1. Week 11- SBA Practice 3
MRCOG FINAL PREPARATION: ENHANCED REVISION PROGRAMME
Author: Mr Fadi Alfhaily
Colchester Hospital University NHS Foundation Trust

2. Aims and objectives
To review: Urinary incontinence in women: management; NICE Clinical guideline Published: 11 September 2013
To discuss briefly the work based assessment tools during UK training in Obstetric and gynaecology.
To do more SBA practice

3. SBA practice
A 30-year-old woman had ovulation induction with human menopausal gonadotrophin injections and has been admitted with clinical features of suggesting she has ovarian hyperstimulation syndrome(OHSS). Which of one following options is one of the diagnostic features of severe OHSS? A
A haematocrit between 0.45 to 0.55 in a full blood count result B
Ovarian volume by ultrasound scan of more than 12 cm3 C
Serum albumin level less than 36 g/l D
Symptom of recurrent vomiting E
Ultrasound scan evidence of ascites
Answer: A
Comments:
Serum albumin of 36 g/l is a normal finding. All the others are features of moderate OHSS.

4. Mrs Weston is admitted at 04:00 hours
Mrs Weston is admitted at 04:00 hours. She is a parous woman and was booked for antenatal care in another hospital and now appears to be distressed with pain. She is now 40 weeks of gestation and does not have her handheld notes. She is keen to have a water birth. Abdominal examination indicates an above average sized baby. A CTG shows a few variable decelerations, baseline rate of 160 beats per minute, and normal baseline variability. On examination her cervix is fully dilated and fetal head appears to be at ‘zero’ station. You have received Mrs Weston’s antenatal notes faxed from her booking hospital which shows an entry 7 months ago stating lack of mental capacity for consent regarding a surgical operation.
Which one of the following plan about consent in this circumstance is most appropriate for Mrs Weston? A
As per Mrs Weston’s wishes allow an hour of pushing in the birthing pool B
Assume lack of capacity because of labour pains and proceed to undertake operative delivery C
Because Mrs Weston lacks capacity, and in her best interest, proceed for an examination under anaesthesia, trial of instrumental delivery D
Explain to her husband and take consent from him for operative delivery of the baby E
Try to reassess Mrs Weston’s mental capacity to consent and then proceed accordingly
Answer: E
Comments:
Because the duration of second stage and abnormal CTG remains unknown it is inappropriate to allow further pushing in second stage particularly in a parous woman. Women do not lack capacity to consent because of pain. The record of lack of mental capacity may have arisen from a transient cause and hence reassessment is necessary. Consent obtained from husband is not a legally viable requirement for carrying out a treatment.

5. Genuine stress incontinence
A 53-year-old woman with symptoms of leakage of urine on coughing and sneezing. She is also complains of frequency and urgency but no urgency incontinence. Urodynamic studies show a bladder capacity of 450ml. The bladder is stable throughout but leakage is observed with cough test without a detrusor contraction. Which of the following is the correct diagnosis? A
Genuine stress incontinence B
Mixed urinary incontinence C
Urinary stress incontinence D
Urodynamic mixed incontinence E
Urodynamic stress incontinence
Answer: E
Comments:
Urinary SI is a symptom not urodynamic diagnosis.

6. Detrusor overactivity
A 47-year-old woman presents to the clinic with symptoms of frequency of micturition, mild urgency, occasional urgency incontinence and stress incontinence of urine. The cystometry shows a bladder capacity of 208ml. Coughing produce a strong increase in detrusor pressure and urinary leakage is observed. Which of the following is the correct diagnosis? A
Detrusor overactivity B
Mixed incontinence C
Overactive bladder D
Poor bladder compliance E
Urodynamic stress incontinence
Answer: A
Comments:
This is cough induced detrusor overactivity.

7. Anti-cholinergic drugs
A 51-year-old P3 presents to the clinic with a history of stress urinary incontinence, urgency and frequency of micturition. Her completed bladder diary shows 10 voids per day. Bladder capacity is only slightly below average and about 40% of her incontinence episodes are associated with activity. What is the most appropriate management for this case? A
Anti-cholinergic drugs B
Bladder training C
No treatment necessary D
Pelvic floor muscle physiotherapy and bladder re-training E
Tension free vaginal tape insertion
Answer: D
Pelvic floor muscle physiotherapy and bladder re-training
Comments:
This lady is likely to have predominantly stress incontinence and the NICE recommendation is a three month trial of pelvic floor physiotherapy as first line treatment.

8. Botox bladder injections
A 49-year-old woman, P3, presents with a history that suggests a mixed urinary incontinence. She has had a course of pelvic floor physiotherapy and muscle training and trial of anticholinergics. During filling cystometry the bladder remained stable. There was leakage of urine on coughing during the test. The symptoms are affecting her quality of life adversely. Which of the following options is the next appropriate management? A
Botox bladder injections B
Clam cystoplasty C
Discuss surgical options of USI D
Mirabegron (B3 adrenoceptor agonist) E
Sacral nerve stimulation
Answer: C
Discuss surgical option od USI
Comments:
Urodynamics shows USI. PFMT has already been tried unsuccessfully. Hence according to NICE, the next management option.
You may want to discuss briefly the recent issues related to mesh insertion for USI and prolapse

9. Anterior repair with bladder buttressing
A 45-year-old woman complains of urgency, frequency of micturition and stress incontinence. She has to wear pads during the day and her symptoms failed to respond to pelvic floor physiotherapy. Urodynamics shows a bladder capacity of 400mls; detrusor pressure reached 3cmH20 during filling; stress incontinence was positive without a detrusor contraction. She voided to completion with a maximum flow rate of 23 ml/s. Based on these urodynamic results, you should advise the following treatment: A
Anterior repair with bladder buttressing B
Surgery for stress incontinence C
Botulinum toxin injection D
Duloxetine E
Electrical stimulation
Answer: B
Surgery for stress incontinence
Reference and comments:
1. NICE Urinary Incontinence Guideline CG171. September 2013.
Diagnosis is urodynamic stress incontinence. She did not respond to first line treatment of pelvic floor exercises, so you should advise surgery as recommended by NICE.

