DRANZCOG 2021

A 36-year-old female smoker attends to discuss contraception at eight weeks postpartum following normal vaginal delivery of her second child. She has no significant past medical history, is well, and breastfeeding. Which of the following is the LEAST appropriate choice? Select one: a. Nuvaring b. Progesterone only pill c. Etonorgestrel implant (Implanon) d. Levonorgestrel-releasing IUD (Mirena)

A (or B?) a). Contains oestrogen as well as progesterone (36, smoking, BF) https://www.fpv.org.au/for-you/contraception/other-methods/nuvaring-vaginal-ring b). B/C must be taken at very regular intervals in order to provide good contraception (93% efficacy in real-use). LARCs more reliable.

A 20-year-old woman presents with oligomenorrhoea and a BMI of 32. She is not sexually active. She is diagnosed with Polycystic Ovarian Syndrome. What is the most appropriate management of this woman? a. Recommend weight loss. b. Levonorgestrel-releasing IUD (Mirena). c. Commence a combined oral contraceptive pill. d. Cyclical progestogens.

A - Lifestyle interventions first

A 21-year-old woman with Type 1 diabetes presents for a first visit at eight weeks gestation. She is undecided about first trimester screening. As part of your counselling, you would inform her of her increased risk of a fetus with: a. congenital heart disease. b. duodenal atresia. c. cleft lip-palate. d. aneuploidy.

A? Stupid question, as: PMID: 25897357 - "PGD can affect almost any organ. However, most congenital defects associated with diabetes occur in the cardiovascular, central nervous and musculoskeletal systems" PMID: 33087319 - "prepregnancy diabetes = RF for congenital anomalies such as congenital heart disease, oral clefts, and anomalies of the central nervous system, digestive system, genitourinary system, and musculoskeletal system"

A 27-year-old woman presents with a heavy vaginal discharge. She tells you that her husband has just returned from a trip to Thailand. A first-catch urine specimen reveals Neisseria gonorrhoea by ligase chain reaction. Which is the most appropriate antimicrobial to treat this infection? a. Ciprofloxacin b. Amoxycillin plus probenecid c. Azithromycin d. Ceftriaxone

C&D For uncomplicated genital, anal, or pharyngeal infection, treat with: ceftriaxone [500 mg; i.m. in 2 mL of 1% lignocaine] and azithromycin [1g, PO, STAT] eTG http://www.sti.guidelines.org.au/sexually-transmissible-infections/gonorrhoea#management https://melbourne.healthpathways.org.au/index.htm

Postpartum haemorrhage is more likely than usual in all these situations EXCEPT: a. following an elective caesarean section for a primigravid woman at term. b. following a 12-hour labour in a 21-year-old woman G1P0, with mild pre-eclampsia. c. following a 24-hour labour in a 17-year-old primigravid woman. d. following a 4-hour labour in a 34-year-old woman G6P5.

a?

Regarding lichen sclerosus, which of the following is correct? a. It responds to potent topical corticosteroids b. It has 1% malignant potential c. It is more commonly seen in pre-menopausal women d. It is treated with wide, local excision

a - DermNetNZ - An ultrapotent topical steroid is often prescribed (eg, clobetasol propionate 0.05%). A potent topical steroid (eg, mometasone furoate 0.1% ointment) may also be used in mild disease or when symptoms are controlled. Not: b). Lifetime risk SCC estimated @ 4-6%. Increased if Dx >70yo (https://coyleinstitute.com/can-lichen-sclerosus-become-cancerous/) DermNetNZ - 5% c). DermNet NZ - onset in women is commonly postmenopausal, a relative lack of oestrogen may be significant.

The frequency of fetal infection after maternal seroconversion for cytomegalovirus in pregnancy is approximately: Select one: a. 5%. b. 80%. c. 50%. d. 20%.

c?

A 27-year-old woman G2P0 presents at 12 weeks gestation. She has a history of Graves' disease treated with radio iodine some years ago. She is currently on thyroxine replacement and is euthyroid. Which one of the following is INCORRECT? a. Screening for thyroid auto antibodies is required b. Estimation of thyroid function tests serially throughout pregnancy is required c. Her dose of thyroxine during pregnancy is likely to increase d. There are no neonatal risks if thyroid function is well maintained

?D. a & b are correct - check TSH every 6/52 and a-TSH-R Ab in the 3rd trimester) c - ? d) Presence of a-TSH-R Ab can cause fetal thyrotoxicosis, even if thyroid function is well maintained

A midwife refers a 28-year-old primigravid woman from Sudan at 22 weeks with a World Health Organisation (WHO) classification Type 3 female genital mutilation performed at the age of eight. What is the recommended management plan? Select one: a. Antenatal deinfibulation b. Elective caesarean section c. Deinfibulation in labour d. Episiotomy

?a Rationale (RANZCOG): If adequate VE is unlikely to be possible due to introital narrowing, advisable to offer antenatal deinfibulation, usually 2nd trimester but can be at any time 1st stage labour if necessary. FGM is not usually an indication for caesarean section. Not necessary to routinely perform a mediolateral episiotomy... but it will frequently be required due to increased scarring & lack of normal skin elasticity at the vaginal introitus

A woman G3P2 at 39 weeks gestation has been induced for maternal discomfort. The following is the CTG recorded six hours after her first dose of vaginal prostaglandins. Bishop's score is five. Which of the following statements about ongoing management is most appropriate? Select one: a. A further dose of vaginal prostaglandins should be given b. No further prostaglandins should be given and the CTG should be observed continuously c. No further prostaglandins should be given and the CTG repeated in two hours d. Perform an artificial rupture of membranes (ARM) and commence oxytocin infusion

?b Bishops not great Contracting 4/10? Enough uterine stimulation Late decels? - Continuous CTG

A 25-year-old woman delivers after 24 hours of labour. Two days post-partum, she has a fever (38.9 degrees C). Which of the following is the most likely cause of these findings? Select one: a. Deep vein thrombosis b. Mastitis c. Influenza d. Endometritis

?d - b/c prolonged labour

A 35-year-old woman presents at 35 weeks gestation with severe abdominal pain and moderate vaginal bleeding. Ultrasound reveals a large retroplacental clot and no fetal heartbeat is detected. The woman's pulse is 120bpm, her blood pressure is 80mmHg systolic and her Hb is 6g/dL. You advise her that a blood transfusion is required but the woman refuses to accept blood or blood products under any circumstances. What is the most appropriate approach to this problem? a. Transfuse crystalloid and colloid only b. Urgently transfuse X-matched blood c. Immediately transfuse O Rh negative blood d. Obtain an urgent order for a blood transfusion from the Guardianship Board

A

Which of the following genetic conditions is not associated with a particular ethnic group? a. Von Willebrand disease b. Cystic fibrosis c. Tay Sachs disease d. Alpha thalassaemia

A

Randomised controlled trials have shown that the use of calcium channel blockers in the management of preterm labour results in: a. a lower risk of delivery within 48 hours. b. less neonatal morbidity. c. lower perinatal mortality. d. a lower risk of preterm delivery.

A 'Canberra Hospital and Health Services Clinical Guideline: Preterm Labour' https://health.act.gov.au/sites/default/files/2020-02/Preterm%20Labour%20Guideline.docx a). "Tocolysis is associated with prolongation of pregnancy for up to seven days" b&c). "there is no clear evidence that it improves neonatal outcomes" d). "it is not associated with a significant reduction in preterm birth before 30, 32 or 37 weeks of gestation" "Women most likely to benefit from tocolytics are those who have not yet completed corticosteroid therapy, or those who require in-utero transfer, and it should be used as a temporary treatment only."

Which of the following is NOT a common side effect associated with the levonorgestrel-releasing IUD (Mirena)? a. Oedema b. Depression c. Mastalgia d. Irregular vaginal bleeding

A Bayer Healthcare Full Prescribing Info. Experience from clinical trials - Table 2, P. 16 https://labeling.bayerhealthcare.com/html/products/pi/Mirena_PI.pdf a). b). 6.4% c). 8.5% d). Unscheduled - 31.9%; Decreased - 23.4%; Increased - 11.9%; Female genital tract bleeding - 3.5%; Amenorrhoea - 18.4% https://www.fpv.org.au/ https://www.mirena-us.com/mirena-side-effects-and-safety The most common adverse reactions (≥10% users) are alterations of menstrual bleeding patterns, abdominal/pelvic pain, amenorrhea, headache/migraine, genital discharge, and vulvovaginitis

Which of the following changes in the cardiovascular and respiratory systems is abnormal in pregnancy? a. Increased pulmonary vascular markings b. Resting pulse rate of 100bpm c. Systolic murmur d. Alteration of the cardiac axis on ECG

A Circulation, Vol. 130, No. 12, 'Cardiovascular Physiology of Pregnancy', Sanghavi et al. b). "heart rate increases progressively throughout the pregnancy by 10-20 bpm, reaching a max HR in the 3rd trimester. Overall change in HR represents a 20%-25% increase over baseline" c). "mild 4-chamber dilation of the heart in pregnancy, there are changes in heart sounds. After the 1st trimester, in the majority of mothers, the first sound is louder and has an exaggerated split (resulting from early mitral closure), an ejection systolic flow murmur is detected in 90%, a 3rd heart sound is detected in 80%, and an AV diastolic flow murmur is detected in 20%. d). ECG changes in a normal pregnancy reflect the increased HR with minor L/R shifts in the QRS axis but no sig changes in ECG time intervals.

