CME: Obstetrics (136605): self-assessment questionnaire

Felicity Coad; Charlotte Frise; Tahseen A Chowdhury

doi:10.7861/clinmed.SAQ.21.5

SAQs and answers are ONLINE for RCP fellows and collegiate members

Format

Candidates are asked to choose the best answer from the five possible answers. This best of five format is used in many medical examinations; however, the questions are not intended to be representative of those used in the MRCP(UK) Part 1 or Part 2 Written Examinations.

The answering process

Go to https://cme.rcplondon.ac.uk
Log on using your usual RCP username and password
Select the relevant CME question paper
Answer all 10 questions by selecting the best answer from the options provided
Once you have answered all the questions, click on Submit

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1. A 27-year-old woman, who was 34-weeks pregnant, was referred to ambulatory care to investigate her history of palpitations. These palpitations occurred on and off over the preceding few days. She had no chest pain or syncope but had been getting more breathless during the course of her pregnancy. She denied a temperature, focal infective symptoms, vaginal discharge or abdominal pain. Her pregnancy had been uneventful so far with reassuring fetal scans and good fetal movements. She was taking 125 μg levothyroxine for hypothyroidism, and vitamin D. Her levothyroxine dose had been increased during pregnancy. Her observations showed a heart rate (HR) of 120 beats per minute (bpm), blood pressure (BP) of 110/65 mmHg, respiratory rate (RR) of 18 breaths per minute, oxygen saturation at 100% on room air and temperature of 37.4°C. She appeared anxious. She had a gravid uterus but no other clinical findings. There was no proteinuria on urine dipstick. Electrocardiography (ECG) showed sinus tachycardia at 120 bpm.

What would you do next?

1. Beta blockers.
2. Blood tests including haemoglobin and thyroid stimulating hormone.
3. Computed tomography pulmonary angiography.
4. Reassure this is normal for pregnancy.
5. Treat for a urinary tract infection.
2. A 38-year-old woman, who was 28-weeks pregnant, presented to the hospital with palpitations. She had 2 days of severe diarrhoea and vomiting after eating a take-away. She described sudden-onset palpitations about 4 hours previously, which were on-going. She was feeling light-headed and fatigued. She reported that her baby was moving less than usual. Her past medical history included one episode of supraventricular tachycardia (SVT) years ago which spontaneously terminated. She was on no regular medications and had no allergies. Her observations showed a HR 180 bpm, BP 85/40 mmHg, RR 20 breaths per minute, oxygen saturation 99% on room air and temperature 36.5°C. She was dehydrated. An ECG showed a narrow complex tachycardia (180 bpm). A midwife from the obstetric unit was requested to come and check her baby urgently. She had 2 L of fluid resuscitation and, following this, her HR remained at 150 bpm and BP 110/80 mmHg.

What would you do next?

1. Further intravenous fluids.
2. Intravenous metoprolol.
3. Nothing until the midwife has checked the baby.
4. Urgent direct current cardioversion with anaesthetic support.
5. Vagal manoeuvres followed by intravenous adenosine if unsuccessful.
3. A 28-year-old woman was noticed to be confused and lethargic following an emergency caesarean section after a 48-hour labour and failure to progress. She was complaining of feeling very thirsty and had empty bottles of water by her bedside. On examination, she looked euvolaemic. Her HR was 85 bpm and BP was 94/67 mmHg. Her investigations were haemoglobin 103 g/L, platelet count 170 × 10⁹/L (150–400), serum sodium 118 mmol/L (137–144), serum potassium 3.9 mmol/L (3.5–4.9) and serum creatinine 54 μmol/L (60–110).

What is the most appropriate treatment?

1. 0.9 sodium chloride.
2. 2.7 sodium chloride.
3. Fluid restriction.
4. Packed red cells.
5. Tolvaptan.
4. A 32-year-old woman presented to the emergency department at 33 weeks’ gestation. She reported 24 hours of vomiting and minimal oral intake. On examination, she looked dry, tachycardic and tachypnoeic. Urinary ketones were 3+. Her arterial blood gas was pH 7.29 (7.4–7.5), partial pressure of carbon dioxide of 2.2 kPa, partial pressure of oxygen of 14.6 kPa (10–14), bicarbonate of 12 mmol/L (18–22), lactate of 0.9 mmol/L (0–1), glucose of 4.1 mmol/L (4–8) and base excess of –12 mmol/L (–2 to +2).