10. Please encourage candidate to review this guidelines and the recent related issues regarding the mesh

13. Advise induction of labour at 38-39 weeks of gestation
A 26-year-old woman in her second pregnancy has recently transferred her antenatal care from another region and presents in your antenatal clinic at 37 weeks of gestation. She gives a history of shoulder dystocia during the first birth. On examination her symphysis fundal height is 38 cm; longitudinal lie; cephalic presentation. She is very anxious and wishes to discuss a plan for delivery in this pregnancy.
Which one of the following advice options is most appropriate in this case? A
Advise induction of labour at weeks of gestation B
Advise an ultrasound scan estimation of fetal weight and review to decide the mode of delivery C
Await spontaneous onset of labour and after delivery of the fetal head carry out routine traction in an axial direction D
Plan delivery by elective caesarean section E
Obtain information about the first birth and the neonatal outcome
Answer: E
Comments:
There is no evidence that the other options reduce the chance of recurrence of shoulder dystocia and more information must be obtained to help with the decision making.

14. Which at is the most appropriate management option? A
A 57-year-old woman with a BMI of 48 attends the gynaecology clinic following an outpatient hysteroscopy for postmenopausal bleeding. Histology result reveals complex endometrial hyperplasia with cytological atypia.
Which at is the most appropriate management option? A
Abdominal hysterectomy B
Abdominal hysterectomy and bilateral salpingo-oophorectomy C
Abdominal hysterectomy and bilateral salpingo-oophorectomy with peritoneal washings D
Mirena® IUS insertion E
Oral progestogens for 6 months followed by repeat hysteroscopy
Answer: C
Abdominal hysterectomy and bilateral salpingo-oophorectomy with peritoneal washings
Reference and comments:
Because of the atypia, this condition has a high chance of progression to endometrial cancer and when the hysterectomy specimen is examined histologically, 25% or more will already have cancer. The correct option therefore is to remove the uterus as if there is already cancer present which involves washings as well as oophorectomy.

15. Amniocentesis should be performed to diagnose fetal varicella syndrome
A pregnant woman presents at 20 weeks of gestation with a rash which has been present for two weeks. She is diagnosed with chicken pox (varicella). Which of the following advice is correct? A
Amniocentesis should be performed to diagnose fetal varicella syndrome B
Fetal varicella infection causes micro-ophthalmia and microcephaly C
Not at risk of fetal varicella syndrome at this gestation D
The baby is highly likely to develop clinical varicella as a neonate E
The risk of neonatal varicella is higher with infection at 20 weeks of gestation than at term
Answer: B
Fetal varicella infection causes micro-ophthalmia and microcephaly
Reference and comments:
RCOG Green Top Guideline No. 13. Chicken Pox in Pregnancy. January 2015.
FVS does not occur with the initial infection, but from subsequent reactivation of the Herpes Zoster virus in utero, which occurs in only a minority of infected fetuses. The risk of developing the syndrome is low even if the fluid is positive for VZV DNA. FVS typically results in the defects listed. There is a small risk of FVS at 20 weeks. The baby is likely to develop varicella if the mother delivers within 4 weeks. At 20 weeks, viability as well as varicella would be an issue in that event. The risk of neonatal varicella is higher at term versus at 20 weeks. Elective delivery should be avoided for 5-7 days.

16. Correlation coefficient
When assessing data from a clinical trial which statistical test is the most appropriate to determine whether there is a significant difference between the mean values of the same measurements made under two different conditions? A
Chi-squared test B
Correlation coefficient C
Paired t-test D
Mann-Whitney test E
Multiple regression
Answer: C
Paired t-test

17. Do an arterial blood gas analysis test
A 25-year-old primigravid woman at 40 weeks of gestation complains that on several occasions she has experienced dizziness, light-headedness and feeling as if she is going to pass out when she lies down on her back to rest. Which is the most appropriate plan of management for this patient? A
Do an arterial blood gas analysis test B
Encourage her not to lie flat on her back C
Monitor with a 24-hour cardiac rhythm tape D
Perform a 12 lead ECG E
Refer her to a neurologist
Answer: B
Encourage her not to lie flat on her back
Reference and comments:
Late in pregnancy, when the mother assumes the supine position, the gravid uterus compresses the inferior vena cava and decreases venous return to the heart. This results in decreased cardiac output and symptoms of dizziness, light-headedness, and syncope. This significant arterial hypotension resulting from inferior vena cava compression is known as supine hypotensive syndrome or inferior vena cava syndrome. Therefore, it is not recommended that women remain in the supine position for any prolonged period of time in the latter part of the pregnancy. When patients describe symptoms of the supine hypotensive syndrome, there is no need to proceed with additional cardiac or pulmonary workup.