Improved rates of effective breastfeeding can be achieved by: a. helping mothers to feed within 30 minutes of giving birth. b. midwives looking after the baby overnight to allow the mother to rest. c. breastfeeding at four-hourly intervals. d. providing formula to only those babies separated from their mothers, e.g. in neonatal unit.

A P. 12 'Promoting Breastfeeding - Victorian Breastfeeding Guidelines', Victorian Gov.

A midwife refers a 28-year-old primigravid woman from Sudan at 22 weeks with a World Health Organisation (WHO) classification Type 3 female genital mutilation performed at the age of eight. What is the recommended management plan? a. Antenatal deinfibulation b. Episiotomy c. Deinfibulation in labour d. Elective caesarean section

A RANZCOG: "In women where antenatal assessment indicates that adequate vaginal examination is unlikely to be possible due to introital narrowing, it is advisable to offer antenatal deinfibulation (see below). This is most commonly performed during the second trimester but can be carried out at any time during pregnancy, or in the first stage of labour if necessary. FGM is not usually an indication for caesarean section." "It is not necessary to routinely perform a mediolateral episiotomy in women with a history of FGM, whether or not deinfibulation has been performed, but it will frequently be required due to increased scarring and lack of normal skin elasticity at the vaginal introitus"

A primigravid woman is in labour at 36 weeks gestation with an uncomplicated twin pregnancy. Epidural analgesia is effective. The first twin was delivered five minutes ago by low vacuum extraction. The second twin is in a transverse lie (the membranes are still intact). There is a sudden loss of bright blood per vaginum and the fetal heart rate drops to 60 bpm. The cervix is still fully dilated. Regarding her management: Select one: a. she should be offered an immediate caesarean section. b. tocolysis with external cephalic version should be attempted. c. internal version and a breech extraction would be advised. d. the mode of delivery would depend on whether the fetal back was facing up or down

A Rationale - Likely cord prolapse - emLUSCS

Which one of the following statements about postpartum haemorrhage is most correct? Select one: a. The most common cause is uterine hypotonia b. Postpartum haemorrhage is a rare cause of maternal morbidity c. If the use of uterotonics fail, hysterectomy is then required d. Ergometrine should never be used in those with hypertension

A a - Tone (70%), Tissue (10-20%), Trauma (10-20%), Thrombin (<1%) Re: d - Ergometrine should be avoided if >140sys, but can be used judiciously in major/severe PPH

A primigravid woman is in labour with an effective epidural at 38 weeks. Her assessments are as follows: Time 1200 & 1300, Cervical dilation 10cm, Cervical effacement fully, membranes ruptured Position 1200 = ROT, 1300 = ROA; Station 1200 = 1cm below spines, 1300 = 2cm below; Moulding 1200 = +, 1300 = ++ Which of the following is correct? Select one: a. Epidural analgesia increases the chance of instrumental delivery. b. An instrumental delivery is indicated if she has not delivered after 30 minutes of active pushing. c. The increase in moulding suggests an obstructed labour and she requires a caesarean section. d. Epidural analgesia increases the chance of caesarean in labour.

A a&d). 'NICE Guideline: Intrapartum care for healthy women & babies', P. 31. Risk can be reduced by delaying pushing for 1hr post-full cervical dilatation. b). NICE guideline, P. 60 - 'diagnose delay in active 2nd stage when >2Hrs & refer to healthcare professional trained to undertake an operative vaginal birth if birth is not imminent' c). RCOG green-top guideline 26 'Assisted Vaginal Birth', P. e85 = when assessing re ?instrumental. caput & moulding should be no more than +2. Mod moulding (+2) = parietal bones are overlapped but easily reduced; severe moulding (+3) = parietal bones have overlapped & are irreducible, indicating cephalopelvic disproportion.

The mother of a 6-month-old baby has not had a menstrual period since delivery. She is breastfeeding the baby three or four times per day. The baby is sleeping for eight hours each night. She wants to continue breastfeeding but does not want another pregnancy at this stage. Which of the following statements is INCORRECT? a. Contraception is not required while she is breastfeeding and amenorrhoeic b. Introducing solids to the baby's diet can reduce the effectiveness of contraceptive protection from breastfeeding c. The combined oral contraceptive pill can supress lactation d. Medroxyprogesterone acetate (Depo Provera) does not suppress lactation

A a). 6mths is the conservative cut-off point for LAM. Need to feed during night too. b). True, however... if you still breastfeed the same amount and prior to each meal it may be possible to continue LAM https://www.breastfeeding.asn.au/bfinfo/lactational-amenorrhea-method-lam-postpartum-contraception c). If you are breastfeeding you cannot take ...COCP because the hormones will decrease (dry up) your breast milk. (After 6 weeks you may start the COCP). https://www.wslhd.health.nsw.gov.au/ArticleDocuments/1022/Fact%20sheet%20Progesterone%20Only%20Pill%20POP%20FINAL%20Jan2018.pdf.aspx d). Only a very small amount of the dose is passed on to your baby through breastfeeding and it does not affect the amount of milk you produce. The contraceptive injection is 94-99.8% effective. If you stop using Depo-Provera® it may take some time for the chance of getting pregnant to return to normal.

Which of the following actions should be taken for a woman with a strong family history of breast and ovarian cancer? a. She should have careful documentation of her family history and be referred to a genetic counselling service for further advice b. She should take the oral contraceptive pill to reduce the risk of cancer c. She should undergo a bilateral salpingo-oophorectomy and removal of both breasts d. She should be offered screening with annual Ca 125 and pelvic ultrasound scans

A a). P.112, RACGP guideline for preventative activities in GP. And https://www.cdc.gov/genomics/disease/breast_ovarian_cancer/breast_ovarian_cancer.htm b). https://www.fpnsw.org.au/factsheets/individuals/contraception/combined-pill-and-cancer - No contraindications to women with a family history of breast cancer using the COCP - With every five years of use, there is approximately a 20% reduction in the risk of OvCa - There is an ongoing debate as to whether the use of the COCP increases the risk of BrCa c). This is an option d). As per RACGP guideline for preventative activities in GP - 'A cancer antigen 125 (CA 125) blood test and transvaginal ultrasound are not recommended as screening tests for ovarian cancer, even in women who are at high risk' Re: BrCa screening - Mammography & U/S or MRI are an option.

Regarding surgical termination of pregnancy, which of the following is correct? Select one: a. It has similar health outcomes to medical termination b. It is complicated by perforation in 1:100 cases c. It requires a general anaesthetic d. Misoprostol 1mg should be given for cervical priming

A a). RANZCOG 'The use of mifepristone for medical abortion': Medical termination <GA9 = 95% success rate b). QLD clinical guidelines 'Termination of Pregnancy', P. 21 - 1-4/1000 c). QLD clinical guidelines 'Termination of Pregnancy' P. 30 - Method may depend on service capabilities and the woman's choice. May be performed with or without oral or intravenous tranquilliser. Analgesics, local anaesthesia and/or mild sedation are usually sufficient d). QLD clinical guidelines 'Termination of Pregnancy' P. 29 - Misoprostol [400mcg, PV, 3-4hrs pre-op] or [400mcg; buccal/SL/PO, 2-3hrs prior to surgery]

Iron metabolism is characterised by: a. increased iron absorption during pregnancy. b. decreased iron absorption during pregnancy. c. decreased absorption of iron in the presence of ascorbic acid. d. increased iron requirements in early pregnancy than in late pregnancy.

A a). SA Perinatal Practice Guidelines, 'Aneamia in Pregnancy', P. 4 - Absorption of iron increases 3-fold by the 3rd trimester, with iron requirements increasing from 1-2mg to 6mg/day d). P.4 - Physiological iron requirements are 3x higher in pregnancy than they are in the menstruating women, with increasing demand as pregnancy advances

Which of the following babies are at most risk of developing neonatal hypoglycemia? a. A baby born to a mother with gestational diabetes, well controlled with diet, exercise and insulin b. A baby born vaginally as a second twin c. A baby delivered as a vaginal breech birth d. A baby born vaginally after a previous caesarean section

A a). South Australian Perinatal Practice Guideline 'Neonatal Hypoglycaemia' (P.6) - "All babies born to mothers with diabetes are at risk of hypoglycaemia regardless of size at birth or the tightness of glycaemic control in pregnancy" c). South Australian Perinatal Practice Guideline - twins have a higher risk of hypoglycaemia d). Can't think why VBAC would = RF for neonatal hypoglycaemia https://www.bettersafercare.vic.gov.au/clinical-guidance/neonatal/hypoglycaemia-in-neonates# - RFs for neonatal hypoglycaemia - prematurity, IUGR, perinatal asphyxia, hypothermia, RDS, sepsis, maternal DM, rhesus isoim, PHHI, macrosomia; Also, LGA, b-blockers, valproate.

