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A 40-year-old woman is seen in the antenatal clinic at 20 weeks of gesta on. Both
Q her booking and anomaly scan are normal. She has a BMI of 24. She had a
previous vaginal delivery at 39 weeks of gesta on of a baby weighing 1.8 kg. She
smokes 20 cigare es per day. What is the next most appropriate inves ga on?

Early growth scan at 26–28 weeks of gesta on

Liquor volume scan at 26–28 weeks of gesta on

Middle cerebral artery Doppler at 32 weeks of gesta on

Umbilical artery Doppler at 26–28 weeks of gesta on
Uterine artery Doppler at 20–24 weeks of gesta on

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11/21/2018 Obstetrics page 1 | StratOG

A 28-year-old woman dies at 47 days postpartum following aspira on during an

Q epilep c seizure. She had a 10 year history of epilepsy. What is the classifica on of
this maternal death?

Early direct maternal death

Early indirect maternal death

Late coincidental maternal death

Late direct maternal death

Late indirect maternal death

A 25-year-old primigravida woman is admi ed to the labour ward with regular

Q contrac ons and draining clear liquor. She is a known carrier for Streptococcus B in
this pregnancy. Shortly a er being given a loading dose of benzylpenicillin, she
becomes wheezy, develops a rash and has difficulty breathing. What is the most
appropriate ini al dose of intramuscular adrenaline?

0.01 mg (0.1 ml of 1:10000)

0.05 mg (0.5 ml of 1:10000)

0.1 mg (0.1 ml of 1:1000)

0.5 mg (0.5 ml of 1:1000)

10 mg (10 ml of 1:1000)

A 42-year-old primigravid woman presents in spontaneous labour at 37 weeks of

Q gesta on. She develops central crushing chest pain which radiates to her le jaw.
Which of the following cardiac biomarkers is most reliable for diagnosing acute
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11/21/2018 Obstetrics page 1 | StratOG

myocardial infarc on during labour and delivery?

Crea nine kinase

Isoenzyme MB
LDH (lactate dehydrogenase)

Myoglobin

Troponin I

The obstetric team are conduc ng a study to evaluate whether there has been any
Q effect on pa ent sa sfac on following the establishment of an outpa ent
induc on of labour (IOL) programme. Women undergoing inpa ent IOL and
women undergoing outpa ent IOL were asked to rate their overall sa sfac on
with the process using a visual analogue scale from 1 (least sa sfied) to 10 (most
sa sfied). What is the most appropriate sta s cal test to assess whether there is a
significant difference in sa sfac on between the two groups?

Chi squared test

Kruskal Wallis test

Mann Whitney U test

Student’s t test
Wilcoxon matched pairs signed rank test

A woman a ends the antenatal clinic at 30 weeks of gesta on and discloses that
Q she had suspected whooping cough 2 months earlier. What is the single best
recommenda on regarding pertussis immunisa on?

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11/21/2018 Obstetrics page 1 | StratOG

Maternal pertussis an bodies should be measured

Maternal vaccina on should be given now

Maternal vaccina on should be deferred un l 38 weeks of gesta on

Maternal vaccina on should be given postnatally

Neonatal immunisa on should be given

You are asked to repair a vaginal tear following a normal delivery. The mother’s
Q weight is 60 kg. She is otherwise well with no allergies. What is the maximum dose
of lidocaine 1% without epinephrine that you can use for perineal infiltra on?

8 ml (80 mg)

12 ml (120 mg)

18 ml (180 mg)

24 ml (240 mg)

36 ml (360 mg)

A woman who is 24 weeks pregnant contacts the maternity day unit repor ng
Q possible exposure to facial shingles 4 days earlier. The pregnant woman believes
she has had chickenpox when she was a child. What advice should she be given?

Offer tes ng for varicella zoster virus (VZV) immunity and, if non-immune,
offer varicella zoster immunoglobulin (VZIG)

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11/21/2018 Obstetrics page 1 | StratOG

Offer tes ng for VZV immunity and, if non-immune, offer varicella

vaccina on

Reassure her that no further ac on is necessary as she is likely to be

immune

Tell her to report the development of a rash, and if it develops, offer her
treatment with oral aciclovir

Tell her to report the development of a rash and, if it develops, offer her
treatment with VZIG

A pregnant woman with a BMI of 25 sees her midwife at 24 weeks of gesta on. A
Q single symphysis fundal height (SFH) measurement is undertaken which is less
than expected for this gesta on. What is the most appropriate management?

Refer if SFH measurement on a customised chart plots below the 10th

cen le
Refer if the SFH measurement on a popula on-based chart plots on the
10th cen le

Refer if there is a discrepancy of 1 cm compared with gesta onal age

Refer if there is a discrepancy of 2 cm compared with gesta onal age

Reassess in 2 weeks me by the same clinician and refer if SFH is s ll less

than expected

A woman has an intrapartum s llbirth. Despite extensive discussion and

Q explana on of the management of the pregnancy and delivery with her
consultant, she s ll expresses dissa sfac on. She indicates that she wishes to
explore further whether the s llbirth should have been avoided. On a ward round
she asks you whom she should contact for help. To which of the following
organisa ons would you direct her in the first instance?

