MRCOG Part 1 – Clinical Management

You are the SHO on labour ward when the emergency buzzer sounds and you attend with your registrar.   The midwife has just performed an artificial rupture of membranes (ARM) on a woman having an induction of labour and there is  frank vaginal bleeding and the CTG shows a prolonged fetal bradycardia.  What is the likely diagnosis?

A 42 year old primigravid woman is booked for induction of labour at 40 weeks gestation. Which of the following methods are not used for induction of labour?

Which of the following is not an increased risk during induction of labour?

Which of the following is not an indication for continuous electronic fetal monitoring using cardiotocography during labour?

You are on call for the labour ward and are asked to insert an intravenous cannula for a woman in labour. Which of the following is not an indication for intravenous access in labour?

You are assisting with a Caesarean section for abnormal cardiotocography with suspected fetal compromise. Which of the following features is abnormal on cardiotocography?

You are the SHO on labour ward and are asked to assist the registrar with fetal blood sampling. Which of the following statements regarding fetal blood sampling is incorrect?

A woman in established labour has an epidural sited and complains of a sudden severe headache which is worse on sitting up and relieved by lying down. On examination all her observations are within normal limits and upper limb and cranial nerve examination is normal.  What is the likely diagnosis?

You are on call for Labour Ward and attend an emergency buzzer with your registrar. On entering the room, the midwife states that she has just performed an artificial rupture of membranes and there has been a cord prolapse.  Which of the following is not a risk factor for cord prolapse?

You are asked to review a 26 primigravid woman in early labour at term who is noted to be hypertensive. She has no known drug allergies but has a past medical history of severe asthma.  On examination, her blood pressure is 170/118 and urinanalyis shows 4+ proteinuria.  What is the most appropriate management?

You are asked to review a 26 primigravid woman in early labour at term who is noted to be hypertensive. On examination, her blood pressure is 170/118 and urinanalyis shows 4+ proteinuria.  As you are assessing her, she has a tonic-clonic seizure and loses consciousness.  What is the most appropriate initial management?

A woman with a previous Caesarean section is admitted in early labour. Which of the following is associated with a lower chance of successful vaginal birth after previous Caesarean?

A woman with a previous Caesarean section is admitted in early labour. Which of the following is not recommended for women having a vaginal birth after Caesarean section (VBAC)?

A woman with a previous Caesarean section is admitted in early labour. Which of the following is not a sign or symptoms of uterine scar rupture?

What is the most common cause of postpartum haemorrhage?

Which of the following is not a risk factor for postpartum haemorrhage?

Which of the following complications is not associated with shoulder dystocia?

You are the on call SHO for Labour Ward and attend an emergency buzzer for shoulder dystocia. What is the first management that should be undertaken?

Which of the following is not an indication for planned Caesarean section?

Which of the following risks is not reduced by planned Caesarean section?

A woman has a vaginal delivery and sustains a perineal tear. On examination, the injury affects the skin and perineal muscles and more than 50% of the external anal sphincter is torn.  What classification of perineal tear is this?

Which of the following is not a risk factor for third or fourth degree perineal tears?

Which of the following statements about third and fourth degree tears is incorrect?

Which of the following does not reduce the risk of obstetric anal sphincter injury?

A woman has a vaginal delivery with an active third stage but retains her placenta. How long should be allowed before diagnosing retained placenta in this scenario?

A woman has a vaginal delivery with a physiological third stage. The placenta is not delivered after 60 minutes following the birth of the baby but there is no active bleeding. What is the most appropriate management?

A woman has a primary post-partum haemorrhage and receives intramuscular ergometrine. Which of the following is a contra-indication to ergometrine?

Which of the following drugs is not used in the management of preterm labour?

Which of the following is not an indication for intrapartum antibiotic prophylaxis in labour?

A woman has an emergency Caesarean section for placental abruption and has a massive postpartum haemorrhage of 3 litres. She is transfused 4 units of packed red cells but bleeding is ongoing so the anaesthetist requests additional blood products while awaiting the most recent coagulation test results.  What is the next most appropriate blood product to give?

Which of the following is not a cause of disseminated intravascular coagulation in labour?

A woman has an emergency Caesarean section for placental abruption and has a massive postpartum haemorrhage of 3 litres. Emergency blood products are requested for immediate transfusion. Which of the following specifications is not required for emergency blood products issued for obstetric patients?

You attend an emergency buzzer for maternal collapse. On entering the room, the midwife informs you that the woman delivered her ten minutes ago and controlled cord traction to deliver the placenta was attempted but that the woman suddenly became very hypotensive and collapsed.  On examination, the placenta is visible at the vaginal introitus and but there does not appear to be significant vaginal bleeding.  What is the likely diagnosis?