18. What is the most appropriate emergency contraception for her? A
A 19-year-old woman has unprotected sexual intercourse with an acquaintance about 48 hours before she consults you for emergency contraception. She has since heard that he may be HIV positive and has made herself an appointment at the local genitourinary medicine clinic for advice.
What is the most appropriate emergency contraception for her? A
EllaOne 30mg (ulipristal acetate) B
Levonelle 1500 (norethisterone 1.5mg) C
Marvelon (COCP) D
Mirena®IUS E
Multiload Cu 375® IUCD
Answer: E
Multiload Cu 375® IUCD
Reference and comments: 1. 2.
The woman is at risk of both unplanned pregnancy and contracting HIV. She will require post exposure HIV prophylaxis and these drugs are inhibitors of liver enzymes so oral hormonal emergency contraception methods are not recommended.
Multiload Cu375®can be inserted up to 120 hours after unprotected intercourse.
Neither Mirena® nor Marvelon® is licensed for emergency contraception.
Without the HIV problem, Levonelle® could be used up to 72 hours.
UK Guideline for the use of post-exposure prophylaxis for HIV following sexual exposure

19. High-dose oral glucocorticosteroids
A 32-year-old woman has had three consecutive first trimester miscarriages. The parental karyotypes are normal and subsequent investigations confirm a diagnosis of anti-phospholipid syndrome (APS). Which management option is the most appropriate? A
A pre-implantation genetic diagnosis with assisted conception treatment B
High-dose oral glucocorticosteroids C
Low dose oral aspirin and low molecular weight heparin injections D
Progesterone supplementation with vaginal pessaries after pregnancy is confirmed E
Referral to a clinical haematologist for advice and treatment
Answer: C
Reference and comments:
1. The investigation and treatment of couples with recurrent first- trimester and second- trimester miscarriage. Green Top Guideline No
A meta-analysis demonstrate that aspirin and heparin significantly increases the live birth rate in women with APS. Corticosteroids do not improve live birth rate in these women. As the karyotype both partners is normal there is no need for genetics referral. There is insufficient evidence in favour of progesterone supplementation.
“Neither corticosteroids nor intravenous immunoglobulin therapy improve the live birth rate of women with recurrent miscarriage associated with antiphospholipid antibodies compared with other treatment modalities; their use may provoke significant maternal and fetal morbidity.”

20. Aggressive chelation prior to conception
An 18-year-old woman is referred to the clinic for pre-conceptual counselling because she is known to have thalassaemia major. She and her husband are considering trying to get pregnant in the next a few months. Which one of the following recommendations is the best option for her? A
Aggressive chelation prior to conception B
Commence chelation during in the first trimester of pregnancy C
Fertility is unaffected and treatment for thalassaemia will depend on the haemoglobin levels of an individual D
Pre-conceptual folic acid 5mg tablets E
Splenectomy is normally necessary prior to pregnancy
Answer: A
Reference and comments:
1. Green-top guideline number 66 Management of Beta thalassaemia in pregnancy
Her health will deteriorate in pregnancy (especially cardiac and endocrinologically) if her iron overload has not been sorted out before. She is likely to be on a chelating agent anyway as she has thalassaemia major and aggressive chelation with Desferrioxamine is recommended as there is some safety data available for this drug (as opposed to Deferasirox and Deferiprone).
Chelating agents are thought to be teratogenic and she should not take anything in the first trimester, restarting her treatment after 20 weeks of gestation.
She should be taking 5mg folic acid as thalassaemia patients have a much higher demand for folic acid and an increased supplementation dose is needed.
She is likely to be relatively infertile because of hypogonadotrophic hypogonadism due to deposits of iron in her pituitary and may need ovulation induction (although if she does not want to start a pregnancy straight away she should use contraception).
Splenectomy used to be the mainstay of management in the past but is no longer first line management although she may already have had it done.

21. Cerebral vein thrombosis
A 31-year-old primigravid woman at 24 weeks of gestation is admitted with gradually worsening continuous right sided headache. She was prescribed antibiotics yesterday for a suspected urinary tract infection because of proteinuria. She has been vomiting all night and is now unable to tolerate oral medication and is becoming confused. Which of the following is the most likely diagnosis? A
Cerebral vein thrombosis B
Migraine C
Pre-eclampsia D
Subarachnoid haemorrhage E
Tension headache
Answer: A
Cerebral vein thrombosis
Reference and comments:
TOG article 'Headaches in pregnancy' (Vol 16 number )
Migraines are classically unilateral but are described as a pulsating headache whereas this one is continuous. Non-focal neurological symptoms such as behavioural changes are a 'red-flag' symptom which suggests a serious intracranial cause for the headache such as cerebral venous thrombosis. Dehydration because of the vomiting is a predisposing factor to CVT, as is pregnancy itself. Subarachnoid haemorrhage classically comes on very suddenly - described as a "thunderclap" headache and this was a subacute onset, but SA is still on the differential list. The diagnosis of tension headache is one of exclusion and she may of course just be severely dehydrated but this patient needs a thorough examination including neurological and checking for pre-eclampsia before a diagnosis of tension headache is given. Pre-eclampsia can occur at this early gestation but there is no mention of blood pressure.

22. Enoxaparin 40 mg once daily
A 36-year-old primigravid woman, with a booking weight of 76kg, is admitted at 38 weeks of gestation with pre-eclampsia. She complains of discomfort in her left leg which measures 4cm larger than the right calf, which is tender. Which is the most appropriate initial management option? A
Enoxaparin 40 mg once daily B
Enoxaparin 60 mg twice daily C
Enoxaparin 80 mg twice daily D
Loading dose of warfarin E
TED stockings
Answer: C
Enoxaparin 80 mgs bd
Reference and comments:
1. RCOG GTG: Thromboembolic Disease in Pregnancy and the Puerperium: Acute Management No 37b. Thromboembolic disease in pregnancy and the puerperium, acute management April 2015.
She needs to be protected against further VTE whilst awaiting the results of investigations. The first two doses are prophylactic rather than treatment so this is not enough heparin. Heparin should be given in doses titrated against the woman booking or early pregnancy weight. It is better to use heparin rather than warfarin as it is easier to manage in this situation where delivery is imminent and TED stockings alone are not enough.

