Which of the following is/are correct concerning diabetes and pregnancy?

• a)
  

  Diabetes mellitus is the commonest pre-existing medical condition of pregnancy

  
  
• b)
  

  Outcomes are equally poor in type 1 diabetes and type 2 diabetes

  
  
• c)
  

  Fewer than 50% of women plan their pregnancy

  
  
• d)
  

  Pregnancy planning is greater in type 2 than type 1 diabetes

  
  
• e)
  

  Optimal glycaemic control during conception and the first trimester can reduce rates of fetal major congenital anomalies in women with pre-gestational diabetes

In the management of pregnant women with type 1 diabetes which of the following is/are true?

• a)
  

  Postprandial glucose self monitoring is recommended

  
  
• b)
  

  Microalbuminuria is associated with an increased risk of pre-eclampsia

  
  
• c)
  

  Hypoglycaemia is the major cause of maternal death

  
  
• d)
  

  Steroid therapy for lung maturation may require 50% increments in insulin dosage

  
  
• e)
  

  Umbilical artery ultrasound has been shown to be a better predictor of fetal outcomes in women with diabetes compared with cardiotocography or biophysical profile

In gestational diabetes mellitus, which of the following is/are true?

• a)
  

  GDM and maternal obesity both independently increase the risk of LGA

  
  
• b)
  

  50% of GDM women can be managed by diet alone

  
  
• c)
  

  Accelerated fetal growth is an indication for insulin therapy

  
  
• d)
  

  Testing of fasting plasma glucose is sufficient as an indication of postpartum glucose tolerance

  
  
• e)
  

  Two thirds of obese GDM women may subsequently develop type 2 diabetes

Pregnancy morbidity and the presence of aPL are the features of the obstetric APS. Which of the following signs and symptoms in a woman with aPL distinguish the obstetric APS from other pregnancy pathologies?

• a)
  

  Two recurrent abortions < week 10 of gestation

  
  
• b)
  

  Hypertension in pregnancy

  
  
• c)
  

  Early onset preeclampsia

  
  
• d)
  

  Late onset preeclampsia

  
  
• e)
  

  Placenta pathology with extensive infarction, necrosis and thrombosis

Rheumatic diseases differ in regard to prominent symptoms, the extent of organ manifestations and autoantibody production. Which of the following is/are observed in RA during pregnancy?

• a)
  

  Seronegative RA improves spontaneously in the majority during pregnancy

  
  
• b)
  

  The presence of rheumatoid factor (RF) is a predictor for improvement during pregnancy

  
  
• c)
  

  The presence of citrullinated proteins (ACPA) is a predictor for improvement during pregnancy

  
  
• d)
  

  Miscarriage, prematurity and small for gestational age infants frequently occur in RA

  
  
• e)
  

  A congenital heart block does not develop in children of women with RA

Which of the following is/are observed in ankylosing spondylitis (AS) during pregnancy?

• a)
  

  AS improves spontaneously in the majority during pregnancy

  
  
• b)
  

  Miscarriage, prematurity and small for gestational age infants frequently occur in AS

  
  
• c)
  

  Disease severity alters the outcome for women with AS

  
  
• d)
  

  Frequent necessity to deliver by Cesarean section due to ankylosis of the sacroiliac joints being a mechanical hindrance for the progression of parturition

  
  
• e)
  

  A congenital heart block does not develop in children of women with AS

Which of the following is/are true regarding von Willebrand Disease (vWD) in pregnancy?

• a)
  

  vWD is the most common congenital bleeding disorder encountered in pregnancy

  
  
• b)
  

  vWF levels are reliable in excluding vWD during the third trimester

  
  
• c)
  

  vWF levels drop to pre-pregnancy levels during the post-partum period and can cause delayed postpartum bleeding in vWD patients

  
  
• d)
  

  DDAVP is safe in pregnancy and will often briefly normalise vWF levels in pregnant women with vWD

  
  
• e)
  

  In DDAVP non-responders Humate-P can be used to normalise vWF levels

A young woman with Factor V Leiden and a prior history of mild pre-eclampsia resulting in birth of small for gestational age child presents for pre-pregnancy counselling. She has no prior personal history of venous thromboembolism. Which of the following should be recommended?