A woman attends in early labour and suddenly collapses with significant frank vaginal bleeding. Despite cardiopulmonary resuscitation and perimortem Caesarean section, she sadly dies.  Post-mortem examination confirms the presence of fetal squamous cells in the pulmonary vasculature.  What is the cause of death?

A 24 year old primigravid woman is being induced for gestational diabetes. She has an artificial rupture of membranes and is commenced on oxytocin.  Over the next 14 hours, she makes adequate progress to 7cm dilated when she is noted to be pyrexial with a temperature of 39.5C, maternal tachycardia of 120bpm and obvious rigors.  The fetal baseline heart rate is 160bpm but there are no other CTG abnormalities.  What is the most appropriate management?

A woman has an emergency Caesarean section for presumed fetal compromise and the baby is born in poor condition. At  birth and one minute of age, the baby has a heart rate of 120bpm but makes no respiratory effort and is pale and does not move spontaneously or in response to stimulation.  At five minutes of age after successful resuscitation, the baby has a heart rate of 150bpm, is pink and moving and is crying weakly both spontaneously and in response to stimulation.  What Apgar scoring should be documented in the postnatal notes?

You are asked to prescribe thromboprophylaxis post-operatively for a postnatal woman who has had an elective Caesarean section for twin pregnancy. Her weight is 100kg and she has a BMI of 28. What is the most appropriate treatment?

You are asked to prescribe thromboprophylaxis post-operatively for a postnatal woman with a history of a previous DVT who has had an instrumental vaginal delivery at term. Her weight is 70kg and she has a BMI of 24. What is the most appropriate treatment?

A RhD negative mother has given birth to a RhD positive infant confirmed by cord blood RhD typing. What is the best management option?

A 30 year old woman delivered seven days ago and presents with a painful right breast. She is systemically well and apyrexial with a well demarcated area of erythema and tenderness over her right breast. What is the most appropriate management option?

What is the definition of secondary postpartum haemorrhage?

Which of the following is not a known cause of secondary postpartum haemorrhage?

Which of the following is not a cause of primary postpartum haemorrhage?

Which women should have a documented assessment of their risk factors for venous thromboembolism in the immediate postpartum period?

A 38 year old woman has delivered her second child by elective Caesarean section. How long is low molecular weight heparin prophylaxis required for?

A 28 year old woman has delivered by elective Caesarean section. What is the most appropriate option for VTE prophylaxis?

A 23 year old woman has just had a spontaneous vaginal delivery of her first child at term,. She had a booking BMI of 47. What is the most appropriate option for VTE prophylaxis?

A 21 year old woman has just given birth to her first child. She had an induction of labour for pre-eclampsia that was diagnosed at 39+4 weeks gestation but did not require antihypertensive treatment. How often should her blood pressure be measured?

A 20 year old woman delivered her first child vaginally one week ago. She is struggling with breastfeeding and asks for advice as she feels she is uncertain about the benefits. Which of the following advice options should be given with caution?

A 38 year old woman is brought into the Emergency Department by her partner. She delivered her first baby 18 days ago but has started acting strangely. She is no longer feeding her baby, doesn’t believe that her baby belongs to her and has accused her partner of swapping her baby. What is the most likely diagnosis?

Which of the following is not screened for by the the NHS Blood Spot Screening Programme?

A 24-year old presents asking for contraceptive advice. She is taking the combined oral contraceptive pill and has forgotten to take her last two pills.  She is currently on Day 5 of her pill packet and has had unprotected sexual intercourse in the last 24 hours.  What is the most appropriate advice?

A 25 year old woman has a medical termination of pregnancy at 14 weeks, following a chorionic villous sampling (CVS) that confirmed that the fetus had Trisomy 13. What clause of the Abortion Act is this performed under?

Which of the following should be recommended for contraception in a patient with pulmonary arterial hypertension?

An 18 year old girl attends the emergency department of her local hospital reporting a serious sexual assault. Which of the following should be offered immediately?

A 24 year old nulliparous woman attends her GP with nausea, abdominal distension and rapid weight gain. She is 6 weeks pregnant following successful IVF treatment for polycystic ovary syndrome. What is the likely diagnosis?

A 25 year old woman presents as she and her partner have being trying to conceive for two years without success. What is the incidence of subfertility?

A 30 year old woman presents as she and her partner have being trying to conceive for two years without success. Her periods are irregular with a cycle length of 35 to 50 days. What test is most useful for assessing ovulation?