The false positive rate of a test used to assess for the presence of a particular disease describes which of the following? a. The proportion of subjects with a positive test result without the disease b. The proportion of subjects with a negative test result with the disease c. The proportion of subjects with a positive test result with the disease d. The proportion of subjects with a negative test result without the disease

A b). False neg c). true positive d). true negative

Betamethasone injection to enhance fetal lung maturity should be administered where delivery is expected and: a. the gestation is between 24 and 34 weeks. b. is given as two doses 12 hours apart. c. the mother has been counselled about the risk of fetal adrenal suppression. d. is contraindicated in mothers with diabetes.

A b). Given 24hrs apart c). Requires more research, but: "(Teramo 1980) found no differences in cortisol concentrations between infants exposed to a single course of antenatal corticosteroids and no exposure to corticosteroids for infants born <24 hours (n=6), 24 to ≤48 hours (n=10) and >48 hours (n=11) after the first dose." d). Not contraindicated, but prepare to have to manage BSLs. In the specific context of late pre-term birth (GA >34, <37), glucocorticoids aren't indicated in women with clinical chorioamnionitis, multiple gestations, or pregestational diabetes. Hypoglycaemia more common in infants treated with betamethasone (https://emedicine.medscape.com/article/260998-overview#a5)

A 21-year-old woman presents with pelvic pain, vaginal discharge and a temperature of 37.8°C. Pelvic examination reveals bilateral tenderness and cervical excitation. She has had no gynaecological surgery and has already been compliant with the doxycycline and metronidazole prescribed. The most appropriate antimicrobial is: a. ceftriaxone. b. amoxycillin. c. azithromycin. d. penicillin.

A eTG - Empirical therapy for non-severe PID Ceftriaxone [500mg, i.m. in 2mL 1% lidocaine, STAT] + Metronidazole [40mg, PO, BD for 14 days] + Doxycycline [100mg, PO, BD, for 14 days] (Azithromycin [1g, PO, STAT & 1wk] can be substituted for Doxycycline if pregnant/BF/non-adherent).

The frequency of fetal infection after maternal seroconversion for cytomegalovirus in pregnancy is approximately: a. 50%. b. 80%. c. 5%. d. 20%.

A https://americanpregnancy.org/healthy-pregnancy/birth-defects/congenital-cmv-birth-defects-26719/ Highest risk of transmission from mother to baby if primary CMV infection in 3rd trimester (40-70%). Lower if the primary infection begins in the first or second trimesters (30-40%) In general, 1/150-200 babies in the USA is born with congenital CMV. This makes CMV the most frequent congenital viral infection. Though this seems like a large percentage of births, only 1/5 of these infants born with congenital CMV will experience any adverse symptoms or long-term issues.

A 26-year-old, G2P1, kindergarten teacher with a 3-year-old child visits you at 12 weeks gestation for her first antenatal check. She has CMV lgM and lgG positive. a. her that she currently has an active CMV infection. b. her to have amniocentesis. c. a repeat test in two weeks. d. that the risk the baby will develop asymptomatic congenital CMV is less than 10%.

A https://americanpregnancy.org/healthy-pregnancy/birth-defects/congenital-cmv-birth-defects-26719/ a). IgM & IgG = primary infection. b). While you can use amniocentesis to assess baby's CMV status (end of 3rd trimester, or in the 14-20 week range), timing isn't right and is high-intervention for questionable benefit to management guidance. c). Wouldn't change management? Would look for if IgM has resolved? d). 10-20% of babies with congenital CMV that are NOT symptomatic at birth will have some degree of long-term hearing loss

1. Which of the following is an example of a direct maternal death? a. Death from massive antepartum haemorrhage associated with placenta praevia at 33 weeks gestation b. Death in a motor vehicle accident at 34 weeks gestation c. A fatal pulmonary embolism at 38 weeks gestation in a woman with recognised antithrombin III deficiency d. A fatal heroin overdose at 26 weeks gestation

A https://patient.info/doctor/maternal-mortality Direct maternal death - those related to obstetric complications during pregnancy, labour or puerperium (six weeks) or resulting from any treatment received. Indirect maternal death - those associated with a disorder, the effect of which is exacerbated by pregnancy. Late maternal deaths - ≥42 days but less than one year after end of pregnancy.

A 60-year-old post-menopausal patient, not on hormone replacement therapy, presents with post-menopausal bleeding. The most likely cause of her complaint is: a. endometrial polyps. b. atrophic vaginitis. c. endometrial hyperplasia. d. genital tract malignancy.

B

A primiparous woman is fully dilated, LOT with less than 1/5th of head palpable abdominally, with the vertex at the ischial spines. You are asked to review her CTG, shown below. PLEASE NOTE: ALL cardiotocographs are recorded at 1 cm/minute. Which of the following is most correct? Select one: a. The CTG shows complicated variable decelerations b. She should be advised to start pushing c. You should recommend a caesarean section d. She should have a trial of Keilland Forceps in theatre

B CTG is ok, maybe late decels. Fully dilated, head well engaged. Hence push

Of the following contraceptive methods, which carries the highest risk of ectopic pregnancy? a. Tubal ligation b. Levonorgestrel-releasing IUD (Mirena) c. Etonorgestrel implant (Implanon) d. Progesterone only pills

B PMID: 2220914 - Our results indicated a more than 500-fold difference in ectopic pregnancy incidence, OCP or vasectomy - 0.005 ectopic pregnancies/1000 women years, Condoms - 0.100, Diaphragms - 0.150, TL - 0.318, IUDs - 1.020, no contraception - 2.6 https://www.mayoclinic.org/diseases-conditions/ectopic-pregnancy/symptoms-causes/syc-20372088 - "The chance of getting pregnant while using an intrauterine device (IUD) is rare. However, if you do, it's more likely to be ectopic. TL also raises your risk, if you become pregnant after this procedure."

In obtaining the centile for a given gestational age on a customised birth weight chart, which of the following parameters is NOT an independent variable? a. Maternal weight b. Maternal age c. Ethnicity d. Parity

B PMID: 29422203 - "The physiologic variables that significantly affect birthweight are consistent in many cohort studies and are quantified through multivariable analysis: fetal sex, maternal height, weight in early pregnancy, parity, and ethnic origin. Adjustment for maternal height and weight is made within normal body mass index (BMI) limits only" https://www.perinatal.org.uk/FetalGrowth/CustomisedCharts/ https://www.gestation.net/literature.htm

Regarding vitamin K prophylaxis for the newborn, which of the following is true? Select one: a. The vitamin K dependent clotting factors are Factors II, VI, VIII, and X. b. Antenatal treatment with phenytoin causes vitamin K deficiency in the newborn. c. Breast fed babies do not require vitamin K at birth. d. Oral administration of vitamin K is never safe.

B The vitamin K-dependent coagulation factors are factors II, VII, IX, X, proteins C and S. AMH: Recommendation is for babies to receive VitK [1mg, i.m., STAT] at birth. Efficacy of antenatal PO supplementation unclear (from GA36, VitK [10-20mg, PO, daily])

A 57-year-old woman presents with complaints of marked urinary urgency, which often results in loss of urine. On examination no stress incontinence was demonstrated. The appropriate management for this woman includes: a. physiotherapy with pelvic floor exercises. b. oxybutynin hydrochloride. c. fluoxetine. d. tension free vaginal tape procedure.

B Urge incontinence as may occur in bladder overactivity whether due to neurogenic bladder disorders (detrusor hyperreflexia) or idiopathic detrusor overactivity. https://www.medicines.org.uk/emc/product/3005#gref

The sensitivity of a test used to assess for the presence of a particular disease describes which of the following? a. The proportion of subjects with a positive test without the disease b. The proportion of subjects with a positive test with the disease c. The proportion of subjects with a negative test with the disease d. The proportion of subjects with a negative test without the disease

B a - false positive c - false negative d - specificity

At the routine antenatal screening tests, a 20-year-old woman has negative RPR (Rapid Plasma Reagin) and positive TPHA (Treponema pallidum haemagglutination). The most likely explanation is that: a. the patient probably has early syphilis. b. the patient probably has been treated for syphilis in the past. c. the result is probably a biological false positive. d. the patient probably has late latent syphilis.