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11/21/2018 Obstetrics page 1 | StratOG

Care Quality Commission

Clinical Commissioning Group

General Medical Council

Pa ent Advice and Liaison Service

Pa ent Associa on

This is the last ques on of this quiz. Press finish to submit your choice(s) and reveal the answer(s).

Royal College of Obstetricians and Gynaecologists

© 2018

Registered charity no. 213280

27 Sussex Place
Regent's Park
London NW1 4RG
UK

Tel +44 20 7772 6200

Fax +44 20 7723 0575

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11/21/2018 Obstetrics page 1 | StratOG

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History
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Your result 100 %

A 40-year-old woman is seen in the antenatal clinic at 20 weeks of

Q gesta on. Both her booking and anomaly scan are normal. She has a BMI of
24. She had a previous vaginal delivery at 39 weeks of gesta on of a baby
weighing 1.8 kg. She smokes 20 cigare es per day. What is the next most
appropriate inves ga on?

A Your answer:
> Umbilical artery Doppler at 26–28 weeks of gesta on 
Correct answer:
> Umbilical artery Doppler at 26–28 weeks of gesta on

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11/21/2018 Obstetrics page 1 | StratOG

The correct answer is umbilical artery Doppler at 26–28 weeks of

gesta on. If women have a major risk factor for fetal growth
restric on they should have serial umbilical artery Doppler scans
from 26–28 weeks of gesta on. This woman has several risk factors
including two major factors: smoking >11 cigare es/day and a
previous small-for-gesta onal-age baby. Note that women with
three or more minor risk factors for fetal growth restric on should
be referred for uterine artery doppler at 20–24 weeks of gesta on.
See Royal College of Obstetricians and Gynaecologists. The
inves ga on and management of the small-for-gesta onal-age
fetus. Green-top Guideline 31. London: RCOG. 2013.
(h ps://www.rcog.org.uk/en/guidelines-research-
services/guidelines/gtg31/)

A 28-year-old woman dies at 47 days postpartum following aspira on

Q during an epilep c seizure. She had a 10 year history of epilepsy. What is
the classifica on of this maternal death?

A Your answer:
> Late indirect maternal death 
Correct answer:
> Late indirect maternal death
The correct answer is late indirect maternal death. A maternal death
that occurs 6 weeks following child birth is termed as late maternal
death. If death occurs of a pre-exis ng medical condi on it is called
an indirect maternal death. See Maternal, Newborn and Infant
Clinical Outcome Review Programme. Saving Lives, Improving
Mother's Care. Lessons learned to inform future maternity care from
the UK and Ireland Confiden al Enquiries into Maternal Deaths and
Morbidity 2009–2012. Oxford: Na onal Perinatal Epidemiology Unit,
University of Oxford. 2014. (h p://www.npeu.ox.ac.uk/mbrrace-
uk/reports)

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11/21/2018 Obstetrics page 1 | StratOG

A 25-year-old primigravida woman is admi ed to the labour ward with

Q regular contrac ons and draining clear liquor. She is a known carrier for
Streptococcus B in this pregnancy. Shortly a er being given a loading dose
of benzylpenicillin, she becomes wheezy, develops a rash and has difficulty
breathing. What is the most appropriate ini al dose of intramuscular
adrenaline?

A Your answer:
> 0.5 mg (0.5 ml of 1:1000) 
Correct answer:
> 0.5 mg (0.5 ml of 1:1000)
The correct answer is 0.5 mg (0.5 ml of 1:1000). The correct dose of
intramuscular (im) adrenaline in anaphylac c shock is 0.5mg. Doses
of 0.01 mg, 0.05mg and 0.1 mg are too small for therapeu c effect
in circulatory collapse by im route and would be more appropriate
doses for iv route. 10mg is too large for an ini al dose but if there is
a subop mal response to ini al dose, then injec ons should be
repeated every 10 minutes and may therefore reach an
accumula ve dose of 10 mg. See the Bri sh Na onal Formulary
(h p://www.bnf.org/bnf/index.htm).

A 42-year-old primigravid woman presents in spontaneous labour at 37

Q weeks of gesta on. She develops central crushing chest pain which radiates
to her le jaw. Which of the following cardiac biomarkers is most reliable
for diagnosing acute myocardial infarc on during labour and delivery?