23. Diagnostic laparoscopy should be the first line of investigation
A 20-year-old nulliparous woman presents with intermittent lower abdomen and pelvic pains for the last nine months. With regards to the investigation and management, which of the following options is the most accurate? A
Diagnostic laparoscopy should be the first line of investigation B
It is very often possible to identify the cause of the pain at the conclusion of the initial clinical assessment C
MRI scan should normally be considered to confirm the clinical diagnosis D
Psychological issues are not particularly common E
Symptoms suggestive of IBS or interstitial cystitis are often present too
Answer: E
Symptoms suggestive of IBS or interstitial cystitis are often present too
Reference and comments:
RCOG Green Top Guideline No

24. HRT is contraindicated for women with sickle cell anaemia
You are supervising a trainee who is counselling a patient concerning the risks of taking HRT. Which of the following statements is appropriate advice? A
Combined HRT increases the risk of venous thromboembolism (VTE) fourfold with 5 years’ use B
HRT is contraindicated for women with a family history of breast cancer C
HRT is contraindicated for women with sickle cell anaemia D
HRT is not necessarily contraindicated for all women on tamoxifen for breast cancer treatment E
Transdermal HRT is associated with a lower risk of VTE when compared with oral HRT
Answer: E
Transdermal HRT is associated with a lower risk of venous thromboembolism when compared with oral HRT.
Reference and comments:
Latest evidence on using HRT in the menopause. Shafaf Bakour et el TOG Volume
NICE Clinical Guideline 23; Nov 2015: Menopause: Diagnosis and management

25. Aim for fasting capillary blood glucose level of 3.5 mmol/l
A 25-year-old woman, P1, who has type 1 diabetes mellitus, books in at the antenatal clinic at 8 weeks pregnant. She injects insulin four times a day but is keen to transfer to an insulin pump. She is known to have early retinopathy and her renal function was normal when she was seen in diabetic clinic a month ago. Which of the following statements best applies to her antenatal pregnancy care? A
Aim for fasting capillary blood glucose level of 3.5 mmol/l B
Blood sugar monitoring should be performed: fasting; before meals; one hour after meals and at bedtime C
Insulin pump is generally considered to be contraindicated in pregnancy D
Renal function test should be repeated at booking E
Repeat retinal assessment at 28 weeks of gestation
Answer: B
Blood sugar monitoring should be performed: fasting; before meals; one hour after meals and at bedtime
Reference and comments:
1. Diabetes in pregnancy: management of diabetes and its complications from preconception to the postnatal period 25 February 2015.
This is the new recommendation in the guideline. The target capillary blood sugars should be fasting of 5.3mmol/l; one hour after meals 7.8mmol/l; 2 hours after meals of 6.4mmol/l. If diabetic retinopathy is present at first assessment, an additional assessment should be conducted at weeks and again at 28 weeks. Offer women with insulin treated diabetes insulin pump therapy during pregnancy if adequate blood glucose control is not obtained by multiple daily injections of insulin without significant disabling hypoglycaemia. If renal function test has been found to be normal within the last three months it does not need repeating.

26. Aortic root > 45mm diameter
A 32-year-old woman with Marfan syndrome attends for pre-conception counselling. Which of the following findings would lead you to advise against pregnancy? A
Aortic root > 45mm diameter B
History of retinal detachment C
Metal mitral valve replacement on lifetime warfarin outside pregnancy D
Previous pregnancy complicated by cervical incompetence E
Previous pregnancy complicated by eclampsia
Answer: A
Aortic root > 45mm diameter
Reference and comments:
Meijboom LJ, Vos FE, Timmermans J, Boers GH, Zwinderman AH, Mulder BJ. Pregnancy and aortic root growth in the Marfan syndrome: a prospective study. Eur Heart J May; 26 (9):
For women with Marfan syndrome pregnancy presents an increased risk of dilatation, dissection, and rupture of the aorta. They should be counselled regarding pregnancy risks only after review of their cardiovascular status, including an estimation of aortic root diameter by scan. Recent studies have suggested an expected rate of aortic dissection of about 3%, which varies from 1% in women with aortic diameter < 40 mm to 10% in high-risk patients (aortic root diameter > 40 mm, rapid dilatation, or previous dissection of the ascending aorta. Pregnancy in women with Marfan syndrome seems to be relatively safe up to an aortic root diameter of 45 mm, at least as far as our observed diameter range of mm is concerned.

27. Bite prevention measures are usually effective
A 32-year-old woman at 22 weeks of gestation in her first pregnancy and is considering a holiday in Nigeria but she is very concerned about the possibility of contracting malaria. Which is the most appropriate advice you should recommend for this woman? A
Bite prevention measures are usually effective B
Prescribe chemoprophylaxis (e.g. mefloquine) to cover trip C
Postpone or cancel trip D
Provide stand-by emergency treatment such as quinine E
Skin repellents are safe (e.g. DEET)
Answer: C
Postpone or cancel the trip
Reference and comments:
1. The prevention of Malaria in pregnancy. Green–top Guideline No. 54a. April 2010.
Pregnant women should consider the risks of travel to malaria endemic countries and consider postponing their trip, unless travel is unavoidable. If travel is unavoidable advise the woman to seek guidance from a centre with expertise on malaria risks and avoidance strategies. Advise women that a fever or flu-like illness while travelling or upon returning home, up to 1 year or more, may indicate malaria and requires medical attention. Advise the woman on the risk of being exposed to malaria at her intended area of travel. There are no measures specific to pregnancy that can be taken to prevent malaria beyond those that non pregnant travellers can apply.