B a). Early syphilis = expect positive RPR/VDRL, which declines over 1yr. TPHA during the primary phase may be negative for antibodies, especially if testing is performed during the first 1-2wks after symptom onset" (ie. Need time for an adaptive immune response) b). Possible c). TPHA has 98-100% specificity -https://www1.health.gov.au/internet/main/publishing.nsf/Content/cda-phln-syphilis.htm Non-treponemal tests (RPR, VDRL) are prone to biological false positives, not TPHA d). Late latent syphilis - hopefully will see low, stable titre in RPR (<=16) and VDRL (<8) -https://www1.health.gov.au/internet/main/publishing.nsf/Content/cda-phln-syphilis.htm

Which of the following statements is NOT true in relation to gestational hypertension (PIH)? a. Complicates 5-10% of all pregnancies b. Treatment of PIH reduces the incidence of admission to NICU c. Molar pregnancy may present with hypertension at less than 20 weeks gestation d. May occur in the absence of proteinuria

B a). NSW Health factsheet = 10-15% b).SOMANZ 'Guideline for the Management of Hypertensive Disorders of Pregnancy (2014)' P.14 - "There is no clear effect of antihypertensive treatment on the risk of neonatal death, preterm birth or SGA, placental abruption, Caesarean section or admission to the neonatal nursery (93)" [PubMed: 11406040] c). Hydatidiform mole can be associated with early-onset PET https://www.cancer.org/cancer/gestational-trophoblastic-disease/detection-diagnosis-staging/signs-symptoms.html d). ? Yes b/c if proteinuria occurs & HTN is arising >GA20, then it fits the definition of PET

A primigravid woman at 38 weeks gestation presents in labour with a singleton pregnancy with an undiagnosed breech presentation. She has progressed rapidly and is now fully dilated. Which of the following is true? Select one: a. An extended breech is more hazardous than a footling breech. b. The risk of short-term neonatal complications is four times higher with vaginal breech compared to caesarean. c. The Mauriceau Smellie Veit manoeuvre will help to prevent a nuchal arm. d. In the 'term breech' trial, entry criteria for inclusion included an ultrasound estimate of fetal weight.

B a). QLD ambulance - Footling breech = increased risk of prolapsed cord. eMedscape - 0-2% frank breech, 5-10% complete breech, 10-25% footling breech. b). Controversial. eMedscape - re term breech trial: "The composite measurement of either perinatal mortality or serious neonatal morbidity by 6 weeks of life was significantly lower in the planned cesarean group than in the planned vaginal group (5% vs 1.6%, P< .0001)." https://www.ogmagazine.org.au/14/2-14/term-breech-trial/) - "The vaginal delivery versus caesarean section perinatal morbidity rates were calculated as 11/1038 vs 5/1038, with a p value of 0.2, which is not statistically significant" and 2yr F/U = nil difference in infant death rates or neurodevelopmental delay. c). MSV manoeuvre holds head in flexed position to allow passage of smallest diameter. SA Perinatal Practice Guideline 'Breech Presentation', P.10 - "If there are nuchal arms attempt Lovset's manoeuvre. This may bring the posterior arm down far enough to flex it and effect delivery" d). "Fetal weight and attitude of the head (the degree of flexion), although considered important as entry criteria, could be assessed clinically if no ultrasound was available". "Of the women enrolled in the trial, 40 per cent entered with no ultrasound assessment of fetal weight or attitude of the head." (https://www.ogmagazine.org.au/14/2-14/term-breech-trial/)

Breech presentation is more likely in all the following situations EXCEPT: a. polyhydramnios. b. subserous fibroid. c. preterm labour. d. bicornuate uterus.

B https://patient.info/doctor/breech-presentations - RFs include a, b, d.

1. Pregnant women with a history of recurrent genital herpes infections: a. should have serial cultures in the last weeks of pregnancy. b. can deliver vaginally if no maternal lesions are present. c. should deliver by caesarean section if membranes rupture before labour ensues. d. should be treated with acyclovir throughout pregnancy.

B https://www.mshc.org.au/SexualHealthInformation/SexualHealthFactSheets/tabid/109/Default.aspx#GSkinCare

A woman G3P2 at 39 weeks gestation has been induced for maternal discomfort. The following is the CTG recorded six hours after her first dose of vaginal prostaglandins. Bishop's score is five. Which of the following statements about ongoing management is most appropriate? a. No further prostaglandins should be given and the CTG repeated in two hours b. No further prostaglandins should be given and the CTG should be observed continuously c. Perform an artificial rupture of membranes (ARM) and commence oxytocin infusion d. A further dose of vaginal prostaglandins should be given

B b). Late decels? - Continuous CTG Bishops not great (in a multi) c&d). Contracting 4/10? = Enough uterine stimulation

The most effective treatment for premenstrual dysphoric disorder is: a. the combined oral contraceptive pill. b. gamma linolenic acid (evening primrose oil). c. fluoxetine. d. cognitive behavioural therapy.

C https://www.jeanhailes.org.au/health-a-z/periods/premenstrual-syndrome-pms#management-treatment-of-pms-symptoms a). Second line b). Recommended for breast swelling & pain c). First line d). Recommended

During labour the most ominous fetal heart rate pattern is: Select one: a. baseline bradycardia with normal variability. b. reduced variability and shallow late decelerations. c. severe variable decelerations. d. deep late decelerations.

B? Early = good, Late = ok, Variable = bad A - could be normal B - Worry a lot about reduced variability if in assoc. w decels. - ?acidosis, baby decompensating. C - D - ?head compression in 2nd stage.

In which of the following scenarios would you have legally fulfilled your duty of care as a medical practitioner? a. A woman arrives at your practice before the clinic opens carrying a sick infant. She is not one of your patients. She asks you if you are a doctor and you reply that you are not. b. One of your regular patients has high grade abnormalities detected on her routine cervical screening. You arrange a referral for colposcopy, but you receive a note from the hospital that your patient did not attend. You try to contact her by telephone, but her number has been disconnected. You take no further action. c. You are on a flight travelling between Brisbane and Auckland. A passenger in first class has collapsed and a call has been made for assistance from any doctors on board. You do not respond. d. You perform an emergency caesarean section on one of your private patients due to fetal distress in labour. Her next pregnancy is complicated by a caesarean scar pregnancy and uterine rupture. You had discussed possible complications with her prior to her initial surgery but had not mentioned this rare but serious complication.

B? a). This was a real case and "provides an example whereby both the Medical Board and WASAT determined that a doctor's misrepresentation in these circumstances may be considered improper conduct, and potentially subject to disciplinary action" AFP, Volume 42, No.10, October 2013 Pages 746-748 - https://www.racgp.org.au/afp/2013/october/duty-of-care/ b). https://www.racgp.org.au/afp/2013/april/the-duty-of-gps/ c). Avant article quotes MBA 3.5 & then points out "The definition of 'unsatisfactory conduct' for doctors in NSW also includes a failure to attend a person in need of urgent medical attention without reasonable cause, after being requested to do so" AFP article says it's untested, but likely you have breeched your duty of care. https://www.medicalboard.gov.au/Codes-Guidelines-Policies/Code-of-conduct.aspx Medical Board of Australia's Good Medical Practice: A Code of Conduct for Doctors in Australia, section 3.5. - "Treating patients in emergencies requires doctors to consider a range of issues, in addition to the patient's best care. Good medical practice involves offering assistance in an emergency that takes account of your own safety, your skills, the availability of other options and the impact on any other patients under your care; and continuing to provide that assistance until your services are no longer required."

A 25-year-old woman delivers after 24 hours of labour. Two days post-partum, she has a fever (38.9 degrees C). Which of the following is the most likely cause of these findings? a. Influenza b. Mastitis c. Endometritis d. Deep vein thrombosis

C

Which one of the following therapies most effectively reduces menstrual blood loss in women with ovulatory menorrhagia and no organic lesions or diseases? a. Endometrial curettage b. Mefenamic acid c. Tranexamic acid d. Cyclic luteal-phase progestogens

C Am Fam Physician. 2012 Jan 1;85(1):35-43. 'Evaluation & Mgmt of AUB in Premenopausal Women' a). Not 1st-line b). NSAIDs decrease prostaglandin levels, reducing menstrual bleeding... naproxen sodium & mefenamic acid decreased flow volume by 46 & 47 %, respectively... no evidence one NSAID more effective than another but cost varies c). Two 650-mg tablets, TDS for the first 5 days of cycle decreased bleeding significantly more than NSAIDs did. $$ d). In contrast to the shorter course of oral progestin therapy used for anovulatory uterine bleeding, progestin therapy for menorrhagia needs to be given for 21 days per month to be effective

A 27-year-old woman and her partner present with a three year history of primary infertility. A diagnostic laparoscopy reveals stage II endometriosis. The remaining investigations for infertility in this couple are normal. Which of the following management options is most appropriate for this patient? a. Combined oral contraceptive pill b. Gonadotrophin releasing hormone therapy c. Laparoscopic excision of endometriosis d. Danazol treatment

C c). RANZCOG; 'Endiometriosis clinical practice guideline', P. 59 ESHRE; 'Management of women with endometriosis', P. 58, 60-61 https://www.eshre.eu/Guidelines-and-Legal/Guidelines/Endometriosis-guideline.aspx Background: d). Danazol = Synthetic androgen. Decreases secretion of FSH & LH, binds to sex hormone receptors in target tissues. Anti-estrogenic, anabolic, weakly androgenic. https://pubchem.ncbi.nlm.nih.gov/compound/danazol

A woman who has an elevated value of maternal serum alpha-fetoprotein at 16 weeks gestation should be counselled that: a. she has a multiple gestation. b. she should have an amniocentesis. c. her fetus has an increased risk of a neural tube defect. d. her fetus has an increased risk of Down syndrome.

