MRCOG Part 2 - 4 Months - EMQ Mock Exam

Option List:

A. Incision at the base of the umbilicus
B. 45-90 degrees to the skin
C. Palmer’s Point
D. 45 degrees to the skin
E. Incision through the POD
F. 90 degrees to the skin
G. Suprapubic incision
H. Hasson’s technique

For each of the following scenario given below, choose the most appropriate option given from the list above. The options may be used once or more than once or not at all.

1. 25 years old woman with BMI of 17 with the previous history of STI’s is undergoing diagnostic laparoscopy for primary infertility. What is the most appropriate incision for the veress needle insertion to reduce entry related complications?

2. 36 years old woman is undergoing diagnostic laparoscopy and her BMI is 40Kg/m2. After taking all the necessary precautions, what is the ideal incision for the insertion of primary trocar to prevent complications?

3. 35 years old woman is undergoing a diagnostic laparoscopy for CPP and this is being done by an ST3 which is the first laparoscopy to be performed by the trainee. The woman has no other associated medical or surgical illness. She has had one previous normal delivery. What is the most ideal incision for this woman?

Option List:

A. Pessary
B. Sacrospinous fixation
C. High uterosacral ligament suspension
D. Sacrocolpopexy
E. Approximation of the uterosacral ligaments using continuous sutures to obliterate the culdesac as high as possible
F. Bursch colposuspension
G. Sacrocolpopexy with mesh repair for SUI
H. Colpocleisis
I. Colposuspension with sacrocolpopexy
J. Attaching the uterosacral and cardinal ligaments to the vaginal cuff

For each of the following scenario described, choose the most appropriate surgical procedure from the list of options provided. Each option may be used once or more than once or not at all

4. 87 year old woman has undergone a hysterectomy 30 years back and now has presented with vaginal vault prolapse. She is a known hypertensive, diabetic with HbA1c of 8.2 and case of coronary artery disease. On examination, she was found to have stage 3 vault prolapse on POPQ classification. What is the most appropriate surgical management for this woman?

5. 60 year old woman was diagnosed to have complete vaginal vault prolapse. She wishes to have a surgery that would retain her sexual function. While taking an informed consent, she was explained about the risk of occult urinary incontinence manifesting as SUI post-surgery. She wishes to have a surgery which would prevent SUI also, which is the most appropriate option?

6. 56 year old woman is undergoing an abdominal hysterectomy for uterine fibroids. While performing the surgery, the most appropriate procedure done to prevent post hysterectomy vault prolapse is?

Option List:

A. Labetalol oral
B. Measure blood pressure atleast 4 times a day until inpatient and then on Day 3 and Day 5 after birth and if abnormal on alternate days until normal
C. Magnesium sulphate intramuscular
D. Methyldopa oral to be stopped within 2 working days and start labetalol
E. Labetalol oral along with Aspirin 150mg
F. Labetalol intravenous
G. Monitor three times a day until discharge and follow her up in the community
H. Aspirin 150mg daily at night from 12 weeks
I. Methyldopa to be stopped within 2 workings days and continue monitoring
J. Antenatal corticosteroids
K. Transfer to the community
L. Measure Blood pressure 4 times a day while inpatient and then every 1-2 days for upto 2 weeks transfer to the community care until the woman is off treatment
M. Explain the risk of Pre-eclampsia and offer regular BP monitoring

For each scenario given above, choose the single most appropriate management option. Each option may be used once or more than once or not at all.

7. 34 year old G2P1L1 with previous normal delivery developed severe preeclampsia and was on labetalol and nifidepine and labour induced at 37 weeks. She delivered vaginally and her intrapartum period was uneventful. The most appropriate way of monitoring the blood pressure for her would be

8. 30 year old nulliparous woman at booking visit was found to have a blood pressure of 140/86, and repeat blood pressure measure again revealed 142/84. What is the treatment that she should be offered?

9. 40 year old G2P1L1 conceived following IVF, has come for a booking appointment. She gives a history of preeclampsia in the previous pregnancy. What is the recommended advice for this woman to avoid Pre-eclampsia?

10. 35 year old primigravida diagnosed to have gestational hypertension was on methyldopa250mg TID during the antenatal period and at 39 weeks delivered vaginally without any complications. The post-natal period, her blood pressure is 150/100. What is the advice that the woman should be offered?

Option List

A. Admit, start labetalol, monitor BP frequently and repeat investigations (FBS,LFT,RFT twice a week) and repeat USG every 2 weeks
B. Urinary reagent strip test 6-8 weeks after birth and further review with their GP or specialist review at 3 months if urine proteinuria is 2+ or more
C. Add labetalol to nifidepine
D. Admit, start labetolol, monitor BP atleast 4 times daily, and blood investigations three times a week and repeat USG every 2 weeks
E. Urinary reagent strip test 6-8 weeks after birth and further review with their GP or specialist review at 3 months if urine proteinuria is 1+ or more
F. Add enalapril to nifidepine
G. Start labetalol, offer outpatient management, and measure blood pressure every 48 hours, repeat urine dipstick every visit and offer blood investigations twice a week and fetal heart rate auscultation every visit
H. Change to amlodipine

11. 25 year old primigravida at 32 weeks of pregnancy was found to have 156/100 at the antenatal visits, and was found to be elevated at the same range when repeated. She was investigated and found to have an albumin: creatinine ratio of 10mg/mmol and also serum alanine transaminase of 74 IU/litre with no signs of nausea, epigastric pain, headache, or vomiting. Physical examination revealed normal findings and ultrasound revealed an adequately grown fetus and CTG was found to be normal. The appropriate management option is.

