MRCOG Part 2 – Maternal Medicine EMQs

• A woman has an uncomplicated vaginal delivery at term but reports palpitations in the subsequent postpartum period.  There is a family history of sudden cardiac death and one of her siblings has recently been diagnosed with long QT syndrome. The ECG is abnormal:

• A woman presents with sudden onset palpitations at 20 weeks in her first pregnancy. On examination, her pulse is 170bpm.  Her ECG shows:

After treatment, her ECG shows a delta wave.

• A woman presents with sudden onset palpitations at 20 weeks in her first pregnancy.  She is known to have mild mitral stenosis for which she does not take any medication. On examination, her pulse is 150bpm.  Her ECG shows:

• A woman presents with sudden onset palpitations at 20 weeks in her first pregnancy. These are intermittent and occur on standing and are relieved by lying down.  Her ECG shows a sinus tachycardia around 115bpm but her other observations are normal.

• A woman presents with sudden onset palpitations, left sided chest pain and shortness of breath at 20 weeks in her first pregnancy.  Her ECG shows:

• A 36 year old woman is referred to maternal medicine clinic at 23 weeks gestation in her second pregnancy with persistent hyperkalaemia and hyponatraemia.  She previously had an uncomplicated first pregnancy and vaginal birth at term.  In this current pregnancy, she has had hyperemesis gravidarum throughout pregnancy and has struggled with symptomatic low blood pressure and occasional episodes of hypoglycaemia.

For each of the following scenarios, select the most likely affected nerve:

• A woman with gestational diabetes and booking BMI of 42 presents at 34 weeks gestation with constant burning pain and paraesthesia over the outer side of the right thigh, extending to the outer side of the knee but no motor weakness.

For each of the following scenarios, select the most likely affected nerve:

For each of the following scenarios, select the most likely affected nerve:

For each of the following scenarios, select the most likely affected nerve:

• A woman has an unassisted vaginal delivery of her first baby after a prolonged second stage of three hours. Postnatally, she reports difficulty adducting both hips with bilateral loss of sensation over the medial thighs.

For each of the following scenarios, select the most likely affected nerve:

• A woman has a complex third degree tear repaired in theatre complicated by major obstetric haemorrhage of 2L with a prolonged time in lithotomy. Postnatally she reports weakness of right sided foot drop with numbeness over the right lateral and anterior calf and foot.

For each of the following scenarios, select the most appropriate management:

For each of the following scenarios, select the most appropriate management:

For each of the following scenarios, select the most appropriate management:

For each of the following scenarios, select the most appropriate management:

For each of the following scenarios, select the most appropriate management:

What is the leading cause of all maternal deaths?

What is the leading cause of direct maternal deaths occurring within 42 days of the end of pregnancy?

What is the leading cause of indirect maternal deaths?

What is the second leading cause of indirect maternal deaths?

What is the least common cause of direct maternal deaths since previous triennium?

For each scenario described below, choose the most causative treatment:

• A 30-year-old woman, Gravida 2 Para 1, is diagnosed at 22 weeks of gestation with a 4 cm invasive ductal carcinoma of the right breast. Histology confirms triple-negative breast cancer (ER-negative, PR-negative, HER2-negative). She is managed by the multidisciplinary team and undergoes a mastectomy at 24 weeks gestation. From 26 weeks onwards, she receives anthracycline and cyclophosphamide chemotherapy with carboplatin plus weekly paclitaxel, as recommended for triple-negative disease in pregnancy.  During her chemotherapy treatment, she has significant difficulties with nausea and vomiting and receives corticosteroids and NK-1 antagonists to mitigate this. She has an uncomplicated induction of labour and spontaneous vaginal birth at 37 weeks gestation. The neonate is healthy at birth, with normal weight and Apgar scores. However, at routine follow-up at 18 months, the child is found to have bilateral sensorineural hearing loss, requiring audiological support.

For each scenario described below, choose the most causative treatment:

• A 30-year-old woman, Gravida 2 Para 1, is diagnosed at 22 weeks of gestation with a 4 cm invasive ductal carcinoma of the right breast. Histology confirms triple-negative breast cancer (ER-negative, PR-negative, HER2-negative). She is managed by the multidisciplinary team and undergoes a mastectomy at 24 weeks gestation. From 26 weeks onwards, she receives anthracycline and cyclophosphamide chemotherapy with carboplatin plus weekly paclitaxel, as recommended for triple-negative disease in pregnancy.  During her chemotherapy treatment, she has significant difficulties with nausea and vomiting and receives corticosteroids and and NK-1 antagonists to mitigate this. She is noted to have significant glycosuria and blood glucose capillary monitoring shows levels all above 9.0mmol.