C https://medlineplus.gov/lab-tests/alpha-fetoprotein-afp-test/ AFP is raised in NTD and lowered in Down syndrome. It can be raised in multiple gestation.

Which of the following statements concerning incarceration of a retroverted gravid uterus is correct? a. It presents with bowel symptoms b. It is usually due to a fibroid uterus c. It presents with urinary retention d. It occurs before 12 weeks of pregnancy

C UpToDate: https://www.uptodate.com/contents/incarcerated-gravid-uterus#H299648 b). RFs do include large fibroids c). Sx - pain & urinary are most common. Often vague. d). GA14-16 most common (20+?)

A 38-year-old woman had intercourse last night (day 14 of 28-day regular cycle). The condom broke. She does not want to become pregnant. She is a heavy smoker and takes sodium valproate for epilepsy. She is known to have a bicornuate uterus. Which one of the following statements would be your advice to her? a. Postcoital IUCD b. Nordiol (levonorgestrel 250mcg and ethinyl oestradiol 50mcg), four pills now and four pills in 12 hours c. Postinor-2 (levonorgestrel 750mcg), one pill now and one pill in 12 hours d. Emergency contraceptive pill is contraindicated

C a). No b/c bicornate uterus b). No, b/c oestrogen - age, smoker c). https://www.nps.org.au/medicine-finder/postinor-2-tablets AFP 'Emergency contraception: Oral and intrauterine options' - Volume 46, No.10, October 2017 Pages 722-726. https://www.racgp.org.au/afp/2017/october/emergency-contraception-oral-and-intrauterine-options/ Australian women have 3 options for emergency contraception: 2x of oral pills (levonorgestrel [LNG]-containing pill and ulipristal acetate [UPA]) and the copper intrauterine device (IUD). Both pills are available from pharmacies without prescription, whereas the copper IUD requires insertion by a trained provider. LNG [1.5mg, PO, STAT - within 72hrs] d). Nohealth

Regarding surgical termination of pregnancy, which of the following is correct? a. Misoprostol 1mg should be given for cervical priming b. It requires a general anaesthetic c. It has similar health outcomes to medical termination d. It is complicated by perforation in 1:100 cases

C a). QLD clinical guidelines 'Termination of Pregnancy' P. 29 - Misoprostol [400mcg, PV, 3-4hrs pre-op] or [400mcg; buccal/SL/PO, 2-3hrs prior to surgery] b). QLD clinical guidelines 'Termination of Pregnancy' P. 30 - Method may depend on service capabilities and the woman's choice. May be performed with or without oral or intravenous tranquilliser. Analgesics, local anaesthesia and/or mild sedation are usually sufficient c). RANZCOG 'The use of mifepristone for medical abortion': Medical termination <GA9 = 95% success rate d). QLD clinical guidelines 'Termination of Pregnancy', P. 21 - 1-4/1000

1. The progesterone only pill is associated with: a. a reduction in the incidence of ovarian cysts. b. a normal menstrual cycle in approximately 40% of women. c. increased vaginal discharge. d. reduced efficacy when taking ordinary broad-spectrum oral antibiotics.

C a). The progestin-only or mini-pill has an unpredictable effect on ovulation and may lead to more cysts. These almost always disappear on their own, but if you've had problems with cysts in the past, the mini-pill may not be the best contraception for you - https://www.bedsider.org/features/223-ovarian-cysts-no-biggie-but-birth-control-can-help b). https://www.nps.org.au/australian-prescriber/articles/progestogen-only-methods-of-contraception - The most common adverse effect of progestogen-only methods is disturbance of bleeding patterns. Erratic cycle length, prolonged episodes of bleeding, and nuisance spotting, but not heavy bleeding, are common. DMPA: By 12 months, 50%+ users amenorrhoeic, ~75% with increasing duration of use. c). Many hormonal contraceptives thicken cervical fluid because of the hormones they contain. It's common for women who take the Pill to have a whitish vaginal discharge quite consistently throughout the month - https://www.jeanhailes.org.au/news/hormonal-health-clues-made-clear d). Drugs.com - The tuberculosis drug rifampin (also known as Rifadin and Rimactane) and possibly other rifamycins like rifabutin. Seizure drugs (carbamazepine, phenytoin, topiramate) barbiturates (phenobarbital), HIV meds, St John's Wort

Regarding episiotomy, which of the following statements is correct? Select one: a. Should always be performed with an instrumental delivery. b. Should be performed between contractions. c. Should be performed beginning at the fourchette, at 45 degrees to the midline. d. Should not be performed unless there is evidence of a perineal tear.

C b). False. Perform when pressure coming through perineum - reduces bleeding. c). Mediolateral episiotomy originating at the vaginal fourchette and usually directed to the right side. The angle to the vertical axis should be between 45 & 60 degrees at the time of the episiotomy - NICE guideline 'Intrapartum care for healthy women and babies'

A mother is concerned that her 14-year-old daughter has not commenced menstruation. Her older sister started at age 13 and the younger sister has just started her periods at age 12. You note that she has widely spaced nipples and no breast development. In addition, she has no axillary nor pubic hair. What investigation is most likely to give the diagnosis? a. Transabdominal ultrasound b. FSH, LH c. Karyotype d. Serum oestradiol

C b). https://www.msdmanuals.com/en-au/professional/pediatrics/endocrine-disorders-in-children/delayed-puberty "LH & FSH levels are the most useful initial tests (see also algorithm Evaluation of primary amenorrhea)." Elevated may indicate gonadal failure (do karyotyping) Lowered may indicate constitutional delay/Secondary hypogonadism (hypogonadotropic hypogonadism) d). Current assays for testosterone & estradiol levels don't always distinguish early pubertal from prepubertal levels Also, https://www.yourhormones.info/endocrine-conditions/delayed-puberty

A woman presents at 28 weeks gestation with ruptured membranes. She is not in labour. There are no clinical signs of infection. In addition to corticosteroids, what treatment would you offer her to reduce the risk of serious neonatal morbidity? a. No treatment b. Oral amoxycillin c. Oral erythromycin d. Oral amoxycillin and clavulanic acid (Augmentin)

C https://www.rcog.org.uk/en/guidelines-research-services/guidelines/gtg73/ - An antibiotic (preferably erythromycin) should be given for 10 days or until the woman is in established labour (whichever is sooner) following the diagnosis of PPROM, and corticosteroids and magnesium sulfate, considered or offered

Which of the following is NOT associated with pelvic floor dysfunction? a. Chronic bronchitis b. Marfan syndrome c. Anorexia nervosa d. Constipation

C? a&c) intrabdominal pressure b). connective tissue weakness

A 36-year-old woman has recently had a uterine evacuation for a partial molar pregnancy. This was her first pregnancy and she is desperate to get pregnant again as soon as permitted. She consults you to discuss the potential risks to any future pregnancies. Which of the following is INCORRECT regarding her ongoing management? a. A bHCG should be performed six weeks after the completion of any future pregnancy regardless of the outcome b. Conception should not be attempted until 12 months after the serum bHCG levels have normalised c. There is no increased risk of other obstetric complications in any future pregnancies d. There is a low risk of a recurrent molar pregnancy

C? a). True (RWH) b). Partial mole = weekly b-HCG until 3x consecutive normal, then stop. Complete mole = monthly b-HCG for up to 6 months after b-HCG levels return to normal... Once you are discharged from the GTD Registry it is safe for you to attempt a new pregnancy (RWH & RANZCOG) d). - 1/100 risk of recurrent molar pregnancy (RWH)

1. A 24-year-old, G2P1, presents at eight weeks for her first antenatal visit. Due to a history of severe postnatal depression she is still taking Fluoxetine (40mg daily). The most appropriate advice for her is to: a. immediately stop her Fluoxetine. b. reduce her Fluoxetine to 20mg per day. c. continue her Fluoxetine at present dose. d. change her to a tricyclic antidepressant.

C? - Could opt for continuation of current dose or reduction. Stay w current dose b/c PND was severe & has been stable on 40mg. Australian Prescriber | Vol 30, No. 5, Oct 2007 - Antidepressants in pregnancy and breastfeeding a). Have to weigh risks vs benefits. Risky to immediately stop meds. Unmedicated depression has risks too. d). TCAs are falling from favour (SEs, overdose risk)

Postpartum haemorrhage is more likely than usual in all these situations EXCEPT: a. following a 24-hour labour in a 17-year-old primigravid woman. b. following a 4-hour labour in a 34-year-old woman G6P5. c. following a 12-hour labour in a 21-year-old woman G1P0, with mild pre-eclampsia. d. following an elective caesarean section for a primigravid woman at term.