• a)
  

  An oral anticoagulant in the antepartum and postpartum periods

  
  
• b)
  

  Low-molecular-weight heparin in the antepartum and postpartum periods

  
  
• c)
  

  Low-molecular-weight heparin postpartum, at least while in hospital

  
  
• d)
  

  Low-molecular-weight heparin postpartum for 6 months

  
  
• e)
  

  No antepartum or postpartum anticoagulants

A 29 year old woman presents at 36 weeks gestation with shortness of breath without a clear alternative diagnosis on history or examination. She is short of breath while climbing half a flight of stairs. She has left leg oedema more than right leg oedema. Your next step in diagnostic management would be which of the following?

• a)
  

  Apply the Wells clinical model for pulmonary embolism

  
  
• b)
  

  D-dimer test

  
  
• c)
  

  Bilateral leg ultrasound imaging

  
  
• d)
  

  CT scan of the chest

  
  
• e)
  

  V/Q scan

Which of the following therapies are generally considered to be safe in pregnancy?

• a)
  

  Cyclophosphamide

  
  
• b)
  

  Interferon-alpha

  
  
• c)
  

  Imatinib

  
  
• d)
  

  Bortezomib

  
  
• e)
  

  Lenolidomide

Which of the following diseases and conditions should be included in chronic kidney disease (CKD):

• a)
  

  Congenital single kidney

  
  
• b)
  

  IgA nephropathy with proteinuria <0.3 g/day

  
  
• c)
  

  e-GFR 65 mL/min before pregnancy

  
  
• d)
  

  Multiple kidney cysts

  
  
• e)
  

  Previous episodes of acute pyelonephritis with small scars

The following statement(s) is/are true about pregnancy on dialysis:

• a)
  

  Pregnancy on dialysis has a less than 50% success rate over 12 gestational weeks

  
  
• b)
  

  Pregnancy on dialysis is possible both on peritoneal dialysis and on haemodialysis

  
  
• c)
  

  The hours of dialysis correlate with the outcome

  
  
• d)
  

  The odds of a successful pregnancy are reduced by about 100 fold with respect to the overall population

  
  
• e)
  

  An increase in fetal malformations is seen

In the presence of proteinuria and hypertension after the 20 ^th gestational week, with unknown previous history:

• a)
  

  The differential diagnosis between PET and CKD is always possible if pre-pregnancy data are available

  
  
• b)
  

  Severely impaired utero-placental flows and fetal growth suggest CKD

  
  
• c)
  

  Haematuria is a hallmark of CKD

  
  
• d)
  

  Normal s-Flt1/PlGF ratio suggests CKD

  
  
• e)
  

  Proteinuria above 6 g/day suggests CKD

A woman who is 36 weeks pregnant presents with a 3 hour history of chest and back discomfort requiring intravenous opiates. The ECG shows sinus tachycardia. What urgent investigation should be performed?

• a)
  

  V / Q scan

  
  
• b)
  

  Doppler ultrasound of the legs

  
  
• c)
  

  CT scan of the aorta

  
  
• d)
  

  MRI scan of the aorta

  
  
• e)
  

  Coronary angiogram

For women with mechanical prosthetic heart valves who are considering pregnancy, the following anticoagulation regime(s) is/are considered appropriate:

• a)
  

  Warfarin should be continued during pregnancy but at a dose ≤5mg to minimise the risk of fetal bleeding

  
  
• b)
  

  Warfarin should be continued at therapeutic dose until 36weeks when this should be switched to LMWH

  
  
• c)
  

  Adjusted dose twice daily LMWH throughout pregnancy

  
  
• d)
  

  Intravenous heparin throughout pregnancy

  
  
• e)
  

  Adjusted dose LMWH for the first trimester followed by therapeutic dose warfarin until 36 weeks, then back to LMWH

Which of the following drugs should be discontinued during pregnancy?