28. Screen for sleep apnoea when she gives a history of snoring
A 31-year-old nulliparous woman, with BMI of 41 and a diagnosis of polycystic ovarian syndrome (PCOS), has been referred to the gynaecology clinic for counselling regarding her long term health risks related to PCOS. Which of the following statements is most effective at reducing her risks? A
Screen for sleep apnoea when she gives a history of snoring B
Screen for type 2 diabetes by fasting blood glucose C
Arrange ECG to screen for cardiovascular disease D
Advise surveillance for ovarian cancer E
Offer Counselling for depression.
Answer: A
Screen for sleep apnoea when she gives a history of snoring
Reference and comments
1.Long term consequences of Polycystic Ovary Syndrome (PCOS). Green-top Guideline No 33 (November 2014).
This is Grade B recommendation. The prevalence of Obstructive Sleep Apnoea (OSA) is increased in obese women with PCOS. Androgen excess and insulin resistance are positively associated with OSA in PCOS. She or her partner should be asked about snoring and day time fatigue/somnolence.
Fasting Blood glucose has been shown to result in under diagnosis of Type 11 diabetes in PCOS. HbA1c warrants better definition for diagnosis of PCOS. GTT is considered appropriate for diagnosis of type 2 diabetes in women with PCOS. Life time risk of CVD is higher in women with PCOS and mostly preventable. All women with PCOS should be assessed for CVD risk by assessing individual CV risk factors. There does not appear to be an association ovarian cancer and no additional surveillance is required. Psychological issues should be considered in all women with PCOS. If the woman is positive for depression/anxiety on screening, further assessment and appropriate counselling and intervention should be offered by a qualified professional.

29. Serological screening for toxoplasmosis and CMV
A 32-year-old primigravid woman, who immigrated to the UK from Nigeria when she was about 12 weeks pregnant, had a normal fetal anomaly scan at 20 weeks. An ultrasound scan at 32 weeks shows the fetal abdominal circumference and estimated fetal weight are both just below the 10th centile and the umbilical artery Doppler waveform analysis shows flow in diastole. Which of the investigations is the next most appropriate in her case? A
Fetal karyotyping B
Repeat growth scan and umbilical artery Doppler studies in two weeks’ time C
Serological screening for toxoplasmosis and CMV D
Test for malaria parasites in the blood E
Uterine artery Doppler studies
Answer: B
Repeat growth scan and umbilical artery Doppler studies in two weeks’ time
Reference and comments:
1. The Investigation and Management of the Small for Gestational Age Fetus. Green top Guideline. No.31 January 2014.
Fetal infections are responsible for 5% of SGA fetuses. Serological screening for toxoplasmosis and CMV should be offered in severe SGA. (Grade C Recommendation). When umbilical artery Doppler flow indices are normal, it is reasonable to repeat every 14 days. (Grade B recommendation). Karyotyping should be offered in severe SGA fetuses detected with structural anomalies and in those diagnosed before 23 weeks. Karyotyping should be offered in severe SGA fetuses detected with structural anomalies and in those diagnosed before 23 weeks.). Malaria is a significant cause of low birth weight worldwide and should be considered who have travelled in endemic areas.

30. Administer facial oxygen whatever the pO2
A pregnant woman is admitted with sepsis and the on-call obstetric consultant advises you to institute the “sepsis six” care bundle. Which of these statements is the most appropriate with regard to this clinical pathway? A
Administer facial oxygen whatever the pO2 B
Intravenous fluids should be used if the woman appears clinically dehydrated C
Lactate level of 4 mmol/l or more signifies severe sepsis D
Oral antibiotics are adequate if she is not vomiting E
The ‘bundle’ must be undertaken within six hours of diagnosis
Answer: C
A lactate level of 4mmol/l or more signifies severe sepsis
Reference and comments:
The 'sepsis six' bundle involves
Measuring the arterial blood gas and administering oxygen if required
Take blood cultures
Commence intravenous antibiotics
Start intravenous fluid resuscitation
Take blood for haemoglobin and lactate levels
Measure the urine output hourly
The suggestion is that the bundle is undertaken within an hour of diagnosis. UK sepsis Trust 2013
Source : MBRRACE report 2014

31. Caesarean delivery is now much less likely to be needed
A morbidly obese 25-year-old nulliparous woman underwent gastric banding surgery six months ago and is referred for fertility advice and pre-pregnancy counselling prior to attempting to conceive. She has already lost 15kg and her BMI is now 40. Which of the following advice is correct in relation to pregnancy after bariatric surgery? A
Breast feeding is contraindicated because of possible vitamin deficiency B
Caesarean delivery is now much less likely to be needed C
Delay conceiving for at least 12 months after the bariatric surgery D
Her risk of pre-eclampsia will be not be reduced as a result of the bariatric surgery E
Investigation for gestational diabetes mellitus is unnecessary as bariatric surgery reduces her risk
Answer: C
Delay conceiving for at least 12 months after the bariatric surgery
Reference and comments:
Unless there is significant nutritional deficiency then breast feeding is not contra-indicated.
Caesarean delivery is not reduced after weight loss surgery. Obstetricians need to be aware of carer bias and avoid C/S unless obstetrically indicated because of increased risks in obese of VTE and wound infection.
Delaying pregnancy for at least 12 months after the surgery is current recommendation. Nutritional deficiencies are common after bariatric surgery and worst in the first 12 months when most weight loss occurs. Prenatal vitamin supplements are recommended and shown to improve outcomes.
The risk of PET is reduced, in some studies down to normal population levels
The incidence of GDM is lower in women who have had gastric banding than in obese comparative group without surgery but you should still investigate if still obese. Caution is advised because large glucose load such as that is a GTT may cause dumping.
Source: TOG. Vol 15 No.1 (2013) Pregnancy outcome following bariatric surgery.