D

Which one of the following is NOT a common problem in the palliative care of women with advanced epithelial ovarian cancer? a. Vomiting and abdominal pain due to small bowel obstruction b. Depression c. Abdominal discomfort due to ascites d. Pain due to bony metastasis

D

Heroin use during pregnancy is associated with: a. increased risk of preeclampsia. b. decreased incidence of placenta praevia. c. delayed onset of labour. d. increased risk of sudden infant death syndrome.

D 'Managing opioid dependence in pregnancy: A general practice perspective'; Volume 42, No.10, October 2013 P. 713-716 IUGR/SGA, pre-term labour, placental abruption, intrauterine passage of meconium, NAS, and foetal & neonatal death (SIDS)

A primigravid woman presents in labour. She ruptured her membranes five hours earlier. Four hours ago, her cervix was 4 cm dilated. On examination she is now 5 cm dilated. LOP at spines. Her CTG is shown below. PLEASE NOTE: ALL cardiotocographs are recorded at 1 cm/minute. Which of the following is most correct? Select one: a. The CTG is saltatory and she requires a fetal blood sample. b. She should be offered a caesarean section in light of the malposition. c. Her progress is within normal limits and she should be encouraged to mobilise for two hours. d. Oxytocin is likely to reduce her risk of caesarean section.

D - Has dilated 1cm in 4hrs = problem (nullip - aiming 1cm/1-2hrs) - Cervix 5cm = should be in active 1st stage labour - Contractions aren't regular (nil mention of if they're painful) = problem - ?oxytocin - LOP not ideal but may change

An 18-year-old woman G0P0 presents to your GP surgery asking about the HPV vaccine (Gardasil/Cervarix). How many injections are needed? a. Two doses - today and six months b. Three doses - today, two months, and six months c. Two doses - today and three months d. Three doses - today, three months, and six months

D Gardasil has been registered in Australia for use in a two dose schedule since 11 July 2017. Two doses of Gardasil spaced at least six months apart have been proven to have equivalent immunogenicity and clinical protection in individuals aged 9-14 years compared to a 3-dose schedule. Gardasil®9 in the - Australian Government Department of Health https://www.health.gov.au › atagi-advice-gardasil9

A previously healthy 23-year-old Caucasian woman G1P0 is seen in the clinic at 27 weeks. Her blood pressure is 140/90. Her urinalysis reveals 3+ proteinuria. At booking she was normotensive and did not have proteinuria. The fundal height measures 27 cm and the fetal heart is heard. She has not noted any change in pregnancy symptoms. What management is most appropriate? Select one: a. Nifedipine slow release 20mg b.d commencing now b. Methyldopa 250mg q.i.d and low dose Aspirin daily c. A period of observation and no immediate medication d. Methyldopa 250mg q.i.d commencing now

D SA Perinatal Practice Guidelines a) - "Nifedipine is generally considered a 2nd line agent during pregnancy for the ongoing management of hypertension." b). Aspirin should be commenced prior to 16 weeks (cease @GA37+). c). - BP 140/90 is borderline, but b/c: Presence of significant proteinuria = PET d). Methyldopa [250-750mg, PO, TDS]

The ratio of cumulative incidences comparing two different groups is: a. odds ratio. b. cumulative incidence. c. reliability. d. relative risk.

D The relative risk (or risk ratio) is an intuitive way to compare the risks for the two groups. Simply divide the cumulative incidence in exposed group by the cumulative incidence in the unexposed group https://sphweb.bumc.bu.edu/otlt/MPH-Modules/EP/EP713_Association/

A 35-year-old primigravid patient presents following two years of primary infertility with an IVF pregnancy. Ultrasound confirms the presence of a DCDA twin pregnancy. Which of the following complications is most commonly associated with multiple pregnancy? a. Congenital malformation affecting either or both twins b. Twin to twin transfusion syndrome c. Postpartum haemorrhage d. Preterm labour less than 32 weeks

D The stem specifies DCDA twins. SA perinatal practice guidelines, P.6 a). Congenital anomalies (more common in monozygotic twins) b). TTS can also occur (but rarely) in dichorionic twins with fused placentae c). Is more common in twin than singleton pregnancies d). Fewer than half of twin pregnancies will continue up to and beyond 38 weeks

A 30-year-old patient, G3P2, at 14 weeks gestation asks you for information about maternal serum screening (quadruple or triple test). Select the most appropriate response. a. The test should only be used in patients with a high risk of Trisomy 21. b. The test should only be used in patients with a low risk of Trisomy 21. c. The test detects at least 90% of all chromosomal abnormalities. d. The test offers more information if done after 15 weeks.

D a&b). Combined 1st semester screening (CFTS) is offered routinely. 2nd TMSS generally discussed if CFTS missed c). 2ndTMSS detects Trisomy 18, 21 +/- NTD. d). 2nd TMSS must be done at/after GA15 in order for NTD to be assessed

A 30-year-old, G2P1 woman, at 12 weeks gestation confides in you that she drinks three to four glasses of vodka most nights. Her medical and surgical history is otherwise unremarkable. You explain to her that the fetus is at increased risk for: a. macrosomia. b. hypospadias. c. cardiac defect d. facial abnormalities.

D a). FAS predisposes to SGA FAS predisposes to b-d). Presume that stem is implying high alcohol exposure, hence warn against worst outcome (CHD)? c). ?More severe alcohol exposure - https://healthresearchfunding.org/fetal-alcohol-syndrome-facts-statistics/

A healthy 40-year-old woman presents with heavy vaginal bleeding and pain. Her last period was 10 weeks ago and she had a positive home pregnancy test four weeks ago. She passes a 3cm diameter sac in the examination room, following which the bleeding slows substantially. What is the most appropriate management? a. The woman's blood group should be ascertained. b. The sac should be sent for cytogenetic analysis. c. The woman should be admitted to hospital for evacuation of retained products of conception. d. The woman should be reassured that she has had a complete miscarriage.

D a). G&H in case bleeding resumes & to guide anti-D. SA perinatal practice guideline says anti-D to all rh neg in 1st trimester b). Yes, but not 1st priority c& d). Likely all passed. Order U/S to assess

A 28-year-old woman attends your surgery at 12 weeks gestation. She has a nuchal translucency which shows a nuchal thickness of 5mm. Which is the most likely cause of the thickened nuchal measurement? a. Choroid plexus cyst b. Pyloric stenosis c. Tracheooesphageal fistula d. Congenital cardiac disease

D https://molecularcytogenetics.biomedcentral.com/articles/10.1186/s13039-016-0279-z "Enlarged NT is not only associated with aneuploidies and other chromosome abnormalities, but also with a number of genetic syndromes, as well as with structural congenital anomalies, mainly cardiac defects" https://radiopaedia.org/articles/nuchal-translucency-1 Thought to be related to dilated lymphatic channels, = non-specific sign of fetal abnormality. NT >3.5mm is getting substantial for risk of aneuploidy (20%); <2mm is essentially normal Aneuploidy Structural defects and syndromes (CHD - if @ 95% = 2% risk, 99% (3.5mm) = 5% risk. Septal defects most common)

Which of the following statements concerning anticoagulation with warfarin is correct? a. Paracetamol administration in normal therapeutic dosage does not cause an adverse interaction. b. The effects of the drug are antagonised within 10 minutes by intravenous administration of vitamin K. c. Breastfeeding is contraindicated. d. There is an increased risk of neural tube abnormality of the fetus.

D a). https://clinicaltrials.gov/ct2/show/NCT01104337 Increased INR was prev. obs in pts treated w warfarin & paracetamol (4g/day). Mech hasn't been determined. A recent in vitro study suggested the toxic metabolite NAPQI appeared to interfere with vitK-dependent γ-carboxylase & vitamin K epoxide reductase activities b). AHA Journal - Reversal of warfarin, Table 1 = 8-12Hr after i.v. VitK. Duration = days. PO VitK works within 24hrs. Both delivery methods equally effective by 24hrs. https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.111.081489 c). Current evidence suggests women may BF while on warfarin. Trace amounts have been found in breast milk however too low to reduce the blood clotting baby. 'Pregnancy and breastfeeding while taking warfarin' - Healthy WA d). True. Warfarin taken in 1st trimester more likely to result in physical abnormalities, 2nd & 3rd trimester more commonly causes abnormalities of the CNS. More extreme symptoms such as severe mental retardation, blindness and deafness occur more often when warfarin is used throughout all trimesters. https://en.wikipedia.org/wiki/Fetal_warfarin_syndrome

A 52-year-old woman had her last menstrual period six months ago. She now complains of hot flushes, a dry vagina and irritability. She requests treatment for symptomatic relief. She has no other significant findings on history and examination. There is a strong family history of osteoporosis. The most appropriate management would be to: a. measure serum FSH, LH and TSH. b. commence treatment with vaginal oestrogen. c. commence treatment with raloxifene d. treat with cyclical oral oestrogen and progestogen.