12. 29 year old G3P1L1 Abortion1 was induced labour at 37 weeks of gestation with mild pre-eclampsia for progressive deterioration of liver function and renal function tests. She delivered vaginally and the intrapartum period was uneventful. The Platelet count, transaminases and serum creatinine 48-72 hours after birth was normal and the blood pressure was normal following delivery. The appropriate follow up care wound be

13. 22 year old woman delivered vaginally, and her antenatal period was complicated by severe pre-eclampsia and following delivery was started on nifidepine. Her blood pressure was not controlled with nifidepine. The next step to control blood pressure is

Option List:

A. Topical local anaesthetic to ectocervix
B. Intracervical instillation of local anaesthetic agent
C. Cervical preparation with 200 mcg misoprostol
D. Intravenous fentanyl and midazolam
E. Paracervical and intracervical block
F. No cervical anaesthesia
G. Oral NSAIDS
H. Oral opiates

For each clinical scenario given below, choose the most appropriate anaesthesia preferred from the list of options given. Each option can be used once or more than once or not at all.

14. 52 year old postmenopausal woman is posted for outpatient hysteroscopy. The most preferred anaesthesia to prevent vasovagal attack during outpatient hysteroscopy is

15. 45 year old P3L3 presented with prolonged heavy bleeding with intermenstrual bleeding. USG showed the following picture. She was posted for hysteroscopy and polypectomy. She wishes to avoid general anaesthesia as she had a friend who did not recover from general anaesthesia.

16. 30 year old had presented with intermenstrual bleeding for the past 1 year. She is nulliparous woman and her cervical smear screening done was normal. USG examination revealed a normal uterine cavity with normal ovaries. She was posted for an outpatient hysteroscopy.

Option List:

A. Interrupted mattress suturing with 2-0 PDS using 3/8th circle needle
B. End-to-end interrupted suturing with 2-0 PDS using ½ circle needle
C. Continuous suturing with 2-0 polyglactin 3/8th circle needle
D. End to end interrupted suturing with 3-0 PDS using ½ circle needle
E. Figure of eight suturing with 2-0 polyglactin 1/2 circle needle
F. End to end interrupted suturing with 3-0 PDS using 3/8th circle needle
G. Overlapping technique with 2-0 polyglactin using 1/2circle needle
H. Overlapping technique with 2-0 polyglactin using 3/8th circle needle
I. Interrupted suturing with 3-0 polyglactin 3/8th circle needle

For each of the clinical scenarios, choose the single most likely suture material and/or the technique from the above options given

17. 20 year old underwent a rotational forceps delivery with kielland’s forceps following which had an internal and external anal sphincter injury and the anal mucosa. The most appropriate suture material and the technique used to repair IAS would be

18. 29 year old primi with GDM delivered vaginally but was complicated by shoulder dystocia. On further examination was found to have a complete tear of the External anal sphincter. The most appropriate repair of the EAS would be done with

19. 25 year old woman delivered by vacuum delivery for fetal distress, on examination was found to have a buttonhole rectal mucosa tear. The most appropriate repair would be

Option List:

A. 6.1%
B. 15%
C. 1.7%
D. 50-60%
E. 2.9%
F. 60-80%
G. 80-90%
H. 17%
I. 30-40%
J. 19%

For each of the following scenario, choose the most appropriate option from the list of options given above. Each option may be used once or more than once or not at all:

20. 20 year old primigravida has presented to the labour room with complaints of leaking P/V and labour pains at 39 weeks. She was found to be in active labour. What is the chance of OASIS in her?

21. 30 year old woman had an instrumental delivery following which she had an External anal sphincter injury and an appropriate repair. What is chance that she would be asymptomatic at the end of 12 months?

22. For a woman who had a third degree perineal tear, if allowed for a subsequent delivery what is the chance of worsening faecal symptoms?

Option List:

A. Inform Police
B. Inform child safeguarding services
C. Offer re-infibulation provided she understands the consequences
D. Clitoral reconstruction should not be performed
E. Treatment of UTI, testing for Hep B, HIV and syphilis and documentation of FGM
F. Re-infibulation can be done only during the repair of the perineum post delivery
G. De-infubulation, additional testing for Hep C along with Hep B, syphilis, and HIV, treat UTI and documentation
H. Deny re-infibulation under any circumstances
I. Refer to cosmetic gynaecologist to do clitoral reconstruction and document the referral

23. 28 year old woman presented to antenatal clinic with symptoms of UTI with 34 weeks of gestation. She was found to have type 3 FGM which was done during her childhood and it was found difficult to perform a vaginal examination and the urethral meatus was not visible. What would be the appropriate management?