• a)
  

  Low dose Aspirin

  
  
• b)
  

  Bisoprolol

  
  
• c)
  

  Atenolol

  
  
• d)
  

  Angiotensin Converting Enzyme Inhibitors (ACEI)

  
  
• e)
  

  Furosemide

Acute fatty liver disease is typically associated with:

• a)
  

  Raised serum bile acids

  
  
• b)
  

  Intense pruritis

  
  
• c)
  

  Raised creatinine

  
  
• d)
  

  Obligate heterozygosity for disorders of long chain fatty acid oxidation

  
  
• e)
  

  Multiple pregnancy

With regards to viral hepatitis:

• a)
  

  Hepatitis C is a blood borne infection

  
  
• b)
  

  The clinical course of hepatitis E is the same in pregnant women as in non-pregnant individuals

  
  
• c)
  

  Hepatitis B is an indication for delivery by elective caesarean section

  
  
• d)
  

  There is no contraindication to breast-feeding in women with hepatitis C

  
  
• e)
  

  It is safe to vaccinate pregnant women against hepatitis B after the first trimester

With regards to the management of liver disease in pregnancy:

• a)
  

  Immunosuppressant treatment with azathioprine should be continued in pregnant women with autoimmune hepatitis

  
  
• b)
  

  In women with hepatitis C infection it is recommended to commence treatment with interferon and ribavirin

  
  
• c)
  

  In women with Wilson’s disease, treatment with penicillamine should be continued in pregnancy

  
  
• d)
  

  Endoscopy and ligation banding of oesophageal varices is contraindicated in pregnancy

  
  
• e)
  

  In women with liver transplants, pregnancy outcomes are improved if conception is delayed by at least one year following surgery

A woman presents to clinic with a blood pressure of 165/112mmHg (confirmed by repeat measurement after at least 15 minutes), at 28 weeks’ gestation. Which of the following management approaches is true/false?

• a)
  

  This woman can be seen in hospital the next day.

  
  
• b)
  

  This woman should receive antihypertensive therapy.

  
  
• c)
  

  This woman may have pre-eclampsia even if she has no proteinuria.

  
  
• d)
  

  This woman may have pre-eclampsia even if she has no symptoms.

  
  
• e)
  

  Magnesium sulphate may be used as an antihypertensive.

In women receiving magnesium sulphate for eclampsia prevention or treatment, which of the following statements is true or false?

• a)
  

  These women have a high risk of respiratory depression (>10%).

  
  
• b)
  

  These women should have their dosage reduced to lower the risk of maternal side effects.

  
  
• c)
  

  These women may develop magnesium toxicity after only a loading dose.

  
  
• d)
  

  These women rarely require calcium gluconate administration.

  
  
• e)
  

  These women should first receive a benzodiazepine (such as diazepam) at the time of a seizure.

A pregnant woman who was previously normotensive, presents to clinic feeling well with a BP of 148/95mmHg at 32 weeks’ gestation. Indicate whether her care provider should pursue each of the following actions.

• a)
  

  Administration of an antihypertensive agent can be considered.

  
  
• b)
  

  Captopril is an appropriate choice of antihypertensive agent for this woman.

  
  
• c)
  

  Captopril is acceptable for use after delivery and during breastfeeding

  
  
• d)
  

  The target blood pressure for this woman should be <130/80mmHg.

  
  
• e)
  

  Antihypertensive therapy will not lower the risk of progression to PET.

During the postnatal care of women who have had pre-eclampsia or another hypertensive disorder of pregnancy, which of the following statements is true or false?

• a)
  

  The highest postpartum blood pressure is immediately after delivery.

  
  
• b)
  

  Women should not breastfeed if they take antihypertensive therapy.

  
  
• c)
  

  Pre-eclampsia may develop postpartum in women who had uneventful pregnancies.