For each scenario described below, choose the most causative treatment:

• A 34-year-old woman, Gravida 2 Para 1, is diagnosed at 24 weeks of gestation with metastatic breast cancer with bone and liver metastases. The primary tumour is ER/PR positive, HER2 negative. She undergoes multidisciplinary team discussion and commences anthracycline-based chemotherapy with taxanes from 25 weeks. Due to extensive lytic bone disease and skeletal pain, she also receives intravenous bisphosphonates at 28 weeks. Pregnancy otherwise progresses uneventfully, and she delivers by vaginal birth at 36 weeks after induction of labour. The neonate is born in good condition, but within 48 hours develops jitteriness, poor feeding, and seizures. Biochemistry confirms severe hypocalcaemia. After calcium infusion and close neonatal monitoring, the baby improves

For each scenario described below, choose the most appropriate diagnosis:

• A 32-year-old woman presents 3 months after an uncomplicated vaginal delivery complaining of palpitations, anxiety, and heat intolerance. She reports difficulty sleeping and increased irritability over the past few weeks. She is breastfeeding and has no significant past medical history. On examination, her pulse is 102 bpm, blood pressure 118/72 mmHg, and she appears mildly anxious. There is no goitre, no thyroid tenderness, and no ophthalmopathy.

  Blood tests show:

  • TSH: suppressed below the pregnancy-specific reference range
  • Free T4: mildly elevated above the pregnancy-specific reference range
  • TSH receptor antibodies (TRAb): negative
  • Thyroid peroxidase antibody (TPOAb): positive

For each scenario described below, choose the most appropriate diagnosis:

• A 26-year-old primigravida presents to the antenatal assessment unit at 9 weeks’ gestation with severe nausea and vomiting for the past two weeks. She reports difficulty keeping food down and has lost 3 kg in weight. She has no significant past medical history. On examination she appears dehydrated. Her pulse is 104 bpm and blood pressure 110/70 mmHg. There is no goitre, no thyroid eye signs, and the thyroid gland is not tender.

  Blood investigations show:

  • TSH: suppressed below the pregnancy-specific reference range
  • Free T4: mildly elevated above the pregnancy-specific reference range
  • Free T3: within the normal pregnancy-specific reference range
  • TSH receptor antibodies (TRAb): negative
  • Thyroid peroxidase antibody (TPOAb): negative

For each scenario described below, choose the most appropriate diagnosis:

• A 29-year-old primigravida presents to the antenatal clinic at 10 weeks’ gestation complaining of palpitations, tremors, and heat intolerance for the past month. She reports unintentional weight loss despite increased appetite and increasing anxiety. She has no previous history of thyroid disease. On examination, her pulse is 110 bpm, blood pressure 118/70 mmHg, and she has a fine tremor of the hands. A diffuse, non-tender goitre is noted.

  Blood investigations show:

  • TSH: below the pregnancy-specific reference range
  • Free T4: elevated above the pregnancy-specific reference range
  • Free T3: elevated above the pregnancy-specific reference range
  • TSH receptor antibodies (TRAb): positive
  • Thyroid peroxidase antibody (TPOAb): negative

For each scenario described below, choose the most appropriate diagnosis:

• A 34-year-old primigravida attends her booking visit at 10 weeks’ gestation. She feels well and has no significant past medical history. She reports mild fatigue but attributes this to early pregnancy. There is no personal or family history of thyroid disease. On examination, her pulse is 78 bpm, blood pressure 112/68 mmHg, and BMI 27 kg/m². There is no goitre and no clinical features of hypothyroidism.

  Routine thyroid function tests performed due to a history of previous infertility treatment show:

  • TSH: within the pregnancy-specific reference range
  • Free T4: below the pregnancy-specific reference range
  • TSH receptor antibodies (TRAb): negative
  • Thyroid peroxidase antibodies (TPOAb): negative

For each scenario described below, choose the most appropriate diagnosis:

• A 31-year-old woman attends her booking appointment at 9 weeks’ gestation. She is Para 1, having had a previous emergency Caesarean section at term and her postnatal recovery was complicated by peripartum thyroiditis. She reports mild tiredness but otherwise feels well. Her mother has a history of autoimmune thyroid disease. On examination, her pulse is 76 bpm, blood pressure 110/70 mmHg, and BMI 25 kg/m². There is no goitre and no clinical signs of hypothyroidism.

  Blood tests show:

  • TSH: elevated above the pregnancy-specific reference range
  • Free T4: within the normal pregnancy-specific reference range
  • Free T3: within the normal pregnancy-specific reference range
  • TSH receptor antibodies (TRAb): negative
  • Thyroid peroxidase antibodies (TPOAb): positive