32. Aspirin 75mg tablets daily
A woman with an uncomplicated pregnancy of 26 weeks of gestation is about to go on a long haul flight to visit relatives in Australia. She has a BMI of 26, is a non-smoker and she will be returning to the UK in a month’s time. Which is the most appropriate advice regarding the prevention of thromboembolism in her case? A
Aspirin 75mg tablets daily B
Graduated compression stockings C
Hydration and mobilisation during the flight D
Low molecular weight heparin injections E
No special measures needed
Answer: B
Graduated compression stockings
Reference and comments:
Prolonged air travel results in a three-fold increase in the risk of VTE but wearing graduated compression stockings results in 16.2 fewer DVTs per 10,000 people (although these results are from a non-pregnant population). It is suggested that all pregnant women wear compression stockings.
If she needs formal thromboprophylaxis because she has other risk factors, LMWH is more effective than aspirin.
Source: Scientific impact paper No.1 "Air travel and pregnancy" (May 2013)

33. Bladder pressure (urodynamic) studies
A parous peri-menopausal woman with a BMI of 25 has a diagnosis of stress incontinence confirmed on urodynamic studies and she has a tension-free vaginal tape operation performed to correct the problem. Her GP refers her back to clinic two weeks after the operation, having already excluded infection with a urine specimen for culture, because she has experienced continuous urinary incontinence after leaving hospital. On examination: temperature 36.7C and pulse rate 78 b/m. There are no masses palpable on abdominal examination but she does have suprapubic tenderness. She would prefer not to have a pelvic examination in clinic because the leakage of urine has made her vagina very sore. What is the next most appropriate management option? A
Bladder pressure (urodynamic) studies B
Examination under anaesthetic C
Prescribe a course of oral antibiotics D
Three swab test using methylene blue dye E
Ultrasound scan measurement of residual urine
Correct answer: D
Three swab test using methylene blue dye
Reference and comments:
The differential diagnosis here is retention with overflow, fistula, de novo detrusor instability or failure of the operation. It is too early to do post-op urodynamics looking for instability and the GP will have already excluded and/or treated UTI with the MSU result. She is not in retention as there are no masses palpable on examination. The three swab test is to exclude vesico-vaginal fistula and would be the next step.

34. A CBD (case based discussion) is a summative assessment
A trainee doctor is required to complete workplace based assessments during their obstetrics and gynaecology training. With regard to these assessments which one of the following is correct? A
A CBD (case based discussion) is a summative assessment B
A mini-CEX (mini-clinical evaluation exercise) is a summative assessment C
An OSATS (objective structured assessment of technical skill) may be a formative or a summative assessment D
An OSATS is a formative assessment E
An OSATS is a summative assessment
Correct answer: C
An OSATS may be a formative or a summative assessment
Reference and comments:
Formative OSATS (supervised learning event, or SLE)
Formative OSATS give trainee the opportunity to practise and get feedback for a given procedure. The trainee should take as many SLEs as necessary until they feel that they are sufficiently competent in a procedure to request an assessment of performance (summative OSATS).
Summative OSATS (assessment of performance, or AoP)
Summative OSATS allow the trainee to demonstrate his/her competence in a procedure and progress in the training. The trainee complete OSATS throughout their training until they are competent to practise independently.

35. This helps his Educational Supervisor give the necessary support.
Workplace-based assessments (WPBAs)
WPBAs are tools used to evaluate the trainee progression through the specialty training programme.
The assessments aim to link teaching, learning and assessment in a structured way.
WPBAs aren’t necessarily used to demonstrate that the trainee is completely competent in a procedure, but rather to identify strengths and weaknesses.
This helps his Educational Supervisor give the necessary support.

36. Different types of WPBA
There are three types of WPBA in O&G training:
OSATS (objective structured assessment of technical skill): A small number of procedures are so fundamental to the practice of O&G that we’ve developed an objective assessment tool to aid the review process. OSATS are validated assessment tools that assess your technical competency in a particular technique.
Mini-CEX (mini clinical evaluation exercise):
The mini-CEX is a generic tool that is used to test many different and varied competences.  
CbD (case-based discussion):
The CbD is a generic tool that formalises case discussion between trainee and trainer. They are designed to be a vehicle for direct feedback about the case under discussion
A small number of procedures are so fundamental to the practice of O&G that RCOG has developed an objective assessment tool to aid the review process.
OSATS are validated assessment tools that assess the trainee competency in a particular technique.
There is a set curriculum that sets out the procedures that are assessed using OSATS.
Trainers will use the mini-CEX to directly assess trainees in:
History-taking
Clinical examination
Formulating management plans
Communicating with patients
Professional and interpersonal skills
Each mini-CEX should take around 20 minutes. The trainer should provide feedback to the trainee immediately after the assessment.
Trainees should organise mini-CEX assessments with a range of trainers.
Skills assessed using CbDs
The CbD is a generic tool that formalises case discussion between trainee and trainer. They are designed to be a vehicle for direct feedback about the case under discussion. The curriculum lists the competences that can be tested using a CbD.
Trainers will use a CbD to assess:
Clinical decision-making
Knowledge
Application of knowledge
Each CbD should involve a different clinical situation.