A 25 year old woman presents as she and her partner have being trying to conceive for one year without success.  She has a history of previous ruptured appendicitis as a child but is otherwise fit and well.  What is the most appropriate investigation to diagnose the cause of subfertility?

A 36-year-old woman with a 3-year history of primary infertility is about to commence a fresh IVF cycle. Which investigation can be used as a predictor of quantitative ovarian response?

A 33-year-old woman presents to hospital one week after oocyte retrieval as part of her IVF treatment cycle. She is complaining of generalised lower abdominal pain, nausea, and abdominal distension. A bedside ultrasound scan has shown evidence of ascites and enlarged ovaries – the left ovary has a mean diameter of 9cm, and the right ovary has a mean diameter of 10 cm. Despite taking paracetamol she is still experiencing significant discomfort. What is the most appropriate management?

A 20 year old primigravida presents  at 7 weeks gestation with persistent nausea and vomiting for the last week. Clinically, she appears dehydrated but has not lost any weight.  She asks if there are any medications to alleviate her symptoms.  What is the most appropriate antiemetic regimen?

A 15 year old girl attends the Early Pregnancy Assessment Unit at approximately six weeks pregnant and ultrasound scan confirms a missed miscarriage. She wishes to have surgical management and signs a consent form for the procedure.  Which of the following statements about consent is incorrect?

A 26 year old woman presents with a 10 day history of left sided lower abdominal pain, vomiting and loose stools. She is usually fit and well with no significant past medical history.  On examination, her abdomen is soft but she has localized peritonism in the left iliac fossa and fullness and tenderness in the left adnexae on bimanual examination.  What is the next most appropriate investigation?

A 26 year old woman presents with a 10 day history of left sided lower abdominal pain. She is usually fit and well with no significant past medical history.  Her urinary pregnancy test is positive.  Which of the following is not a risk factor for ectopic pregnancy?

A 26 year old woman presents with a 10 day history of left sided lower abdominal pain. She is usually fit and well with no significant past medical history.  Her urinary pregnancy test is positive.  Which of the following is not a risk factor for ectopic pregnancy?

A 26 year old woman presents with profuse painless vaginal bleeding and severe nausea and vomiting. She is currently 9 weeks pregnant by her last menstrual period.  A trans-vaginal ultrasound scan shows a suspected molar pregnancy.  She has a surgical evacuation of the uterus and is referred to a gestational trophoblastic disease tertiary centre for follow-up.  What is the best method of monitoring for gestational trophoblastic disease?

A 40 year old woman presents with vaginal bleeding and cramping lower abdominal pain. She is approximately seven weeks pregnant by her last menstrual period. She is very upset as she is worried she is having a miscarriage.  What percentage of pregnancies end in miscarriage?

A recent randomised trial has demonstrated a benefit in progesterone therapy for women with early pregnancy bleeding and one or more previous miscarriages. What is the recommended regime to use for these women?

Hyperemesis Gravidarum is diagnosed when there is protracted nausea and vomiting with the triad of more than 5% pre-pregnancy weight loss, dehydration, and electrolyte imbalance. What antiemetic regime would be considered first line?

What is the incidence of ectopic pregnancy in the UK?

A 25-year-old woman presents to your early pregnancy unit with vaginal bleeding and a positive pregnancy test. Her last menstrual period was 7 weeks ago. She is a Para 1 who had an emergency caesarean section 2 years ago for fetal distress. A transvaginal ultrasound scan is performed which shows an anteverted uterus, with a closed cervix. A gestation sac is seen within the uterine cavity, medial to the interstitial portion of the fallopian tubes. It measures 32 x 26 x 23mm. Within the gestation sac is a yolk sac and a fetal pole with a CRL measuring 6 mm, no cardiac activity is detected. There was no evidence of a pregnancy in the adnexae. There is a small amount of anechoic free fluid in the pouch of Douglas. What is the most likely diagnosis?

A 25-year-old woman presents to the emergency department with diarrhoea and a positive pregnancy test. Her last menstrual period was approximately 7 weeks ago, her cycles are 35 days in length. She is a para 1 who had an emergency caesarean section 4 years ago for fetal distress. A transvaginal ultrasound scan is performed which shows an anteverted uterus, with a closed cervix. The cavity of the uterus is empty. Both ovaries appeared morphologically normal, with a corpus luteum seen on the right ovary. Adjacent to the right ovary is an echogenic ring measuring 23 x 22 x 19 mm. There was no evidence of free fluid in the pouch of Douglas. What is the most likely diagnosis?