A Your answer:
> Troponin I 
Correct answer:
> Troponin I
The correct asnwer is Troponin I. Troponin I is unaffected by labour,
anaesthesia or delivery. See Wuntakal R, She y N, Ioannou E,
Sharma S, Kurian J. Myocardial infarc on and pregnancy. The
Obstetrician & Gynaecologist 2013;15:247–55.
(h p://onlinelibrary.wiley.com/doi/10.1111/tog.12052/full)

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The obstetric team are conduc ng a study to evaluate whether there has
Q been any effect on pa ent sa sfac on following the establishment of an
outpa ent induc on of labour (IOL) programme. Women undergoing
inpa ent IOL and women undergoing outpa ent IOL were asked to rate
their overall sa sfac on with the process using a visual analogue scale from
1 (least sa sfied) to 10 (most sa sfied). What is the most appropriate
sta s cal test to assess whether there is a significant difference in
sa sfac on between the two groups?

A Your answer:
> Mann Whitney U test 
Correct answer:
> Mann Whitney U test
The correct answer is the Mann Whitney U test. See Campbell MJ,
Machin D, Walters SJ. Medical sta s cs: a textbook for the health
sciences (medical sta s cs). Wiley-Blackwell. 2007.

A woman a ends the antenatal clinic at 30 weeks of gesta on and discloses

Q that she had suspected whooping cough 2 months earlier. What is the
single best recommenda on regarding pertussis immunisa on?

A Your answer:
> Maternal vaccina on should be given now 
Correct answer:
> Maternal vaccina on should be given now
The correct answer is that maternal vaccina on should be given
now. Despite high vaccina on coverage in Britain since the 1990s,
pertussis con nues to display 3–4 yearly peaks in ac vity. In 2012
there was a major leap in pertussis, with levels above those
reported in the previous 20 years. It was seen in all age groups.
Infants under 3 months are at highest risk of complica ons and
death. In view of the outbreak in 2012 all pregnant women are
offered pertussis vaccina on during pregnancy.

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11/21/2018 Obstetrics page 1 | StratOG

You are asked to repair a vaginal tear following a normal delivery. The
Q mother’s weight is 60 kg. She is otherwise well with no allergies. What is
the maximum dose of lidocaine 1% without epinephrine that you can use
for perineal infiltra on?

A Your answer:
> 18 ml (180 mg) 
Correct answer:
> 18 ml (180 mg)
The correct answer is 18 ml (180 mg). The maximum dose of
lidocaine is 3 mg/kg. As the woman's weight is 60 kg, the dose is 3 x
60 = 180 mg total dose. 1% lidocaine contains 1 x 10 mg/ml = 10
mg/ml. Therefore the maximum volume is 180 /10 = 18 ml of 1%
lidocaine. See StratOG Core Training eTutorial on Obstetric analgesia
and anaesthesia (h ps://stratog-live.rcog.org.uk/tutorials/core-
training/management-labour-and-delivery/obstetric-analgesia-and-
anaesthesia) and Anaesthesia UK. Pharmacology of regional
anaesthesia. Accessed online 27 January 2015
(h p://www.frca.co.uk/ar cle.aspx?ar cleid=100816).

A woman who is 24 weeks pregnant contacts the maternity day unit

Q repor ng possible exposure to facial shingles 4 days earlier. The pregnant
woman believes she has had chickenpox when she was a child. What advice
should she be given?

A Your answer:
> Offer tes ng for varicella zoster virus (VZV) immunity and, if non- 
immune, offer varicella zoster immunoglobulin (VZIG)
Correct answer:
> Offer tes ng for varicella zoster virus (VZV) immunity and, if non-
immune, offer varicella zoster immunoglobulin (VZIG)
The correct answer is offer tes ng for varicella zoster virus (VZV)
immunity and, if non-immune, offer varicella zoster immunoglobulin
(VZIG). VZV is highly contagious and can be transmi ed by
respiratory droplets, direct personal contacts or fomites. It is
possible to catch it from both chickenpox and herpes zoster (HZ) but
it is highly unlikely if the HZ is in non-exposed sites. VZIG is effec ve
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11/21/2018 Obstetrics page 1 | StratOG

when given up to 10 days a er contact. The pregnant woman

should then be considered as infec ous for 8 to 28 days a er
receiving VZIG.

A pregnant woman with a BMI of 25 sees her midwife at 24 weeks of

Q gesta on. A single symphysis fundal height (SFH) measurement is
undertaken which is less than expected for this gesta on. What is the most
appropriate management?