37. Formative vs summative WPBAs
WPBAs are either:
Formative (assessments for learning), used to provide feedback
Summative (assessments of learning), used to allow you to demonstrate competence in a given clinical situation
The O&G training programme includes both formative and summative OSATS. Mini-CEX and CbDs are formative only.
Summative assessments are known formally as Assessments of Performance (AoP).
Summative assessment
Assessments of learning
Allow trainees to demonstrate competence in an observed procedure.
Formative assessments are known formally as Supervised Learning Events (SLEs).
Formative assessment
Assessments for learning
Provide documented feedback for trainees.

38. A 35-year-old woman attends the gynaecology clinic following her surgical evacuation of the uterus of her first pregnancy. Histology has confirmed a complete mole. Which is the recurrence risk of a molar pregnancy for this woman? A
1 in 40 B
1 in 80 C
1 in 120 D
1 in 160 E
1 in 200
Answer: B
1 in 80
Reference and comments:
In women whose last pregnancy was a complete or partial molar pregnancy, their risk of having a further molar pregnancy is low (1/80): more than 98% of women who become pregnant following a molar pregnancy will not have a further molar pregnancy nor are they at increased risk of obstetric complications. If a further molar pregnancy does occur, in 68–80% of cases it will be of the same histological type. Women should be advised not to conceive until their follow-up is complete. Women who undergo chemotherapy are advised not to conceive for 1 year after completion of treatment. RCOG GTG No 38;

39. You wish to offer prophylactic antibiotics to a woman about to have a Caesarean section. During your discussion you mention the risk of infection from endometritis, urinary tract and wound infection. She wishes to know what the infection risk would be if she were to decline per-operative antibiotics. What percentage risk is correct? A
<1% B
1-2% C
4-6% D
8-10% E
12-15%
Answer: D
8-10%
Reference and comments:
Offer women prophylactic antibiotics at CS before skin incision. Inform them that this reduces the risk of maternal infection more than prophylactic antibiotics given after skin incision, and that no effect on the baby has been demonstrated. Choose antibiotics effective against endometritis, urinary tract and wound infections, which occur in about 8% of women who have had a CS
Nice Guideline 132 on Caesarean section.

40. Inflate the cuff to 10mm Hg above palpated systolic blood pressure
According to the modified 2014 NICE guideline on Antenatal Care a standardised technique for the measurement of blood pressure is recommended. Which one of the following techniques is correct? A
Inflate the cuff to 10mm Hg above palpated systolic blood pressure B
Lower the column slowly, by 5mmHg per second C
Read the blood pressure to the nearest 5mm Hg D
Measure the diastolic blood pressure at disappearance of sounds (phase V) E
Measure the diastolic blood pressure at muffling of sounds (phase IV)
Answer: D
Measure the diastolic blood pressure at disappearance of sounds (phase V)
Reference and comments:
Blood pressure should be measured as outlined below: remove tight clothing, ensure arm is relaxed and supported at heart level use cuff of appropriate size inflate cuff to 20–30 mmHg above palpated systolic blood pressure lower column slowly, by 2 mmHg per second per beat. Read blood pressure to the nearest 2 mmHg. Measure diastolic blood pressure as disappearance of sounds (phase V).
NICE guideline Modified 2014

41. Repeat quantitative hCG in 48 hours
A 23-year-old woman attends the early pregnancy unit at 7 weeks of gestation with vaginal spotting, left iliac fossa pain and one episode of diarrhoea. A transvaginal scan has shown a 2x4mm echo-lucent area in the uterine cavity with no yolk sac or fetal pole. There is a moderate amount of free fluid in the pelvis. The serum hCG level is 2300 IU/l. Her observations are: temperature 36.5oC, blood pressure 100/65mmHg, pulse 120 bpm, oxygen saturation 98%, respiratory rate 24 per minute, pain score moderate. Select the most appropriate initial management from the options below. A
Repeat quantitative hCG in 48 hours B
Rescan in seven days C
Intramuscular methotrexate D
Laparoscopy E
Laparotomy
Answer: D
Laparoscopy
Reference and Comments:
This should be an obvious ectopic but the CEMACE reports have shown that women who have diarrhoea as part of their clinical picture (due to peritoneal irritation from blood) are misdiagnosed and deaths have resulted from this. This element of the answer therefore links to clinical governance and the ongoing audit into maternal deaths and substandard care.
The tachycardia and tachypnoea are highly significant in a young woman and indicate concealed haemorrhage which is likely to be due to a ruptured ectopic pregnancy. The small echolucent area in the uterus is too small to be a seven weeks of gestation sac and is much more likely to be a pseudo-sac. Young women maintain their blood pressure until nearly exsanguinated but since her blood pressure is being maintained at the moment, a laparoscopic approach is justified.
The relevance of the symptom of diarrhoea is that haemoperitoneum can cause this symptom from peritoneal irritation by the blood. CEMACE reports have shown that women who have diarrhoea as part of their clinical picture are more likely to have their diagnosis delayed and this has been described as substandard care which has been linked to maternal deaths.