A 45-year-old woman presents to the early pregnancy unit with vaginal bleeding and a positive pregnancy test. Her last period was 8 weeks ago. She is a para 1 having had an emergency caesarean section 3 years ago for failure to progress in the second stage of labour. She has been complaining of significant nausea. A transvaginal ultrasound scan is performed which shows an anteverted uterus, with a closed cervix. There was a complex intrauterine mass measuring 50 x 45 x 44 mm containing multiple cystic areas and an area of fluid collection within the uterine cavity. There is no evidence of any fetal tissue. Both ovaries appear morphologically normal with a corpus luteum on the right ovary. What is the most likely diagnosis?

A 30-year-old woman presents to the early pregnancy unit with abdominal pain and a positive pregnancy test. Her last menstrual period was approximately 14 weeks ago, her cycles are 35 days in length. She is a para 1 who had an emergency caesarean section 2 years ago for fetal distress. A transvaginal ultrasound scan is performed which shows an anteverted uterus, with a closed cervix. The uterine cavity is empty. Both ovaries appeared morphologically normal, with a corpus luteum seen on the right ovary. A gestation sac surrounded by loops of bowel and containing a fetus is seen in the pouch of Douglas. The crown rump length is 85mm and cardiac activity is noted. What is the most likely diagnosis?

A 25-year-old woman presents to the early pregnancy unit with vaginal bleeding and a positive pregnancy test. Her last menstrual period was approximately 6 weeks ago, her cycles are 35 days in length. She is a para 1 who had an emergency caesarean section 2 years ago for fetal distress. A transvaginal ultrasound scan is performed which shows an anteverted uterus, with a closed cervix. A cystic structure is seen within the uterine cavity in the midline, measuring 14 x 12 x 11mm. Both ovaries appeared morphologically normal, with a corpus luteum seen on the right ovary. There was no evidence of a pregnancy in the adnexae and no evidence of free fluid in the pouch of Douglas. What is the most likely diagnosis?

A 40-year-old woman presents to the early pregnancy unit with vaginal bleeding and a positive urinary pregnancy test. Her last period was 8 weeks ago. She is known to your department as she has been seen in a general gynaecology clinic complaining of pressure symptoms secondary to fibroids. Her last scan 6 months ago had shown an enlarged multifibroid uterus, with the largest 3 fibroids having mean diameters of 15, 12 and 11 cm respectively. On clinical examination she has a mass arising from the pelvis which is palpable above the umbilicus. What is the most appropriate management?

A 36-year-old woman presents to the Early Pregnancy Unit with vaginal bleeding and a positive pregnancy test. She is a Para 2 having had two emergency caesarean sections. Her last period was 7 weeks ago. She has a BMI of 39. What is the most appropriate management?

A 31-year-old women who is Para 2 has presented to the Early Pregnancy Unit complaining of a one-week history of vaginal bleeding which was heaviest yesterday, accompanied by crampy central lower abdominal pain. She has a positive pregnancy test, and her last period was 6 weeks ago. A transvaginal ultrasound scan has been performed which shows an empty uterine cavity. The cervical canal is closed. There is no evidence of an extrauterine pregnancy. Both ovaries appear morphologically normal, with a corpus luteum being seen on the right ovary. What is the most appropriate management?

At what gestation does the gravid uterus reach the umbilicus?

Which of the following is not a risk factor for preterm birth?

Symphysio-fundal height is used to screen for fetal growth restriction in low risk obstetric populations.  How often should symphysio-fundal height be measured?

Symphysio-fundal height is used to screen for fetal growth restriction however certain groups of patients are unsuitable for fundal height measurement and require serial assessment of fetal growth by ultrasound.  Which of the following is not an indication for ultrasound assessment of fetal growth?

A 22 year old woman attends a booking antenatal appointment with her community midwife at 8 weeks gestation. She tells her midwife that she thinks she may have been ‘circumcised’ as a child and on examination, there is evidence of Type 1 FGM.  Which of the following countries has a very high prevalence of FGM?

A 28 year old woman presents at 36 weeks gestation in her third pregnancy as she has noticed pain and numbness in both her hands which is worse at night. On examination, there is normal tone and power but loss of sensation to the thumbs, index fingers and middle fingers bilaterally.  Upper arm reflexes and coordination are normal.  What is the likely diagnosis?

A 22 year old Somalian woman attends a booking antenatal appointment with her community midwife at 8 weeks gestation.  She tells her midwife that she thinks she may have been ‘circumcised’ as a child and on examination, there is evidence of Type 1 FGM.  Which of the following statements regarding FGM and UK law is incorrect?