A Your answer:
> Refer if SFH measurement on a customised chart plots below the 
10th cen le

Correct answer:
> Refer if SFH measurement on a customised chart plots below the
10th cen le
The correct answer is refer if SFH measurement on a customised
chart plots below the 10th cen le. Abdominal palpa on is poor at
predic ng small-for-gesta onal-age (SGA) babies, especially in a
mixed risk popula on. SFH using a customised growth chart which
takes into account maternal height, weight, parity and ethnic group
improves the predic on of SGA babies, but there is wide varia on in
the predic ve accuracy ranging from a sensi vity of 27–86% and a
specificity of 80–93%. See Royal College of Obstetricians and
Gynaecologists. The inves ga on and management of the small–
for–gesta onal–age fetus. Green-top guideline 31. London: RCOG.
2014. (h ps://www.rcog.org.uk/en/guidelines-research-
services/guidelines/gtg31/)

A woman has an intrapartum s llbirth. Despite extensive discussion and

Q explana on of the management of the pregnancy and delivery with her
consultant, she s ll expresses dissa sfac on. She indicates that she wishes
to explore further whether the s llbirth should have been avoided. On a
ward round she asks you whom she should contact for help. To which of the
following organisa ons would you direct her in the first instance?

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11/21/2018 Obstetrics page 1 | StratOG

A Your answer:

> Pa ent Advice and Liaison Service

Correct answer:
> Pa ent Advice and Liaison Service
The correct answer is the Pa ent Advice and Liaison Service. If a
pa ent has a complaint or concern, it is best dealt with by the
provider of the health care in the first instance. Other organisa ons
may be appropriate if the ini al response is not sa sfactory.

Royal College of Obstetricians and Gynaecologists

© 2018

Registered charity no. 213280

27 Sussex Place
Regent's Park
London NW1 4RG
UK

Tel +44 20 7772 6200

Fax +44 20 7723 0575

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11/21/2018 Obstetrics page 2 | StratOG

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Gesta onal diabetes is a common complica on of pregnancy. What hormonal

Q factor is predominantly responsible?

Cor sol
Estrogen

Human chorionic gonadotrophin

Human placental lactogen
Progesterone

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A 28-year-old woman a ends for prepregnancy counselling. Her maternal

Q grandfather and her mother's brother have haemophilia A. Her husband is healthy
but she has been screened and is a carrier. What is the risk that her future son
would inherit this disease?

0%

25%
50%

75%
100%

A 27-year-old primigravida presents at 36 weeks of gesta on in labour. She reports

Q watery vaginal discharge for a while. On examina on her temperature, pulse and
blood pressure are normal. She is contrac ng moderately and clear liquor can be
seen draining. The fetal heart rate is 136 bpm. On vaginal examina on the cervix is
3 cm dilated. Membranes are absent. What is the most appropriate management
to reduce the risk of early onset neonatal infec on?

Intrapartum an bio c prophylaxis if rupture of membranes occurred 18

hours before onset of labour

Intrapartum an bio c prophylaxis if rupture of membranes occurred 24

hours before onset of labour

Intrapartum an bio cs if the mother develops signs of infec on

Neonatal an bio c prophylaxis

Prescribe intrapartum an bio c prophylaxis with any dura on of prelabour

rupture of membranes

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A 30-year-old woman books in the antenatal clinic at 12 weeks of gesta on with a

Q BMI of 40. This is her first baby and she is normally fit and well with no family
history of note. With regard to her BMI, which complica on of pregnancy is the
highest risk compared to women with a normal BMI?

Emergency caesarean

Gesta onal diabetes

Postpartum haemorrhage

S llbirth

Venous thromboembolism

A pregnant woman is iden fied as being suscep ble to rubella from her first
Q trimester booking blood results. When discussing this result at the next antenatal
clinic appointment, what is the most appropriate advice that she should be given?

A single dose of MMR (mumps measles rubella vaccine) should be offered

at the six-week postnatal check

A single dose of MMR should be offered immediately postnatally

A single dose of MMR should be offered immediately postnatally with a
second dose at the six-week postnatal check

A single dose of rubella immunoglobulin should be offered as soon as

possible
A single dose of rubella vaccine should be offered as soon as possible

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A 25-year-old primigravida presents at 32 weeks of gesta on with itching.

Q Following a blood test, she is diagnosed with obstetric cholestasis. Which
pharmacological agent would be the most effec ve treatment?

Dexamethasone

S-adenosyl methionine

Topical emollients
Ursodeoxycholic acid

Vitamin K

A 32-year-old woman is in labour in her second pregnancy. Her previous delivery

Q was by caesarean sec on. What is the most consistent indicator of uterine rupture
for this woman?

Abnormal CTG

Acute onset of scar tenderness

Haematuria

Loss of sta on of the presen ng part

Severe abdominal pain

A 29-year-old primigravida presents with chest pain and is diagnosed with

Q myocardial infarc on. Her BMI is 29 and she does not have any significant medical
or family history. What is the most likely cause of acute myocardial infarc on in
this case?

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Coronary artery atherosclerosis

Coronary artery dissec on

Coronary artery embolism

Coronary artery spasm

Coronary artery thrombosis

A 35-year-old woman has recently undergone gastric bypass surgery. She is

Q planning a pregnancy. How long should she be advised to delay concep on for?