24. 34 year old primigravida from Ethiopia has come in labour at 39+ weeks of gestation. On examination was found to have a type 3 FGM and after discussion with the woman was decided to go ahead with infibulation. She is requesting re-infibulation. What is the most appropriate action to be taken?

25. 20 year old woman from Somalia had undergone a type 2 FGM when she was a child. She wishes to get a clitoral reconstruction as she is getting married. The most appropriate management would be?

Option List:

A. Paired cord blood sample collection and if cord arterial PH under 7.1, incident reporting should be done
B. Wait for 1 more hour for a possible vaginal delivery
C. Vacuum assisted delivery to help rotation of the head
D. Abandon vacuum delivery and perform emergency LSCS
E. Sequential use of rotational forceps to aid delivery of the baby
F. With adequate analgesia in place, outlet forceps delivery
G. Low forceps delivery with appropriate analgesia
H. Paired cord blood sample collection and if cord arterial PH under 7.2, incident reporting should be done
I. Shift to theatre to perform a low forceps delivery

26. 32 year old G2P1L1 with a BMI of 31 at 40 weeks of gestation was induced labour with PGE2 gel. She progressed well into the second stage of labour. She was fully dilated 2 hours ago and active pushing for almost an hour, the examination findings revealed, no fetal head was palpable per abdomen, vertex was at +2 and caput + with no moulding and the fetal head in left occipito transverse position. The woman is extremely exhausted and Electronic fetal monitoring shows late decelerations. What is the most appropriate action?

27. 27 year old primigravida is admitted with spontaneous onset of labour at 39+ weeks. Her antenatal period was uneventful except that she is Rh negative. At admission, she was found to have 4 contractions in 10 minutes lasting for 40-45 seconds and admission CTG was reactive. She progressed well with epidural analgesia and was fully dilated for three hours and pushing for almost more than 1 hour. Examination findings revealed less than 1/5^th of head palpable per abdomen and vertex at +1 station and in right occipito transverse position and no catput or moulding. CTG reveals variable deep decelerations with no accelerations and reduced variability. She was shifted to the theatre and with appropriate analgesia, rotational vacuum delivery was attempted and there was no progressive descent with moderate traction with each contraction. What is the most appropriate management?

28. 30 year old Primigravida woman had a spontaneous onset of labour at 39+5 days and progressed well into labour. There was a presumed fetal compromise hence outlet forceps delivery of the baby was done. The most appropriate action would be.

Option List:

A. Oxybutynin
B. Tolteridine
C. Darifenacin
D. Mirabegron
E. Colposuspension
F. Desmopressin
G. Transvaginal sling procedures
H. Oxybutynin with bladder training
I. Mirabegron with bladder training
J. Botulinum toxin A
K. Botulinum toxin B
L. Duloxetine

29. 58 year old woman who had recovered from myasthenic crisis 6 months back. Following this she had presented with symptoms of urgency, urge incontinence and frequency. Urinary dipstick evaluation by the GP showed no evidence of infection, following which 6 weeks of bladder training was advised. The woman did not achieve satisfactory benefit from the bladder training programme. What is the next step of management?

30. 50 year old multiparous women presented with stress urinary incontinence and no history frequency was advised supervised pelvic floor muscle training for 6 months with very little effect. She wishes to have a definitive benefit but is not willing to undergo surgery. The best drug for the management is

31. 60 year old woman multiparous woman with increased frequency, urgency and urge incontinence and nocturia. She was put on oxybutynin which she did not tolerate. So, she was put on transdermal oxybutynin, but the nocturia was a troublesome that makes her use the washroom four to five times. The next best management would be

Option List:

A. Bladder wall injection of botulinum toxin A 100 units
B. Long term indwelling urethral catheterisation
C. Bladder wall injection of Botulinum toxin A 200 units
D. Open colposuspension
E. Indwelling suprapubic catheter
F. Intramural bulking agents
G. Vaginal sacrospinous hysteropexy with sutures
H. Laparoscopic colposuspension
I. Vaginal hysterectomy with or without vaginal sacrospinous fixation with sutures
J. Sacrohysteropexy with mesh

For each of the following clinical scenario, choose the single most appropriate management from the list of options given above. Each option may be used once, more than once or not at all

32. 45 year old P3L3, all delivered by caesarean section, had presented to the GP with complaints of stress urinary incontinence. She has not had any satisfactory relief and wants a permanent relief. She is very unhappy using any mesh. The most appropriate management option is?

33. 49 year old woman has been treated with bladder training along with oxybutynin for overactive bladder. She was reviewed after 4 weeks during which was found to have no benefit. She is distressed that her quality of life is affected and wants a definitive treatment. The best management option would be.