You are asked to consent a patient for an emergency Caesarean section. Which of the following is the least common complication of Caesarean section?

You are asked to consent a patient for an emergency Caesarean section. Which of the following is the most common complication of Caesarean section?

You are asked to consent a patient for an emergency Caesarean section. You describe the risks of the operation to the patient and she is concerned about the risk of postpartum haemorrhage which you describe as 5 in 1000.  What term should be used to describe this risk?

You are assisting the on call registrar with an emergency Caesarean section. The registrar is concerned that the patient is high risk and has asked the consultant to attend.  Which of the following factors is not associated with a higher risk of operative complications?

You are asked to attend a trial of instrumental delivery. The registrar performs a forceps delivery.  Which of the following is not a complication associated with instrumental delivery?

A 32 year old woman books for antenatal care at approximately 6 weeks by LMP.  This is her first pregnancy and is unplanned.  She is fit and well with a BMI of 25 and no significant past medical history. However her sister developed severe pre-eclampsia during her first pregnancy and she wishes to know what she can do to reduce her risk of developing pre-eclampsia.  What is the best management option?

A 29 year old is referred for consultant led antenatal care due to her risk of pre-eclampsia.  Which of the following confers a high risk factor for pre-eclampsia?

A 39 year old is seen at 12 weeks gestation for a routine antenatal appointment in her second pregnancy.  She is noted to have raised blood pressure at 145/95mmHg, her urinanalysis is normal and she is asymptomatic.  She has a family history of hypertension but did not have any hypertensive disorder in her previous pregnancy.  What is the most appropriate management?

A 30 year old woman attends for pre-pregnancy counselling as she is planning to try to conceive and has a history of poorly controlled chronic hypertension for which she takes ramipril 5mg once daily.  She is also a poorly controlled asthmatic who has previously been admitted to ITU on two occasions with exacerbation of her asthma.  What is the most appropriate management?

A 40 year old woman attends at 13 weeks of pregnancy for a routine antenatal appointment in her first pregnancy. She is noted to have a blood pressure of 170/105 but she is asymptomatic and her urinanalysis is normal.  Her blood pressure at booking was 145/90.  What is the likely diagnosis?

A 34 year old primigravidae presents with a two day history of worsening shortness of breath and a non-productive cough at 26 weeks gestation.  She  has a history of asthma since childhood for which she takes regular salbutamol and beclometasone inhalers and she has been admitted to hospital with an acute exacerbation one year ago.  She reports that she has not been taking her regular asthma medication since she fell pregnant as she is worried that they may harm the baby.  On examination, there is widespread wheeze on auscultation of the lungs and her PEFR is 70% of predicted but all other observations are normal and she is able to speak in full sentences.  What is the most appropriate treatment?

A 23 year old woman books for routine antenatal care at 8 weeks gestation and is recommended to take Vitamin D supplementation.  Which of the following groups of patients are not at higher risk of Vitamin D deficiency?

A 33 year old patient with a BMI of 41 attends to have her IUCD removed as she is planning to try to conceive.  Which of the following maternal risks is not increased in pregnant women with obesity?

A 26 year old primigravida attends antenatal clinic at 30 weeks of gestation as she is planning to travel abroad for a family event in Australia. She requests a letter to give to the airline to allow her to travel.  Which of the following statements regarding air travel in pregnancy is incorrect?

A 36 year old woman presents frequently to secondary care in her first pregnancy with multiple symptoms that she is very concerned about. Which of the following is not a common symptom in pregnancy?

A 36 year old woman presents frequently to secondary care in her first pregnancy with multiple symptoms that she is very concerned about despite reassurance and there are concerns that she may be at risk of domestic abuse.  Which of the following is not associated with domestic abuse?

A 36 year old woman books for antenatal care and is concerned because she has a history of mental health illness and she wants to know how it will affect her pregnancy.  Which of the following is not a risk factor for postnatal psychosis?

A 26 year old woman books routine antenatal care at 8 weeks gestation with her community midwife.  At the appointment, she is offered routine screening for a number of haematological conditions.  Which of the following haematological conditions is not routinely screened for in the UK at booking?

A 25 year old patient recently attended for her routine cervical smear and has received a letter telling her that her smear is abnormal and inviting her for colposcopy.  However, she has just discovered that she is pregnant and her last menstrual period was 7 weeks ago.  Her cervical smear result reports that high grade dyskaryosis is present.  What is the most appropriate management plan?