1 year
2 years

3 years

4 years

5 years

A 36-year-old woman a ends the antenatal clinic at 20 weeks of gesta on. She has
Q had three previous caesarean sec ons and has a normal placental site. She
consented for another caesarean sec on. What is the most likely surgical
complica on?

Bladder injury

Blood transfusion

Bowel injury

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11/21/2018 Obstetrics page 2 | StratOG

Fetal lacera on

Hysterectomy

This is the last ques on of this quiz. Press finish to submit your choice(s) and reveal the answer(s).

Royal College of Obstetricians and Gynaecologists

© 2018

Registered charity no. 213280

27 Sussex Place
Regent's Park
London NW1 4RG
UK

Tel +44 20 7772 6200

Fax +44 20 7723 0575

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Your result 100 %

Gesta onal diabetes is a common complica on of pregnancy. What

Q hormonal factor is predominantly responsible?

A Your answer:
> Human placental lactogen 
Correct answer:
> Human placental lactogen
The corerct answer is human placental lactogen. See Nelson-Piercy
C. Handbook of obstetric medicine. Fourth edi on. CRC Press. 2010.

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11/21/2018 Obstetrics page 2 | StratOG

A 28-year-old woman a ends for prepregnancy counselling. Her maternal

Q grandfather and her mother's brother have haemophilia A. Her husband is
healthy but she has been screened and is a carrier. What is the risk that her
future son would inherit this disease?

A Your answer:
> 50% 
Correct answer:
> 50%
The correct answer is 50%. Haemophilia A is an X-linked recessive
disorder so 50% of her sons will be affected and 50% of her
daughters will be carriers.

A 27-year-old primigravida presents at 36 weeks of gesta on in labour. She

Q reports watery vaginal discharge for a while. On examina on her
temperature, pulse and blood pressure are normal. She is contrac ng
moderately and clear liquor can be seen draining. The fetal heart rate is 136
bpm. On vaginal examina on the cervix is 3 cm dilated. Membranes are
absent. What is the most appropriate management to reduce the risk of
early onset neonatal infec on?

A Your answer:
> Prescribe intrapartum an bio c prophylaxis with any 
dura on of prelabour rupture of membranes

Correct answer:
> Prescribe intrapartum an bio c prophylaxis with any
dura on of prelabour rupture of membranes
The correct answer is prescribe intrapartum an bio c prophylaxis
with any dura on of prelabour rupture of membranes. In preterm
labour, an bio cs should be considered if membranes rupture at
any me prior to the onset of labour. If the woman is at term,
an bio cs should only be given if the woman has had a posi ve
culture for GBS in this pregnancy or has clinical signs of infec on.
See Na onal Ins tute for Health and Clinical Excellence. Neontal
infec on (early onset): an bio cs for preven on and treatment.
CG149. London: NICE; 2012.
(h p://www.nice.org.uk/guidance/cg149)
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A 30-year-old woman books in the antenatal clinic at 12 weeks of gesta on

Q with a BMI of 40. This is her first baby and she is normally fit and well with
no family history of note. With regard to her BMI, which complica on of
pregnancy is the highest risk compared to women with a normal BMI?

A Your answer:
> Venous thromboembolism 
Correct answer:
> Venous thromboembolism
The correct answer is venous thromboembolism. The risk of
diabetes is about three mes higher. The risk of hypertensive
disease is two-to-three mes higher. Caesarean sec on, s llbirth
and postpartum haemorrhage are about twice as likely in women
with a high BMI. Venous thromboembolism is, however, nine mes
higher in this group. See the CMACE/RCOG Joint Guideline.
Management of women with obesity in pregnancy. CMACE. 2010
(h ps://www.rcog.org.uk/globalassets/documents/guidelines/cmac
ercogjointguidelinemanagementwomenobesitypregnancya.pdf).

A pregnant woman is iden fied as being suscep ble to rubella from her
Q first trimester booking blood results. When discussing this result at the next
antenatal clinic appointment, what is the most appropriate advice that she
should be given?

A Your answer:
> A single dose of MMR should be offered immediately postnatally 
with a second dose at the six-week postnatal check
Correct answer:
> A single dose of MMR should be offered immediately postnatally
with a second dose at the six-week postnatal check

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The correct answer is a single dose of MMR should be offered

immediately postnatally with a second dose at the six-week
postnatal check. The clinical diagnosis of rubella is unreliable and
since the risk to the fetus is in the first 16 weeks of pregnancy it is
important that the woman is immunised before she can become
pregnant again. Between 2005 and 2009 there were six cases of
congenital rubella, five of whom were born to mothers who were
born outside the UK. See the NHS Screening Programme website:
Infec ous diseases in pregnancy
(h p://webarchive.na onalarchives.gov.uk/20150408175925/h p:/
/infec ousdiseases.screening.nhs.uk/rubella) (accessed
02/07/2015) and the HPA Guidance on viral rash in pregnancy
(h ps://www.gov.uk/government/uploads/system/uploads/a achm
ent_data/file/322688/Viral_rash_in_pregnancy_guidance.pdf)
(accessed 19/11/2014).