34. 45 year old had presented with stage 3 pelvic organ prolapse with no demonstrable anterior or posterior wall prolapse. she wishes to have a definitive treatment. She wishes to retain her uterus and is not keen on removal of uterus. The best treatment option would be

Option List:

A. 4-5%
B. 0.5%
C. 6%
D. <0.02%
E. 5%
F. 20%
G. 2-3%
H. 10%

From the list of options given above, choose the most appropriate single best option for the questions given below. Each option may be used once or more than once or not at all

35. G3P2L2 has had two previous caesarean section and is planned for an elective repeat CS. What is the chance that she might go into labour before 39 weeks?

36. 38 year old G2P1L1 has had previous one caesarean section. She wishes to have an elective repeat CS at 39 weeks. What is her actual risk of developing uterine rupture even if she has an ERCS?

37. 29 year old woman has had a previous CS done for breech delivery. She wishes to have a repeat CS at 38 weeks. What is the risk of transient respiratory morbidity ?

Option List:

A. Within 10 days postpartum
B. Discussion regarding induction of labour immediately
C. Discussion regarding induction of labour after 37+0 weeks
D. Topical emollients
E. Every week until LFT becomes normal
F. Beyond 10 days- 6 weeks postpartum
G. At the post-natal visit at 8 weeks
H. Urso deoxycholic acid
I. Dexamethasone

38. 29 year old woman with 36+5 weeks pregnancy was diagnosed to have obstetric cholestasis. LFT done was in the upper limit of the pregnancy specific ranges and the bile acid were found to be more than 20 mmol/litre. She has intractable itching responding to topical emollients. What is the best management option?

39. 26 year old woman had delivered vaginally following induction of labour for severe obstetric cholestasis nearing term. When should she be offered measurement of liver function tests?

40. 35 year old G2P1L1, has come with intense itching all over the body including palms and soles. She was prescribed emollients by her GP, which did not have any effect. Itching is so intense that it is disturbing her sleep. The best treatment option for to reduce itching and to improve liver function test for her is

Option List:

A. Non-steroidal anti-inflammatory
B. Referral to urologist
C. Danazol
D. Oral contraceptive pills
E. LUNA
F. Mebeverine hydrochloride
G. Diagnostic laparoscopy
H. Screen for sexually transmitted infection
I. Gastroenterology referral
J. Refer her to specialist doctor for diagnostic and /or operative laparoscopy
K. Referral to pain team
L. Referral for counselling
M. Gabapentin
N. Do pregnancy test and screen for sexually transmitted infections

For each of the following clinical scenarios, what would be the most appropriate management from the options above? Each option may be used once, more than once or not at all.

41. A 58-year-old woman had a transobturator vaginal tape procedure (TOT) about 12 months ago. She has been complaining of groin pain on the left side for some time now, which started about six weeks after the procedure. The pain radiates down the back of thigh and she feels as if there is an electric current that passes down the leg.

42. A 66-year-old woman complains of lower abdominal pain when typically the bladder fills up. Ultrasound scan suggested a small cyst on the left ovary.

43. A 23-year-old woman says she is in a new relationship and is finding it hard to have penetrative sex. She has recently been complaining of lower abdominal pain. You notice that during the whole consultation she is looking at her feet and not maintaining eye contact.

44. A 34-year-old woman has history of irregular menses. She attends the gynaecology clinic with complaints of irregular vaginal bleeding and postcoital bleeding and complains of chronic pelvic pain since many years.

45. You are a GP and see a 38-year-old woman complaining of heavy menstrual bleeding, severe dysmenorrhoea. An ultrasound scan was highly suggestive of an endometrioma on the left adnexa.

46. A 26-year-old woman referred by her GP complains of lower abdominal pain for over 12 months. She feels that the pain occasionally gets better with the passage of stools. You advise her referral to gastroenterologist but right now she will not be able to follow it. In view of her symptoms what is the treatment?

Option List:

A. Break both the clavicles
B. Elective Caesarean section
C. Emergency Caesarean section
D. Episiotomy
E. Delivery of the posterior arm
F. Fundal pressure
G. Lovset manoeuvre
H. McRoberts’ position and suprapubic pressure
I. Downward traction
J. Rubin manoeuvre
K. Reverse Wood screw manoeuvre
L. Get the patient to roll over onto all fours
M. Symphysiotomy
N. Ask the patient to stop pushing and buttocks at the edge of the table.
O. Suprapubic pressure
P. Wood screw manoeuvre
Q. Zavanelli procedure
R. Do a mild traction in an axial direction to confirm the diagnosis.

Instructions: For each clinical scenario described below, choose the single most appropriate management option from the list of options above. Each option may be used once, more than once, or not at all.

47. A 27-year-old healthy woman has no significant medical history, no complaints during 9 months of pregnancy. She has a normal labour and a spontaneous delivery of the fetal head. On expulsion of the head, the head remains tightly applied to the vulva. The midwife activated the emergency buzzer and declared that there is shoulder dystocia. You attended immediately.

48. A 35-year-old woman with two children attends the antenatal clinic at 37weeks’ gestation to discuss mode of delivery. She had her last delivery 2 years ago and gives a history of a difficult delivery with forceps, following which her child developed Erb’s palsy.