D a). https://www.menopause.org.au/hp/management/treatment-options 'A practitioner's toolkit for the management of the menopause' P2. FSH/oestradiol rarely needed. LH of no Dx value. TSH is part of 50yo health assessment. HealthPathways Melbourne 'Menopause' - "If menopause is not clear on Hx and confirmation is required, take 2x FSH & estradiol measurements 6 weeks apart" b). Would address dry vagina c). https://www.menopause.org.au/hp/information-sheets/971-serms-their-role-in-menopause-management Raloxifene does not improve menopausal symptoms, and may in fact worsen them. Use limited postmenopausal women who do not have troublesome symptoms of menopause. SEs include hot flushes, leg cramps, leg swelling", "shown in clinical trials to increase bone density in the spine and hip & reduce the risk of spinal # in women w osteoporosis" d). HealthPathways Melbourne - check for HRT contraindications, consider alternatives. If intact uterus & ≤ 1 year since last menstrual period (LMP), prescribe a cyclical regimen

Which of the following statements about oral contraception is correct? a. The progestogen-only oral contraceptive pills exert their principal action by inhibiting ovulation. b. The contraceptive efficacy of pills containing 30-35mcg of ethinyl oestradiol is not affected by anticonvulsant medications. c. The newer contraceptive pills containing desogestrel or gestodene have been shown to be more effective in preventing conception than traditional oral contraceptive pill varieties. d. Arterial thrombosis in women on the combined oral contraceptive pill is more likely in women over the age of 35 years even when they are non-smokers.

D a). https://www.ncbi.nlm.nih.gov/books/NBK430882/ b). PMID: 20369030 - Estrogens & progestogens are metabolized by cytochrome P450 3A4. AEDs, such as phenytoin, phenobarbital, carbamazepine, felbamate, topiramate, oxcarbazepine and primidone, induce cytochrome P450 3A4, leading to enhanced metabolism of either/both the estrogenic & progestogenic component of OCs... OCs can also decrease [AEDs] such as lamotrigine &, thereby, increase the risk of seizures. c). https://www.nps.org.au/australian-prescriber/articles/gestodene-with-ethinyloestradiol - Re gestodene (and in separate article re gestodene): "Cycle control may be better than with monophasic pills containing levonorgestrel, although there have not been any comparative studies" d). VTE - "OCP's are contraindicated in smokers 35+ due to significant risk for cardiovascular events & specifically DVT. Risk of VTE is increased among OC users (3-9/ 10,000 woman-yrs), compared with nonusers who are not pregnant and not taking hormones (1-5/10,000 woman-years), the risk is even greater in those 35+ & smoking

Which of the following statements best describes prescribing pharmacological therapies to treat major depression during pregnancy? a. Current studies suggest that all selective serotonin reuptake inhibitors (SSRIs) are relatively safe in pregnancy b. There is a significant risk of preterm delivery with tricyclic antidepressants (TCAs) exposure in pregnancy c. Neonatal withdrawal from selective serotonin reuptake inhibitors (SSRIs) has been associated with detrimental long-term impact on neurological development d. Discontinuation of antidepressant medication in early pregnancy significantly increases the risk of recurrent depression

D b). Australian Prescriber | Vol 30, No. 5, Oct 2007 - Antidepressants in pregnancy and breastfeeding - TCAs have fallen from favour and many have been withdrawn (outside of the context of pregnancy). Their AEs & risk of fatality from overdose make them hazardous... some doctors continue to prescribe them after considering risks & benefits... few documented problems arising from their use, but this is perhaps due to lack of extensive research. c). PMID: 19935046 - Seems not. More evidence needed. d). PMID: 19935046, P. 707 - In mild-mod depression, behavioural therapy can be effective. Aust prescriber - Up to 75% of women who abruptly cease their medication may develop a recurrence of their depression before delivery.

You see a couple who ask about the best time to have intercourse in order to maximise their chances of becoming pregnant. The woman has a 28-day cycle. Which one of the following would you advise? a. Avoid intercourse until day 14. b. Have intercourse at any time, but use the fertile phase (e.g. from day 12 to 18). c. Have intercourse from day 12 to day 16 of her cycle and rest at other times. d. Have intercourse at any time, but use the fertile phase (e.g. from day 10 to 16).

D https://kidspot.co.nz/pregnancy/menstrual-cycle-fertile-phase/ Egg - 12-24 hours Sperm - 3-5 days Ovulation (textbook) - D14 Fertile window - D10-16 = closest

Which one of the following infective conditions in the mother is likely to pose the greatest risk to the neonate? a. Gardinerella Vaginalis infection b. Trichomonas Vaginalis infection c. Human Papilloma Virus d. Primary Genital Herpes infection

D? Risk of HSV infection in neonates born to mothers w primary genital HSV infection who seroconvert before delivery is very low, in contrast to the high (up to 50 per cent) risk of neonatal infection when mothers acquire HSV infection just prior to delivery a). Intrauterine infection can result in preterm birth, FGR. Postnatally, several neonatal cases causing pneumonia, meningitis, osteomyelitis, septicemia, and death had been reported b). https://www.health.gov.au/resources/pregnancy-care-guidelines/part-g-targeted-maternal-health-tests/trichomoniasis in pregnancy may be associated w increased risk of preterm birth and low BW. Has been associated w genital & respiratory infections of the newborn. Most common curable STI globally, with a prevalence among women of 8.1% c). PMID: 21600804 - doesn't seem alarmed by clinical risk to neonate

Definition of primary, secondary, major & severe PPH

Primary = Blood loss >500mL within 24hrs of delivery Secondary = Blood loss >500mL 24Hr-6wks post-partum Major = >1L Severe = >1.5L

1. A 30-year-old nulliparous woman presents complaining of pain on intercourse. She is in a long standing, steady relationship and has problems with arousal. She has no significant history and examination reveals a mobile retroverted uterus with no tenderness or other abnormalities. The most likely diagnosis is: a. inadequate vaginal lubrication. b. endometriosis. c. vulvodynia. d. vaginismus.

a

Pregnant women with a history of recurrent genital herpes infections: Select one: a. can deliver vaginally if no maternal lesions are present. b. should be treated with acyclovir throughout pregnancy. c. should have serial cultures in the last weeks of pregnancy. d. should deliver by caesarean section if membranes rupture before labour ensues

a

You are asked to give a teaching session to the local midwifery students on the routine management of labour. Which of the following is INCORRECT? a. If meconium is present in the liquor, the mouth and nose of the baby should be suctioned on the perineum before the birth of the body. b. Free intake of oral fluids should be encouraged during labour to reduce the risk of dehydration. c. Delayed cord clamping should not be practised when the baby requires resuscitation. d. In an uncomplicated 2nd stage, a mother may be allowed to deliver in whatever position she finds most comfortable.

a

1. A 24-year-old woman has a presumptive diagnosis of unruptured ectopic pregnancy. Which of the following is true? a. Salpingostomy must be followed up with serial measurement of beta-hCG levels b. Serum progesterone is of no value in making the diagnosis c. Salpingostomy is associated with a negligible risk of persistent ectopic pregnancy d. Linear salpingostomy has been shown in randomised controlled trials to be associated with a better future pregnancy rate than salpingectomy

a RCOG 'The Mgmt of Tubal Pregnancy' (2010) a). Australian Family Physician - Early pregnancy bleeding; Volume 45, No.5, May 2016 Pages 283-286 - "In women who have had a salpingostomy, hCG levels should be measured weekly until negative due to the potential for retained pregnancy tissue in the affected tube. In the case of a salpingectomy, histological confirmation of a tubal pregnancy is usually all that is required." b). Am Fam Physician. 2005 Nov 1, 'Dx & mgmt. of ectopic pregnancy';72(9):1707-1714. Serum progesterone levels can detect pregnancy failure and identify patients at risk for ectopic pregnancy, but they are not diagnostic of ectopic pregnancy. Single progesterone level to distinguish ectopic pregnancy from non-ectopic pregnancy = 15% sens, >90% spec; Single progesterone level to distinguish pregnancy failure from viable intrauterine pregnancy = 95% sens, 40% spec c). Persistent ectopic in 5-10% cases - https://www.surgeryencyclopedia.com/Pa-St/Salpingostomy.html d). In the presence of a healthy contralateral tube there is no clear evidence that salpingotomy should be used in preference to salpingectomy. "...reviews show there is not an increased chance of subsequent intrauterine pregnancy after salpingotomy compared with salpingectomy" Addit: Medical mgmt. = b-HCG<3000IU/L = Methotrexate [50mg/m2, im, STAT] & b-HCG @ D4, 7, further if not falling by >15%

Regarding Tibolone, which one of the following statements is correct? a. It increases sex hormone binding globulin (SHBG) b. It has significant breast stimulation properties c. It is a synthetic oestrogen d. It does not increase the risk of venous thromboembolism (VTE)

a) Aust. Menopause Soc. (AMS) MHT info sheet - "Androgenic effects are thought to enhance testosterone availability by reducing sex hormone binding globulin (SHBG)." b). It doesn't increase breast density [AMS Info Sheet & PMID 11967497] c). AMS Info Sheet - "Tibolone is a synthetic steroid hormone derived from the Mexican yam. The metabolites of tibolone have estrogenic, androgenic and progestogenic effects" (However it is contraindicated in women who have had BrCa). "Tibolone is a synthetic steroid molecule which is, in essence, a progestogen" d). Controversial. AMS info sheet & NPS medicinewise - Lack of data re DVT. https://www.menopause.org.au/hp/information-sheets/1195-venous-thrombosis-thromboembolism-risk-2018 - "Tibolone has been associated with an increased risk of stroke but the pooled data from four studies did not find that tibolone was associated with the risk of VTE"

You are asked to give a teaching session to the local midwifery students on the routine management of labour. Which of the following is INCORRECT? a. If meconium is present in the liquor, the mouth and nose of the baby should be suctioned on the perineum before the birth of the body. b. Delayed cord clamping should not be practised when the baby requires resuscitation. c. In an uncomplicated 2nd stage, a mother may be allowed to deliver in whatever position she finds most comfortable. d. Free intake of oral fluids should be encouraged during labour to reduce the risk of dehydratio

a).