A 25-year-old primigravida presents at 32 weeks of gesta on with itching.

Q Following a blood test, she is diagnosed with obstetric cholestasis. Which
pharmacological agent would be the most effec ve treatment?

A Your answer:
> Ursodeoxycholic acid 
Correct answer:
> Ursodeoxycholic acid
The correct answer is ursodeoxycholic acid. Pruri s in pregnancy is
common, affec ng nearly a quarter of pregnant women. Obstetric
cholestasis is diagnosed when abnormal liver func on tests are
found in associa on with pruri s. Normal pregnancy values should
be used with an upper limit of normal 20% below nonpregnant
levels for transaminases, γ-glutamyl transferase and bilirubin.
Alkaline phosphatase is generally raised in pregnancy due to
placental produc on.
Topical emollients may provide temporary relief of pruri s. S-
adenosyl methionine is not recommended and dexamethasone
should only be used as part of a trial. Vitamin K should be
prescribed if the prothrombin me is prolonged, but is not an
effec ve treatment. See Royal College of Obstetricians and

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Gynaecologists. Obstetric cholestasis. Green-top Guideline 43.

London: RCOG; 2011. (h ps://www.rcog.org.uk/en/guidelines-
research-services/guidelines/gtg43/)

A 32-year-old woman is in labour in her second pregnancy. Her previous

Q delivery was by caesarean sec on. What is the most consistent indicator of
uterine rupture for this woman?

A Your answer:
> Abnormal CTG 
Correct answer:
> Abnormal CTG
The correct answer is abnormal CTG. Vaginal birth a er an
uncomplicated lower segment caesarean sec on is successful in 72–
76% of women. The risk of uterine rupture is 22–74/10 000 (0.22–
0.74%). This is lower if the woman labours preterm (34/10 000 vs
74/10 000). An abnormal CTG is the most consistent finding in
dehiscence, occurring in 55–87% of cases. See Royal College of
Obstetricians and Gynaecologists. Birth a er previous caesarean
birth. Green-top Guideline 45. London: RCOG; 2007.
(h ps://www.rcog.org.uk/en/guidelines-research-
services/guidelines/gtg45/)

A 29-year-old primigravida presents with chest pain and is diagnosed with

Q myocardial infarc on. Her BMI is 29 and she does not have any significant
medical or family history. What is the most likely cause of acute myocardial
infarc on in this case?

A Your answer:
> Coronary artery dissec on 
Correct answer:
> Coronary artery dissec on

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The correct answer is coronary artery dissec on. Cardiac disease

remains a significant cause of maternal death with 54 deaths per
100 000 materni es in the most recent triennial report (2009–
2012). There are profound physiological changes in pregnancy that
affect the heart. The most common cause is atherosclerosis, and
diabetes and smoking are significant risk factors. In women with no
cardiovascular risk factors, coronary artery dissec on may occur. It is
thought that this results from changes in the vessel wall related to
high progesterone levels. See Wuntakal R, She y N, Ioannou E,
Sharma S, Kurian J. Myocardial infarc on and pregnancy. The
Obstetrician & Gynaecologist 2013;15:247–55
(h p://onlinelibrary.wiley.com/doi/10.1111/tog.12052/full).

A 35-year-old woman has recently undergone gastric bypass surgery. She is

Q planning a pregnancy. How long should she be advised to delay concep on
for?

A Your answer:
> 1 year 
Correct answer:
> 1 year
The correct answer is 1 year. The majority of bariatric surgery is
carried out on women of childbearing years. Current advice is to
delay concep on for a year. However, data to support this
recommenda on is lacking, with many studies showing no
difference in outcomes in those women conceiving earlier than 12
months and those conceiving later. See Khan R , Dawlatly B,
Chappa e O. Pregnancy outcome following bariatric surgery. The
Obstetrician & Gynaecologist 2013;15:37–43
(h p://onlinelibrary.wiley.com/doi/10.1111/j.1744-
4667.2012.00142.x/full).

A 36-year-old woman a ends the antenatal clinic at 20 weeks of gesta on.

Q She has had three previous caesarean sec ons and has a normal placental
site. She consented for another caesarean sec on. What is the most likely
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11/21/2018 Obstetrics page 2 | StratOG

surgical complica on?

A Your answer:
> Blood transfusion 
Correct answer:
> Blood transfusion
The correct answer is blood transfusion. Elec ve repeat caesarean
sec on is associated with increasing risks that rise with each
successive pregnancy. Blood transfusion rises from 7.9% with a third
caesarean sec on to 14.1% with the fi h caesarean. See Royal
College of Obstetricians and Gynaecologists. Birth a er previous
caesarean birth. Green-top Guideline 45. London: RCOG; 2007
(h ps://www.rcog.org.uk/en/guidelines-research-
services/guidelines/gtg45/).