49. A 25-year-old healthy woman has a normal labour and a spontaneous delivery of the fetal head. On expulsion of the head, the head remains tightly applied to the vulva. The midwife activated the emergency buzzer and declared that there is shoulder dystocia. Meanwhile what is expected from midwife?

50. A 32-year-old Chinese lady with short stature develops gestational diabetes. She is being induced at 38 weeks for fetal macrosomia. After delivery of the head shoulder dystocia is diagnosed with both fetal shoulders above the pelvic brim. What is the appropriate next step?

Option List:

A. Will continue treatment with tranexamic acid.
B. Counsel the patient directly for hysterectomy considering age, ET and BMI in mind.
C. Undertake outpatient hysteroscopy and endometrial biopsy
D. Undertake outpatient hysteroscopy and endometrial biopsy and discuss risk/benefits of insertion of Mirena LNG-IUS with the woman prior to hysteroscopy.
E. General anaesthetic day-case hysteroscopy and endometrial ablation
F. Request a full blood count, endocrine profile (FSH, LH, testosterone, prolactin, day 21 progesterone, estradiol, TFTs) and fasting glucose/HbA1c.
G. Hysteroscopic polypectomy
H. Undergo imaging, with biomarkers and MDT meeting before any treatment.
I. Laparotomy with hysterectomy
J. Staging Laparotomy with hysterectomy and bilateral salpingectomy
K. Hysteroscopic guided polypectomy with endometrial biopsy
L. Laparoscopic hysterectomy with bilateral salpingo-oopherectomy
M. LNG-IUS followed by EB after 3 months

For each patient described below choose the single most appropriate management option from the list. Each option may be used once, more than once, or not at all.

51. Mrs.X is a 48-year-old woman, para 3, BMI- 38, presenting to secondary care with a 3-year history of worsening HMB with irregularity of her menstrual cycle. She is unresponsive to a 4 month course of transexamic acid treatment. Her cervical smear 12 months ago was normal. The woman’s pelvic ultrasound shows endometrial thickness of 15 mm with no uterine structural abnormalities and normal ovaries. What is the further line of management?

52. A 54-year-old woman nulliparous, was operated for breast cancer 3 years back and is on Tamoxifen. She now complains of bleeding per vagina on and off for last 3 months. USG reveals multiple polys. What will be the next step in her management?

53. A 54-year-old woman nulliparous, was operated for breast cancer 3 years back and is on Tamoxifen. She now complains of bleeding per vagina on and off for last 3 months. USG reveals multiple polys. Polypectomy and EB done. Biopsy report reveals atypical hyperplasia. What is management for this patient?

Option List:

A. V/Q scan
B. Lung ventilation scan
C. Pulmonary angiography
D. ECG
E. Lung perfusion scan
F. Arterial blood gases
G. Chest X-ray
H. Lower limb Doppler ultrasound scan
I. D-dimers
J. CTPA
K. Spirometry
L. Lower limb venogram

Instructions: For each of the scenarios below, select the single most appropriate subsequent investigation from the above list. Each option may be used once, more than once, or not at all.

54. A healthy 28 year old woman presents at 35 weeks gestation with sudden onset of shortness of breath and chest pain. She has a pulse of 120 / min, BP 120/80 and SO2 = 94% on air. She is administered a therapeutic dose of low molecular weight heparin. Chest X-ray and lower limb Doppler’s are normal. Following counselling, the woman prefers the investigation that exposes her foetus to the lowest level of radiation.

55. A healthy 32 year old woman presents at 36 weeks gestation with sudden onset of shortness of breath and pleuritic chest pain. She has a pulse of 110 / min, BP 120/80 and SO2 = 95% on air. She is administered a therapeutic dose of low molecular weight heparin. Chest X-ray and lower limb Dopplers are normal. Her mother suffered from breast cancer at age of 55years. She wants to decrease any fetal exposure to radiation.

Option List:

A. Commence intravenous prophylactic unfractionated heparin
B. Commence prophylactic low molecular weight heparin
C. Remove catheter 8 hours after giving the last dose of heparin
D. Change to prophylactic intravenous unfractionated heparin
E. Remove catheter 12 hours after giving the last dose of heparin
F. Change to heparinoid (danaparoid sodium)
G. Remove catheter 24 hours after giving the last dose of heparin
H. Check for antiphopholipid antibodies and Commence prophylactic low molecular weight heparin
I. Change to low-molecular weight heparin (LMWH)
J. Withhold heparin for 12 hours before giving spinal anaesthesia
K. Commence prophylactic low molecular weight heparin
L. Withhold heparin for 24 hours before giving spinal anaesthesia
M. Commence dalteparin
N. Withhold heparin for 6 hours before giving epidural anaesthesia
O. Monitor anti-Xa levels
P. Withhold heparin for 12 hours before giving epidural anaesthesia
Q. Stop LMWH and control bleeding, may require change to UFH.
R. Remove catheter 3 hours after giving heparin
S. There should be gap of 4 hours between LMWH and removal of epidural catheter.