42. Advise expectant management
A 27-year-old woman presents with painless vaginal bleeding six weeks after her last period. Her urine pregnancy test was positive 10 days ago. A transvaginal ultrasound scan shows a gestation sac containing a yolk sac and a fetal pole of 6.3mm. Fetal cardiac activity is absent. Her serum hCG level is 1500 IU/l. Select the most appropriate management plan from the list below. A
Advise expectant management B
Offer surgical evacuation of products of conception C
Offer medical management of miscarriage D
Rescan in seven days E
Rescan in 14 days
Answer: D
Rescan in seven days
Reference and comments:
NICE has acknowledged that it is difficult to confirm the diagnosis of missed miscarriage in one scan where the CRL is less than 7mm. It is highly likely that this is a missed miscarriage but since the new guidance came into effect in 2013 a repeat TVS a minimum of seven days after the first scan must be offered. If the CRL was 7mm or more, then a second opinion on the scan or a repeat scan in seven days must be offered.

43. Termination of pregnancy with mifepristone and misoprostol
A couple have decided to terminate their pregnancy following a diagnosis of hypoplastic left heart at 22+2 weeks of gestation. Which is the most appropriate management option? A
Termination of pregnancy with mifepristone and misoprostol B
Induce labour with ARM and syntocinon C
Offer feticide D
Induce labour with prostaglandin E2. E
Advise that TOP after 22 weeks is not available
Answer: C
Offer feticide
Reference and comments:
This is a termination under clause E of the Abortion Act where “there is substantial risk that the child would be born with serious physical or mental disabilities” and there is no gestation limit for this clause of the Act. While it might be possible to induce labour with ARM and syntocinon the recommended regimen is oral mifepristone followed 48 hours later by up to five doses of oral or vaginal misoprostol. The regimen of two doses of mifepristone is applicable to intrauterine death rather than termination of pregnancy. Studies have suggested that, due to the development of the thalamus by 22 weeks, the fetus may have awareness and be able to feel pain so the RCOG has issued guidance that best practice is to offer feticide after 21+6 weeks gestation prior to administering drugs to induce abortion.
This SBA also demonstrates the structure of the NHS with tertiary level fetal medicine services in each region supported by quaternary level neonatal cardiac surgery services in centres such as London, Bristol and Birmingham etc.
Candidates should understand the principles of conscientious objection to TOP i.e. even if they would not participate in TOP, they should ensure the patient is referred onto a colleague who would be prepared to discuss it with them.

44. Combined oral contraceptive pill
A 15-year-old girl attends your GP surgery requesting contraception advice as she is sexually active using condoms but wants a more secure form of contraception. She has no relevant past medical history and you deem her to be Fraser competent. Which is the best form of contraception for her? A
Co-cyprindiol B
Combined oral contraceptive pill C
Depot medroxy progesterone acetate D
Etonorgestrel subdermal implant E
Levonorgestrel intrauterine delivery system
Answer: D
Etonorgestrel subdermal implant

45. Aspirin 75mg oral tablets
A woman with an uncomplicated pregnancy of 24 weeks of gestation is about to go on a long haul flight to visit relatives in Singapore. She has a BMI of 42, is a non-smoker and she will be returning at 30 weeks of gestation. Select the best advice regarding thromboembolism prevention in her case: A
Aspirin 75mg oral tablets B
Graduated compression stockings C
Hydration and mobilisation during flight D
Low molecular weight heparin injections E
No special measures needed
Answer: D
Low molecular weight heparin injections
Reference and comments:
Prolonged air travel results in a three-fold increase in the risk of VTE but wearing graduated compression stockings results in 16.2 fewer DVTs per 10,000 people (although these results are from a non-pregnant population). It is suggested that all pregnant women wear compression stockings but this woman has a BMI of 42 which is another risk factor. If she needs formal thromboprophylaxis because she has other risk factors, LMWH is more effective than aspirin.
Source: Scientific impact paper No.1 "Air travel and pregnancy” (May 2013)

46. In the antenatal clinic you see a woman who has suffered from bipolar disorder for many years. She has recently spent several months in hospital because of a relapse in her psychiatric condition which resulted in a severe manic episode. Whilst in hospital she did not have any periods and a scan organised by her GP has shown that she is unexpectedly 20 weeks pregnant. Her current medication is lithium 600mg t.d.s.
which is keeping her mood stable. With regard to her lithium medication whilst she is pregnant, select the most appropriate advice: A
Breast feeding is possible as lithium does not transfer to breast milk B
Continue with lithium because there is a high risk of relapse of her psychiatric symptoms C
Lithium causes a thousand-fold increased risk of a serious fetal heart condition such as Ebstein's anomaly D
Scanning is advised in the third trimester because lithium may cause oligohydramnios E
Stop taking the lithium immediately because there is a high risk of fetal abnormality
Answer: B
Continue with lithium because there is a high risk of relapse of her psychiatric symptoms
Reference and comments:
Lithium is not recommended in breast feeding and usually replaced by an alternative mood stabiliser e.g. Sodium valproate.
She should continue with lithium because of the high risk of serious psychiatric relapse which could lead to puerperal psychosis in spite of the extra fetal risks, which are not as high as a thousand-fold. There is a ten-fold risk of Ebstein's anomaly (but the incidence is still only in 1000 even on lithium, so the absolute numbers are small). She is 20 weeks pregnant anyway, so well past the time when organs are forming.
Lithium causes polyhydramnios
Source: NICE Guideline on 'Antenatal and postnatal mental health' 2007 ‘Prescribing in pregnancy' (Rubin and Ramsay, BMJ books 2008)
SIGN Guideline 60 'Postnatal depression and puerperal psychosis'