Royal College of Obstetricians and Gynaecologists

© 2018

Registered charity no. 213280

27 Sussex Place
Regent's Park
London NW1 4RG
UK

Tel +44 20 7772 6200

Fax +44 20 7723 0575

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11/21/2018 Obstetrics page 3 | StratOG

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You are asked to review a woman following a forceps delivery. She presents with
Q le lateral calf paraesthesia, sensory loss between her first and second toes and
foot drop with inversion. Which nerve compression is the likely cause of her
symptoms?

Common peroneal nerve

Lateral cutaneous nerve of thigh

Lateral femoral nerve

Obturator nerve
Perianeal nerve

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The midwives on the postnatal ward are concerned about the behaviour of a first
Q me mother, who they are about to discharge home. They ask you to review her.
She had an elec ve caesarean sec on for a breech presenta on 3 days ago. She is
otherwise fit and well, but has a past history of depression. Which symptoms
would concern you the most and lead you to the diagnosis of postpartum
psychosis?

Bewilderment and perplexity

Insomnia and worthlessness

Irritability and anxiety

Mood swings ranging from ela on to sadness

Tearfulness and crying spells

A 25-year-old pregnant woman with sickle cell disease a ends the antenatal clinic
Q at 8 weeks of gesta on. What prenatal tes ng should be discussed in the first
instance?

Amniocentesis

Chorionic villus biopsy

Fetal sexing at 10 weeks of gesta on

Noninvasive prenatal tes ng

Partner tes ng

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A primigravida wishes to opt for epidural analgesia in labour at term but she has
Q heard that regional analgesia increases the risk of opera ve vaginal delivery which
she is keen to avoid. Assuming she opts for an epidural analgesia, how can the
second stage of labour be managed to reduce this risk for her?

Allow up to two hours for passive descent

Commence oxytocin infusion at full dilata on

Discon nue epidural at the onset of the second stage

Use a partogram to monitor progress

Use the lithotomy posi on to deliver

A 30-year-old primigravida a ends the delivery suite at 40 weeks of gesta on with

Q prelabour rupture of membranes. On reviewing the notes she has a posi ve result
for group B streptococcus (GBS) in her urine one week ago. She has no known drug
allergies. According to the NICE guidelines which an bio c should she receive?

Ampicillin orally

Benzyl penicillin intravenously

Benzyl penicillin orally

Cefalexin orally

Cefuroxime intravenously

A 30-year-old pregnant woman who is at 28 weeks of gesta on presents to the

Q Day Assessment Unit complaining of flu-like symptoms. She tells you that she
recently went on holiday to Kenya. What is the most appropriate test for the
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diagnosis of malaria?

Blood culture

Polymerase chain reac on (PCR) on maternal serum

Rapid diagnos c test

Serology for an body detec on

Thick and thin blood film for parasites

A 28-year-old primigravida, presents at 36+3 weeks of gesta on in the antenatal

Q clinic with a breech presenta on. There are no obstetric or fetal contraindica ons
to external cephalic version (ECV). An ini al ECV without tocolysis failed two days
earlier. What is the most appropriate management op on?

Another ECV with tocolysis

Another ECV without tocolysis

Caesarean sec on at 38 weeks of gesta on

Postural management

Vaginal breech delivery

A 34-year-old primigravida presents to the maternity assessment unit with a

Q second episode of decreased fetal movements at 34+4 weeks of gesta on. She is
known to be low risk and has had an otherwise uneven ul pregnancy. What is the
most appropriate management op on?

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11/21/2018 Obstetrics page 3 | StratOG

Advise formal kick coun ng and review in two days

Arrange a biophysical profile and, if normal, reassure

Offer two doses of Betamethasone 12 hours apart and deliver within 48

hours

Perform a CTG and arrange a scan

Perform a CTG and, if normal, reassure

A woman presents for booking in the first trimester, she is taking lithium for her
Q mental health. How o en should her serum lithium levels be checked?

Every 1 week un l 36 weeks of gesta on

Every 2 weeks un l 36 weeks of gesta on

Every 4 weeks un l 36 weeks of gesta on

Every 8 weeks un l 36 weeks of gesta on

Once in each trimester

A 25-year-old woman is found to have a platelet count of 110 x 10*9/l when tested
Q rou nely at 28 weeks of gesta on. Her platelet count at 12 weeks of gesta on was
352 x 10*9/l. She has no history of illness. What is the most likely diagnosis from
the list below?

Gesta onal thrombocytopenia

HIV

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Immune thrombocytopenia

Thrombocytosis

Vitamin B12 deficiency

This is the last ques on of this quiz. Press finish to submit your choice(s) and reveal the answer(s).