56. A 40-year-old woman, para 1, presents to the obstetric day assessment unit at 28 weeks of gestation with 3 episodes for reduced fetal movements (normal cardiotocograph [CTG] and colour Doppler). Her notes indicate that she had DVT at 20 weeks of gestation during her current pregnancy and is on 80 mg LMWH twice daily. Her booking blood results were normal. However, her recent blood test reveals a platelet count of 60 x 109/L.

57. A 35-year-old woman, gravid 3, para 2, is admitted to the antenatal ward for an elective caesarean section for breech presentation. She had pulmonary embolism during this pregnancy and has been on a therapeutic dose of LMWH (90 mg twice daily) for the last three months. She took her last dose just before coming into the ward.

58. A 43-year-old woman, para 3, presents to the EPAU at 12 weeks of gestation with mild vaginal bleeding. She gives a history of unprovoked deep venous thrombosis (DVT) 1 year prior to this pregnancy and was treated with warfarin for 6 months. In both last pregnancies she developed pre- eclampsia. Currently, the general practitioner has started her on aspirin in view of a previous history of pre-eclampsia.

59. A 26 -year-old woman, para 1 (delivered 6 hours ago), gives a history of previous thrombophilia. Her mode of delivery was caesarean section for a prolonged second stage of labour. She had a massive postpartum haemorrhage and her current haemoglobin level is 8 g/dL. The midwife comes to inform you about the minimal soakage of the caesarean section wound dressing.

60. A 36-year-old woman, para 3, is reviewed by the senior house officer in the postnatal ward. She had a caesarean section for failure to progress and has been using an epidural for pain relief for the last 4 hours following caesarean section. The midwife wants to give her the dose of prophylactic LMWH. What advice is given to midwife?

Option List:

A. Stop heparin
B. Thrombophilia screen
C. Convert warfarin to low molecular weight heparin
D. Stop warfarin
E. Advise against pregnancy
F. Warfarin as soon as possible
G. Convert low molecular weight heparin to warfarin
H. Close observation for additional risk factors
I. Graduated elastic compression stockings
J. Low molecular weight heparin as soon as possible
K. Low molecular weight heparin from 12 weeks

Instructions: For each scenario described below, choose the single most appropriate antenatal management from the above list of options. Each option may be used once, more than once, or not at all.

61. A 28 year old woman attends the antenatal clinic at 16 weeks gestation. She suffered a DVT at the age of 20 in the axillary vein.

62. A 32 year old woman attends the antenatal clinic at 8 weeks gestation. She suffered a DVT at the age of 18 but does not recall the specific circumstances. Her sister suffered from pulmonary embolism at the age of 42.

63. A 32 year old woman attends the antenatal clinic at 22 weeks gestation. She is known to be a carrier of the factor V Leiden mutation but has never had a thromboembolic event. Her BMI is 24.

Option List:

A. Administer regional analgesia if APTT is normal
B. Administer regional analgesia if APTT and PT are normal
C. Administer protamine sulphate then regional analgesia
D. Administer prophylactic dose of LMWH
E. Check anti-Xa levels then administer regional analgesia if normal
F. Advice that regional analgesia is contra-indicated
G. Request accepted and administer regional analgesia
H. Remove epidural catheter
I. Check APTT then remove epidural catheter if result is normal
J. Advise against removal of epidural catheter
K. Wait for 2 hours then administer LMWH

Instructions: For each scenario described below, choose the single most appropriate management from the above list of options. Each option may be used once, more than once, or not at all.

64. A 24 year old woman with a previous DVT and has been treated with a prophylactic dose of low molecular weight heparin during pregnancy. She presents in spontaneous labour at 37 weeks gestation and requests epidural analgesia. Her last dose of heparin was 16 h earlier.

65. A 26 year old woman with a previous DVT and has been treated with a prophylactic dose of low molecular weight heparin during pregnancy. She presents in spontaneous labour at 37 weeks gestation and receives epidural analgesia, as her last dose of heparin was 14 h earlier. Her epidural catheter is removed about 2 hours ago. When can she be given her next dose of LMWH?

66. A 25 year old woman with a BMI of 36 has an emergency caesarean section at full dilatation under spinal anaesthesia because of foetal distress. The procedure was uncomplicated with blood loss of 700ml. She is now post-surgery and your attention is drawn to instructions on post-partum thromboprophylaxis.

Option List:

A. Chlorpropamide
B. Glibenclamide
C. Gliclazide
D. Insulin aspart
E. Insulin detemir
F. Insulin glargine
G. Insulin lispro
H. No treatment required
I. Isophane insulin (NPH insulin)
J. Metformin
K. Phenformin
L. Sitagliptin
M. Pioglitazone
N. Rosiglitazone
O. Tolbutamide
P. Troglitazone

For each of the following clinical scenarios, choose the single most appropriate medication from the list of options above. Each option may be used once, more than once or not at all.

67. A woman with a BMI of 33 kg/m2 and persistent glycosuria underwent a glucose tolerance test at 26 weeks of gestation.

