MRCOG Part 2 – Management of Labour & Delivery EMQ

Option List
A. Early ultrasound assessment for fetal anaomalies
B. Uterine artery Doppler at 20-24 weeks of gestation
C. USG assessment for fetal echogenic bowel
D. Uterine artery Doppler at 24-28 weeks of gestation
E. Serial assessment of the fetal size from 26-28 weeks
F. Aspirin 150mg from now till birth of the baby
G. Assessment for SGA is not indicated for this women
H. Umbilical artery Doppler assessment in third trimester
I. Serial fetal growth and Doppler assessment from 26-28 weeks
J. Aspirin 75 mg daily from 16 weeks till 34 weeks of pregnancy
K. Umbilical artery Doppler assessment every 2 weeks
L. Monitor the SFH on a customised growth chart

1. Ms. Spencer 26 year old G2P1L1 attends the clinic for a booking visit at 12+5 weeks. Her previous pregnancy was 1 year back ended up in a normal vaginal delivery following induction of labour at 37 weeks for a small for gestational age and the weight of the baby was at the 9th centile. She is otherwise fit and fine with a BMI of 20, non-smoker and non alcoholic, and has good diet pattern. The most appropriate step in the management of this woman is

2. 36 year old G3P2L2 attends the booking clinic. She has had two previous normal vaginal deliveries. John and Jim are 8 years and 6 years respectively. Her first pregnancy was complicated by eclampsia 36 weeks and was induced at 36 weeks. At present, her BMI is 27, she is a non-smoker and non-alcoholic. The most appropriate step in the assessment of SGA for the woman is

3. 21 year old G2P1L1 presented to the booking clinic with 13 + weeks of pregnancy. Her previous pregnancy was complicated by severe Pre-eclampsia and had a preterm delivery by caesarean section at 35 weeks of gestation. Her BMI is 26 and her first trimester aneuploidy screen showed PAPPA 0.44. The most appropriate step that is clinically relevant for her now is

4. 24 year old primigravida with a BMI of 25 at booking was assessed to be low risk for SGA. During the study of fetal anatomy, the following appearance was noted. The appropriate management option would be?
Fig I

Fig II

Option List
A. Fortnightly ultrasound for AC and EFW and umbilical artery Doppler
B. Weekly AC and EFW with daily umbilical artery Doppler and ductus venosus monitoring
C. Delivery is recommended following a course of steroids
D. Uterine artery Doppler at 24-28 weeks of gestation
E. Serial assessment of the fetal size from 26-28 weeks
F. Aspirin 150mg from now till birth of the baby
G. Assessment for SGA is not indicated for this women
H. Umbilical artery Doppler assessment in third trimester

5. 42yr old primigravida with BMI of 27 conceived following Assisted reproduction, underwent SGA assessment of the fetus. The fetal growth was plotted on the graph and is given below

The uterine artery Doppler showed the following appearance

The most appropriate management for her is.

6. 30 year old G3P2L2 at 30 weeks was diagnosed to have an fetus with EFW which when plotted on the graph was <5th percentile. The umbilical artery Doppler revealed the following appearance

The most appropriate management option for the woman is

7. This is a linked question to Q5. The woman in Q5 was further followed up and at 30 weeks showed the Doppler waveform as given below. What is the most appropriate action?

Option List
A. Normal Doppler of the uterine artery in the second trimester
B. Normal uterine artery Doppler in the first trimester
C. Reduced pulsatility index vasodilation of the MCA
D. Normal Doppler of the uterine artery in the second trimester
E. Normal uterine artery Doppler in the third trimester
F. Increased pulsatility index
Identify the following images

8. Image 1

9. Image 2

10. Image 3

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.

11. 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?

12. 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?

13. 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?

MRCOG Part 2 – Management of Labour & Delivery EMQ

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8. Question

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6. Question

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13. Question

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