A G3P2 woman presents at 32 weeks gestation with ruptured membranes. She has a temperature of 37°C. The fetal heart is 140. She is contracting regularly and is 4cm dilated. What would be the most appropriate course of action? a. Administer parenteral penicillin or amoxycillin b. Continue to observe c. Administer oral amoxycillin d. No therapy but take swabs for culture

a). B/C prem labour - may have been induced by infection. Priority is protecting Mo & Ba. & unclear how long PPROM

A 32-year-old woman presents with a 12 week history of postcoital bleeding. Her periods are regular and her LMP was two weeks ago. She has taken the same combined oral contraceptive pill for eight years. She describes no dyspareunia or abnormal vaginal discharge. Her last cervical screening test was one year ago and was normal. All the following could account for her symptoms EXCEPT: a. ectropion. b. nabothian cyst. c. cervical polyp. d. cervical cancer.

b a). Ectropion is a common cause of post-coital bleeding (5-25% women w ectropion; esp in 3rd trimester) b). https://www.draliabadi.com/gynecology/cervical-conditions/nabothian-cysts/ - pus/mucus D/C is more common, as the etiology is overgrowth of epithelial cells over a cervical mucus gland c). PMID: 25045355 - "There are multiple etiologies for this common complaint in which most are benign such as cervicitis or cervical polyps. However, the most serious cause of postcoital bleeding is cervical cancer" d). Up-to-Date: About 11 percent of women with cervical cancer present with postcoital bleeding (range 0.7 to 39 percent)

A 20-year-old woman was raped 72 hours ago. She is at day 15 of a 29-day menstrual cycle and was not using contraception. Which form of emergency contraception is most effective in this instance? a. Prescribe a mini pill b. Insert a copper IUD c. Prescribe a combined oral contraceptive pill d. Prescribe levonorgesterol 750mcg stat, repeat in 12 hours

b - Copper IUD [1, IUD, STAT out to 5 days/up to 5 days post-ovulation]

A 30-year-old is considering having an IUD inserted. She is married and has a 3-year-old daughter and would like another child in the future. Which one of the following is the most significant contraindication to inserting an IUD? a. She had LLETZ treatment for CIN2 two years ago b. She has a uterine septum c. She had chlamydia cervicitis diagnosed and treated when she was 18 years old d. Her daughter was born by caesarean section

b - RANZCOG 'LARC' - only absolute contraindications to IUD use are pregnancy, insertions after puerperal sepsis or septic abortion, unexplained vaginal bleeding, Gestational trophoblastic disease (GTD) with rising βhcg, endometrial cancer, distortion of the uterine cavity from fibroids or congenital abnormality, and current Pelvic Inflammatory Disease (PID)

You receive an urgent request to attend a delivery of a term infant who has been documented as having an abnormal CTG during the second stage. The baby is born apnoeic, pale and floppy, and you decide to commence resuscitation. Which one of the following statements is true? Select one: a. If the heart rate is 80/min you should start chest compressions. b. If the infant has primary apnoea, vigorous drying and stimulation may be all the resuscitation that is required. c. It is most likely that you are dealing with primary apnoea. d. You should immediately intubate the baby.

b? (or c?) Not a). - chest compressions if HR<60 Not d) - give PPV for HR<100, not immediate intubation

The Australian Diabetes in Pregnancy Society (ADIPS) criteria for diagnosis of gestational diabetes are: Select one: a. fasting plasma glucose ≥5.5; 1hr plasma glucose ≥10.0; 2hr plasma glucose ≥8.5 b. fasting plasma glucose ≥5.5; 1hr plasma glucose ≥12.0; 2hr plasma glucose ≥8.0 c. fasting plasma glucose ≥5.1; 1hr plasma glucose ≥10.0; 2hr plasma glucose ≥8.5 d. fasting plasma glucose ≥5.1; 1hr plasma glucose ≥12.0; 2hr plasma glucose ≥8.0

c

A healthy 35-year-old woman has just delivered her fourth baby spontaneously. Prior to the delivery a small amount of fresh bleeding was noted. The cardiotocograph showed deep variable decelerations, but a normal baseline. Following delivery of the placenta, she feels faint and short of breath. Her blood pressure is 105/60, pulse 90/min. Ongoing heavy vaginal bleeding is noted. Which of the following statements is the most likely diagnosis? a. Utero-cervical laceration b. Amniotic fluid embolism c. Uterine atony d. Retained placental tissue

c - Based on fact that tone is most common cause of PPH (RANZCOG - 'Mgmt of PPH')

1. Which of the following is NOT a risk factor for shoulder dystocia? a. Maternal BMI of 35 b. Labour at 42 weeks gestation c. Mid-cavity forceps delivery d. A woman with a partner of significantly larger stature

c - intervention, not RF

1. A 35-year-old woman complains of a grey malodorous vaginal discharge especially evident post-coitally.What is the most likely cause? a. Candida albicans infection. b. Florid cervical erosion. c. Trichomonas infection. d. Bacterial vaginosis.

d

A 2-hour-old term neonate is diagnosed with Trisomy 21. The baby has hypotonia and appears centrally cyanosed and tachypnoeic. What is the likely diagnosis? Select one: a. The baby has phenylketonuria b. The baby has suffered intrapartum hypoxia c. The baby has transient tachypnoea of the newborn d. The baby has a cardiac defect

d CVS abnormalities common in DS (~50%) 3 most common heart conditions: atrioventricular septal defect, patent ductus arteriosus, and tetralogy of Fallot. AVSD is the most frequently diagnosed

When referring to contraception, the Pearl Index: a. for tubal ligation is 1 in women over 35. b. requires a study of at least 100 women to be calculated. c. represents the number of pregnancies per 1000 women-years of use. d. will differ based on the age group studied.

d - Because fecundity varies according to age. https://www.drugs.com/medical-answers/birth-control-failure-rates-pearl-index-explained-3554953/ Not: a). Can't find stats for >35, but PI = 0.18% [PMID: 12499754]; 0.5% (https://studmed.uio.no/elaring/fag/obstgyn/gyn/contraception.html) b). Not necessarily. Pearl Index = (Number of pregnancies x 12) x 100 / (Number of women in the study x Duration of study in months) c). Pearl Index = the number of contraceptive failures for a birth control method per 100 woman years (HWY) of use.

Regarding Erb's palsy, which of the following is correct? Select one: a. It occurs because of stretching of C8/T1 nerve roots. b. It persists longer than six months in 50% of cases. c. It follows 5-15% of all cases of shoulder dystocia. d. It could be prevented mostly by correct antenatal identification of selected cases needing caesarean section

d? a). Klumpke's paralysis - Lower BP injury (C8, T1) Erb's Palsy = upper brachial plexus (C5, 6) eg. hyperextension between the head & shoulder during difficult childbirth. - Paralysis of muscles responsible for abduct, flex & lateral rotation, hence arm hangs straight at side in medial rotation (pronated) w wrist in the 'waiter's tip' position C5 myotome = deltoid, some elbow flexion C6 myotome = biceps, Brachioradialis (elbow flexion) and supination b). RWH 'Shoulder Dystocia' guideline = generally recovers within 12 months. PMID: 19680484 - the rate of complete recovery is 80-96%, esp if improvement begins in the first 2wks. c). Unable to verify this stat. Not in RANZCOG, RCOG, RWH guidelines, Google. See PMID: 19680484 for good discussion. d). RFs = LGA (eg. GDM) and shoulder dystocia. Reduced but can still be seen in LUSCs

What is the fetal vertex? a. An area bounded by the posterior fontanelle and the lamboid structure b. The junction of the sagittal, coronal and frontal suture c. An area bounded by the anterior and posterior fontanelles and the parietal eminences d. The junction of the lamboid and sagittal sutures

https://www.gfmer.ch/Obstetrics_simplified/foetal_skull.htm The vertex is the area of the vault bounded; anteriorly by the anterior fontanelle and the coronal suture, posteriorly by the posterior fontanelle and lambdoidal suture, laterally by 2 lines passing by the parietal eminencies