Her results are as follows:
Fasting glucose
7.3 mmol/l
2-Hour glucose
10.1 mmol/l
What immediate treatment is recommended?

68. A 36-year-old woman is newly diagnosed with gestational diabetes at 27 weeks of gestation. She has modified her diet and undertaken an exercise regime but her plasma glucose levels remain slightly elevated after 2 weeks of this new regime. She was advised to start medication, but she wish to take oral drug than insulin. What is the most appropriate treatment for her?

69. A woman with type 2 diabetes was taking Rosiglitazone prior to pregnancy as she could not tolerate the gastrointestinal side effects of metformin. She was switched to insulin therapy in the antenatal period. She has now delivered and wishes to breastfeed. If oral hypoglycaemic agents are required, what treatment would be recommended?

Option List:

A. Fasting glucose ≤5.3 mmmol/l, 1-hour postprandial glucose ≤7.8 mmol/l, 2-hour postprandial glucose ≤6.4 mmol/l
B. Fasting glucose 4–7 mmol/l, preprandial glucose 5–7 mmol/l
C. Fasting glucose 5–7 mmol/l, preprandial glucose 4–7 mmol/l
D. Fasting glucose ≤5.6 mmmol/l, 1-hour postprandial glucose ≤7.2 mmol/l, 2-hour postprandial glucose ≤6.4 mmol/l
E. Fasting glucose >5.6 mmol/l and 2-hour postprandial glucose >7.8 mmol/l
F. Fasting glucose >5.6 mmol/l or 2-hour postprandial glucose >7.8 mmol/l
G. Glucose levels >4 mmol/l
H. Glucose levels between 4 and 7 mmol/l
I. One-hour postprandial glucose 7.8 mmol/l
J. Preprandial glucose 4–6 mmol/l
K. Fasting glucose >6 mmol/l
L. Two-hour postprandial glucose 6.4 mmol/l

Each of the following clinical scenarios relates to a woman with diabetes. From the list of options above, for each woman select the single most appropriate test result. Each option may be used once, more than once or not at all.

70. A 30-year-old woman at 26 weeks of gestation is seen in the combined antenatal clinic following a diagnosis of gestational diabetes. What would be the recommendation for target levels of blood glucose during the pregnancy?

Option List:

– Image A

– Image B

– Image C

MATCH THE ABOVE IMAGE OPTIONS WITH THE STATEMENTS BELOW, ANSWER MAYBE REPEATED/NOT USED

71. “Pinpoint” submucosal hemorrhages on cystoscopy

72. Distinctive inflammatory lesion with characteristic central fragility, which ruptures on hydrodistension.

73. It is usually a solitary lesion but 2-3 lesions may be present. This lesion is typically visible before the bladder is distended. On cystoscopy, it appears as a circumscript reddened mucosal area with small vessels radiating towards a central scar

74. Petechial oozing on increasing distention pressure

75. Lesion typical in grade 3 BPS

Option List:

A. Haemorrhagic cyst
B. Dermoid cyst
C. Suspicious malignant cyst
D. Endometrioma
E. Simple cyst
F. Mucinous cystadenoma

76. 28 year old P1 presenting to the ER with worsening left sided pelvic pain. No abnormal discharge. No vaginal bleeding. No fever. LMP: 2 weeks ago. Not currently sexually active. General examination appears uncomfortable, non-toxic Abdomen: soft, mild LLQ tenderness to palpation, No guarding/rigidity. Speculum exam: normal; Bimanual examination: Uterus normal size, mobile. No frank Cervical motion tenderness. Fullness on the left. Urine pregnancy test negative Abd/pelvic US ordered revealed an 8 mm cyst unilocular anechoic with no solid component

77. 36 year old P2 with sudden onset pain in right lower quadrant. Some N/V associated with pain, now better. No vaginal discharge. No fevers. Not currently sexually active. LMP 3 weeks ago, some irregularity Vital signs – pulse 100, regular G/E: uncomfortable Abdomen: soft, ND, RLQ pain No Rigidity/Guarding Speculum exam: normal BME: normal uterus, mild Cervical motion tenderness but localizes to the right. Tender mass on the right. Voluntary guarding Urine pregnancy test neg
WBC 11.2 Hgb 10.9 Plts 287
Imaging ordered Cystic mass with diffuse low-level echoes; “reticular pattern” of internal echoes

78. 35 year old presenting with severe menstrual pain. Life long problem, seems to be getting worse with longer episodes of pain, mostly around menstrual cycle, but pretty much anytime. Using NSAIDS for pain but no longer enough. Is developmentally delayed but speaks for herself and is appropriate LMP; on day 5 today. Mostly regular Vitals Stable.Gen: Tired. Non-toxic Abdomen: soft, diffuse, mild tenderness. Large anterior firm mass. Mild R/G. Speculum: normal BME: Large anterior mass. RVE: no nodularity. Tender Urine pregnancy test neg
WBC 7.2
Hgb 10.7
Plts: 299
Imaging ordered Homogenous and hypoechoic mass Diffuse low-level echoes (Ground Glass) No internal flow of color

79. 31 year old presenting with a history of intermittent severe left sided pelvic pain. Has occurred two separate times. Not related to menstrual cycle. Was going to come in earlier, but pain went away. No abnormal discharge. No fevers. On COCs, satisfied. Monogamous, married. Considering conception soon. Vitals stable. Gen: Well. Healthy Abdomen: soft, non tender throughout. Vaginal: normal BME: 5-6cm left sided mass, non tender, mobile.