What is the most appropriate immediate treatment?

1. 0.9% sodium chloride.
2. 5% glucose.
3. 10% glucose.
4. Hartmann's solution.
5. Intravenous insulin.
5.Which of the following is true regarding the diagnosis of intrahepatic cholestasis of pregnancy?

1. Aspartate aminotransferase (AST) is more sensitive and specific than alanine aminotransferase (ALT).
2. Alkaline phosphatase (ALP) is a useful marker in diagnosing and monitoring liver dysfunction.
3. It typically presents with pruritus in the first trimester.
4. Presence of a rash, especially on the forearms and legs, is a marker of disease severity.
5. Serum bile acid concentrations should be measured.

6. What is the best distinguishing feature between acute fatty liver of pregnancy (AFLP) and HELLP (haemolysis, elevated liver enzymes and low platelets) syndrome?

1. Abdominal ultrasound findings of ascites and a bright liver in AFLP.
2. AFLP has a higher prevalence in women with raised body mass index (BMI).
3. Coagulopathy is more common in HELLP syndrome.
4. Hypoglycaemia, prodromal vomiting and polyuria and polydipsia are more prevalent in AFLP.
5. Transaminase and bilirubin levels are significantly higher in AFLP.
7. A 37-year-old woman was admitted to hospital with severe COVID-19 on day 9 of her illness. She was hypoxic requiring supplementary oxygen, lymphopenic (lymphocytes of 0.4 × 10⁹/L (0.7–4.6)) with raised inflammatory markers (white cell count 12.8 × 10⁹/L (4–11) and C-reactive protein 95 mg/L (<10)).

Which of the following represents the most appropriate management plan in terms of treating the maternal condition?

1. Start supplementary oxygen aiming for saturations >92%, prescribe dexamethasone and tocilizumab, and consider venous thromboembolism (VTE) prophylaxis.
2. Start supplementary oxygen aiming for saturations >92%, prescribe prednisolone and tocilizumab, and consider VTE prophylaxis.
3. Start supplementary oxygen aiming for saturations >94%, prescribe dexamethasone, tocilizumab and remdesivir, and consider VTE prophylaxis.
4. Start supplementary oxygen aiming for saturations >94%, prescribe prednisolone and remdesivir, and consider VTE prophylaxis.
5. Start supplementary oxygen aiming for saturations >94%, prescribe prednisolone and tocilizumab, and consider VTE prophylaxis.

8.Which of the following statements about the COVID-19 vaccination and pregnancy are correct?

1. All vaccines should be avoided in women planning pregnancy within the next 3 months.
2. If a woman has received the first dose of the AstraZeneca vaccine and then becomes pregnant, she should receive either the Pfizer or Moderna vaccine for the second dose.
3. The COVID-19 vaccination should not be advised in pregnancy.
4. The COVID-19 vaccination should only be advised in women who are classified as clinically vulnerable.
5. Women who are pregnant should be offered the Pfizer or Moderna vaccination where possible.
9. A 30-year-old woman presented with headache and ankle swelling at 29 weeks’ gestation. Her BP was 173/100 mmHg in the right arm and 169/101 mmHg in the left arm. Urine dipstick testing showed 2+ of protein.

What is the most appropriate management?

1. Labetalol 200 mg orally and arrange an urgent computed tomography of her chest.
2. Labetalol 200 mg orally and arrange an urgent computed tomography of her head.
3. Labetalol 200 mg orally and arrange for urgent delivery of the baby.
4. Labetalol 200 mg orally and investigate for secondary hypertension.
5. Labetalol 200 mg orally and monitor blood pressure.
10. A 36-year-old woman presented to the midwife for her first appointment at 10 weeks’ gestation. Her blood pressure was 161/90 mmHg. Urine dipstick testing showed 2+ blood and 3+ protein. She had noted ankle swelling for the past month.