  
  
• d)
  

  These women are at increased risk of hypertension in the future.

  
  
• e)
  

  These women are at increased risk of cardiovascular disease in the future.

The following statement(s) is/are true about skin manifestations in pregnancy:

• a)
  

  Hormonal changes are the only cause of such manifestations

  
  
• b)
  

  Pruritus is a constant symptom when skin changes develop

  
  
• c)
  

  Cutaneous lesions can develop any time during pregnancy

  
  
• d)
  

  Blood tests and skin biopsy are always recommended in order to rule out severe diseases

  
  
• e)
  

  The earlier we treat, the better the outcome is

The following statement(s) is/are true about physiological skin changes during pregnancy:

• a)
  

  They are always reversible

  
  
• b)
  

  They do not affect pregnancy outcome

  
  
• c)
  

  Breast areolas are the most commonly affected site by hyperpigmentation

  
  
• d)
  

  Presence of spider telangiectasias should lead to liver status check up

  
  
• e)
  

  Tretinoin cream is a very effective treatment of striae distensae

A 27-year-old woman presents with a 5-day history of pruritic skin eruption in the second trimester of her first pregnancy. Her medical history was unremarkable. Physical examination revealed erythematous papules and plaques on the abdomen with newer similar lesions on the thighs. Which of the following features is/are true regarding this?

• a)
  

  Involvement of peri-umbilical area confirms the diagnosis of bullous pemphigoid even if the patient is not multiparous

  
  
• b)
  

  Involvement of areas with striae distensae is suggestive of polymorphic eruption of pregnancy even if the eruption onset is in the second trimester

  
  
• c)
  

  A skin biopsy with direct immunofluorescence is recommended in order to rule out pemphigoid gestationis

  
  
• d)
  

  Presence of pruritus in this patient is mostly suggestive of intrahepatic cholestasis

  
  
• e)
  

  When there is pruritus, bile salts levels should be tested systematically

Regarding the same patient in the previous question; direct immunofluorescence is negative. Treatment options could include which of the following?

• a)
  

  Topical steroids

  
  
• b)
  

  Topical emollients

  
  
• c)
  

  Systemic steroids

  
  
• d)
  

  Antihistamines

  
  
• e)
  

  UVB phototherapy

The following statements regarding phenylketonuria (PKU) is/are true:

• a)
  

  High maternal tyrosine levels cross the placenta and lead to the maternal PKU syndrome in babies born to mothers with PKU.

  
  
• b)
  

  Treatment is with a high protein, low carbohydrate diet.

  
  
• c)
  

  The maternal PKU syndrome consists of intrauterine growth retardation, developmental delay, congenital cardiac disease and dysmorphic features.

  
  
• d)
  

  Risk of the maternal PKU syndrome is approximately 20% in women with average phenylalanine levels of 1200 umol/L throughout pregnancy.

  
  
• e)
  

  Maternal protein intake usually needs to be decreased in the second and third trimesters to maintain good metabolic control.

The following statement(s) is/are true further regarding metabolic disorders:

• a)
  

  Compared to the second and third trimesters of pregnancy the post-partum period is recognized to be a lower risk for metabolic decompensation in women with disorders of protein / energy metabolism.

  
  
• b)
  

  Post-partum decompensation of cardiomyopathy in women with GSD III is recognized.

  
  
• c)
  

  Babies born to mothers with PKU should be commenced on a low protein diet in the newborn period.

  
  
• d)
  

  Women with galactosemia need baseline assessments and monitoring for ovarian insufficiency from age 16-18 years.

  
  
• e)
  

  Pregnancy is a risk factor for thrombosis in women with homocystinuria.

Which antidepressant medication(s) may be associated with an increased rate of congenital cardiovascular malformations?

• a)
  

  Fluoxetine

  
  
• b)
  

  Sertraline

  
  
• c)
  

  Paroxetine

  
  
• d)
  

  Citalopram

  
  
• e)
  

  Escitalopram