Urine pregnancy test neg
WBC 6.3
Hgb 13.2
Plts: 342
Imaging Ordered showed a Hypoechoic mass with hyperechoic nodule, containing calcifications with a fat-fluid level.

80. 58 year old P2 presenting with vaginal spotting. No pain. Mild GI dyspepsia. No constipation or diarrhea. Otherwise well. Menopausal ~6 years. No HRT. Vitals stable. General examination: Well. Healthy Abdomen: soft, non tender throughout. Vaginal: normal, no blood in vault, no lesions.

BME: normal uterus, right sided fullness, non tender, moderately mobile. Normal left adnexa
Bedside TVUS done:
Endometrial echo 5.3mm, homogeneous. 6cm right sided cystic adnexal lesion, with vascularized nodularity. LO not seen. No FF.
CA 125 awaited

Option List:

A. 15
B. 4
C. 7.5
D. 20
E. 32
F. Any level
G. In association with anti-c

Referral to fetal medicine specialist should take place at what level for the following antigens from the above option list.

81. D

82. Kell

83. E

84. C

85. Unidentified antigen

Option List:

A. Advice against pregnancy
B. Advice regarding diet, nutrition and contraception for 6 months
C. Cessation of smoking and lifestyle modification
D. Complete blood count, HbA1c, blood sugar and renal function tests
E. Complete blood count, screening for asymptomatic bacteriuria
F. Genetic counselling
G. lifestyle advice and high-dose folic acid supplement
H. omega fatty acids supplement
I. Immune status and partner screening
J. Folic acid 1 mg
K. Prophylactic antibiotics
L. Prophylactic cervical cerclage
M. Rubella screening and 400 mcg folic acid daily
N. Screening for sexually transmitted infections
O. Multidisciplinary review

For each of the following questions, choose the single-most appropriate option from the list A–O. Each option may be chosen once, more than once or not at all.

86. A 34-year-old Asian woman attends the preconception clinic for advice before planning her pregnancy. She weighs 98 kg and her BMI is 35. Her recent blood sugar levels are within normal limits. Her HbA1c is 5.2%.

87. A 28-year-old Asian woman is contemplating pregnancy after a year. She has sickle cell disease, and is duly immunised and vaccinated and is under regular review of her hematologist. Partner is evaluated and does not have any haemoglobinopathy.

88. A 42-year-old woman seeks preconception advice. She is a known epileptic and is on polytherapy AED.

89. A 29-year-old banker seeks advice regarding pregnancy. She is a hemophila carrier and smokes socially. She was never in a long-term relationship and was screened negative for STIs recently. She is now planning pregnancy with her current partner.

90. A 27-year-old woman attends the outpatient clinic for advice. She has undergone a weight reduction surgery 6 months back and has achieved her target BMI of 28. She is having regular cycles but complains of easy fatiguability.

Option List:

A. Chlamydia trachomatis
B. Neisseria Gonorrhoea
C. Mycobacterium genitalium
D. Trichomonas Vaginalis
E. Candidiasis

91. A 32 year lady diagnosed with PID received treatment with Moxifloxacin and has been called for TOC at 4 weeks. Which is the most likely organism?

92. Organism for which TOC is only required in some cases like a pregnancy and not earlier than 3 weeks

93. TOC 7 days following treatment using RNA NAAT

94. TOC 14 days following treatment using DNA NAAT

95. Most commonly reported curable bacterial STI in the UK with a high frequency of transmission, with concordance rates of up to 75% of partners being reported

Option List:

A. Aspirin 75 mg
B. Aspirin 150 mg
C. Aspirin plus LMWH
D. LMWH 7 days
E. LMWH 6 weeks

96. A 23-year-old woman with β-thalassaemia major attends the antenatal clinic at 8 weeks of gestation. Cardiac function tests performed 12 weeks ago were normal. She has had a splenectomy. Her current blood test results are: Haemoglobin 105 g/l Platelets 650 × 109/l and Serum fructosamine 275 mmol/l

97. A 28 year old year patient with beta thalassemia presents to the EPU. She is 8 weeks pregnant. You note she has had a splenectomy. Her current platelet count is 450 x 10³/ml.

98. A 32 year primigravida BMI 40 at 12 weeks of gestation with twins

99. 36 year old thalassemic patient delivered vaginally, being discharged

100. Known case of sickle cell disease delivered vaginally after prolonged labour, being discharged

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MRCOG Part 2 – 4 Months – EMQ Mock Exam

MRCOG Part 2 – 4 Months – EMQ Mock Exam

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