)

  Cleavage stage biopsy is preferred to blastocyst biopsy as the former provide more cells for examination.

The following statements are true about inherited bleeding disorders:

• a)

  Von Willebrand disease (VWD) is the most common inherited bleeding disorder.

• b)

  VWD is an X-linked genetic disorder.

• c)

  The most common type of VWD is of the severe form.

• d)

  Carriers of haemophilia may have low factor levels.

• e)

  Bleeding tendency in women with factor XI deficiency correlates well with their factor levels.

The following statement(s) is/are true about lymphomas:

• a)

  Hodgkin’s lymphoma is the second most common cause of haematological malignancy in pregnancy.

• b)

  Diffuse large B-cell lymphoma is an aggressive lymphoma, and treatment should not be delayed.

• c)

  Follicular-cell lymphoma is an aggressive form of Non-Hodgkin’s lymphoma, which should be treated with R-CHOP chemotherapy (rituximab with cyclophosphamide, doxorubicin, vincristine and prednisone).

• d)

  Rituximab is a monoclonal antibody directed against CD22 antigen on the lymphocyte membrane.

• e)

  Burkitt’s lymphoma is an aggressive form of lymphoma which requires urgent treatment.

A 27-year old woman presents at 18 weeks of pregnancy with epistaxis, bleeding gums and pancytopaenia. She is found to have a prolonged activated partial thromboplastin time, prothrombin time and very low fibrinogen. Which of the following statement is true?

• a)

  The most likely diagnosis in this woman is Hodgkin’s lymphoma.

• b)

  This presentation is considered a haematological emergency and the woman will require urgent treatment with fresh frozen plasma, platelet transfusion and cryoprecipitate.

• c)

  ABVD chemotherapy (doxorubicin, bleomycin, vinblastine, dacarbazine) is the treatment of choice.

• d)

  The most likely diagnosis is acute promyelocytic leukaemia.

• e)

  Treatment with all-trans-retinoic acid will improve the coagulopathy.

A 42-year lady who is known to suffer from essential thrombocythaemia and taking anagrelide is referred to your clinic at 6 weeks of gestation. Past medical history includes diabetes and below knee, deep-vein thrombosis 10 years previously. Which of the following is appropriate management?

• a)

  Refer to a haematologist, stop anagrelide.

• b)

  Refer to haematologist, continue on anagrelide, start low-molecular-weight heparin.

• c)

  Refer to haematologist, stop anagrelide, start hydroxycarbamide, aspirin and low-molecular-weight heparin.

• d)

  Start aspirin and low-molecular-weight heparin

• e)

  Refer to haematologist, continue on anagrelide and start aspirin.

After a vacuum-assisted vaginal delivery, a woman has lost an blood loss estimated at 2500 ml. The following statement(s) about her management is/are appropriate:

• a)

  Surgical interventions are often more effective than medical treatment for massive postpartum haemorrhage (PPH).

• b)

  For uterine balloon tamponade, the balloon should be inflated to at least 1000 ml to exert sufficient counter pressure on the endometrium to stop bleeding.

• c)

  Laparotomy and incision over the lower uterine segment is needed to apply B-Lynch uterine compression sutures.

• d)

  There is a universal significant reduction in the need for peripartum hysterectomy over the years because of various uterus-conserving surgical interventions.

• e)

  Uterine artery embolisation is more commonly used for elective rather than emergency surgery in obstetrics

Reversal of coagulopathy is critical with massive PPH. The following information about the use of blood products is appropriate:

• a)

  The British Committee for Standards in Haematology’s guidelines suggests that blood transfusion should be started once the haemoglobin falls below 10 g/dl.

• b)

  Blood transfusion for a patient can be commenced without a full blood count result.

• c)

  Increasing the ratio of fresh frozen plasma to packed red cells during acute obstetric hemorrhage helps to prevent coagulopathy.

• d)

  Recombinant factor VII is a newly licensed novel drug for the treatment of massive postpartum haemorrhage.

• e)

  Tranexamic acid should be routinely used in PPH.

The following statement(s) is/are true regarding the aetiology and resuscitation of a woman with postpartum haemorrhage.

• a)

  A shock index of greater than 0.9 is associated with a need for intensive therapy on admission.

• b)

  Clinical symptoms and signs of hypovolaemic shock often manifest early in women in the immediate postpartum period.

• c)

  A loss of 1 L of blood should be replaced with a maximum of 2 L of crystalloid to avoid fluid overload.

• d)

  Blood loss estimation is more likely to be underestimated than overestimated.

• e)

  Non-pneumatic antishock garment does not play a role in developing countries such as the UK.