Royal College of Obstetricians and Gynaecologists

© 2018

Registered charity no. 213280

27 Sussex Place
Regent's Park
London NW1 4RG
UK

Tel +44 20 7772 6200

Fax +44 20 7723 0575

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Your result 100 %

You are asked to review a woman following a forceps delivery. She presents
Q with le lateral calf paraesthesia, sensory loss between her first and second
toes and foot drop with inversion. Which nerve compression is the likely
cause of her symptoms?

A Your answer:
> Common peroneal nerve 
Correct answer:
> Common peroneal nerve

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12/8/2018 Obstetrics page 3 | StratOG

The correct answer is the common peroneal nerve. The common

peroneal nerve is prone to compression at the fibular head during
posi oning in s rrups. See Kuponiyi O, Alleemudder DI, Latunde-
Dada A, Eedarapalli P. Nerve injuries associated with gynaecological
surgery. The Obstetrician & Gynaecologist 2014;16:29–36
(h p://onlinelibrary.wiley.com/doi/10.1111/tog.12064/abstract).

The midwives on the postnatal ward are concerned about the behaviour of
Q a first me mother, who they are about to discharge home. They ask you to
review her. She had an elec ve caesarean sec on for a breech presenta on
3 days ago. She is otherwise fit and well, but has a past history of
depression. Which symptoms would concern you the most and lead you to
the diagnosis of postpartum psychosis?

A Your answer:
> Bewilderment and perplexity 
Correct answer:
> Bewilderment and perplexity
The correct answer is bewilderment and perplexity. Most of these
symptoms are features of 'baby blues' which affects 30–80% of
births in the first week postpartum. Confusion, bewilderment and
perplexity are worrying symptoms and should alert you to the
diagnosis of postpartum psychosis. See Di Florio A, Smith S, Jones I.
Postpartum psychosis. The Obstetrician & Gynaecologist
2013;15:145–50
(h p://onlinelibrary.wiley.com/doi/10.1111/tog.12041/full).

A 25-year-old pregnant woman with sickle cell disease a ends the

Q antenatal clinic at 8 weeks of gesta on. What prenatal tes ng should be
discussed in the first instance?

A Your answer:
> Partner tes ng 
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Correct answer:
> Partner tes ng
The correct answer is partner tes ng. Ideally this will have been
ascertained this in advance. Preconcep on counselling is very
important if the couple are iden fied as an 'at risk couple'. This is
not just if her partner carries HbS, but also if there are other
condi ons detected, e.g. β-thalassaemia or HbC.

A primigravida wishes to opt for epidural analgesia in labour at term but

Q she has heard that regional analgesia increases the risk of opera ve vaginal
delivery which she is keen to avoid. Assuming she opts for an epidural
analgesia, how can the second stage of labour be managed to reduce this
risk for her?

A Your answer:
> Allow up to two hours for passive descent 
Correct answer:
> Allow up to two hours for passive descent
The correct answer is allow up to two hours for passive descent.
Primiparous women are likely to have fewer rota onal or mid-cavity
opera ve deliveries when pushing is delayed for 1–2 hours or un l
they have a strong urge to push. Although a small trial suggested
that star ng oxytocin at full dilata on reduced the opera ve
delivery rate, NICE concluded it should not be used on the basis of
one study. See Na onal Ins tute for Health and Clincial Excellence.
Intrapartum care. CG190. London: NICE; 2014
(h ps://www.nice.org.uk/guidance/cg190) and Royal College of
Obstetricians and Gynaecologists. Opera ve vaginal delivery. Green-
top Guideline 26. London: RCOG; 2011
(h ps://www.rcog.org.uk/en/guidelines-research-
services/guidelines/gtg26/).

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12/8/2018 Obstetrics page 3 | StratOG

A 30-year-old primigravida a ends the delivery suite at 40 weeks of

Q gesta on with prelabour rupture of membranes. On reviewing the notes
she has a posi ve result for group B streptococcus (GBS) in her urine one
week ago. She has no known drug allergies. According to the NICE
guidelines which an bio c should she receive?

A Your answer:
> Benzyl penicillin intravenously 
Correct answer:
> Benzyl penicillin intravenously
The correct answer is benzyl penicillin intravenously. GBS
(streptococcus agalac ae) is an important cause of neonatal
morbidity and mortality. Studies have shown that both ampicillin
and benzyl penicillin reduce the incidence of early onset disease,
but benzyl penicillin is recommended because it is less likely to
promote an bio c resistance. If penicillins are contraindicated,
clindamycin is recommended unless there is evidence of local
resistance pa erns that would suggest using an alterna ve. See
Mugglestone MA, Murphy MS, Visin n C, Howe DT, Turner MA.
An bio cs for early-onset neonatal infec on: a summary of the
NICE guideline 2012. The Obstetrician & Gynaecologist 2014;16:87–
92 (h p://onlinelibrary.wiley.com/doi/10.1111/tog.12085/full).

A 30-year-old pregnant woman who is at 28 weeks of gesta on presents to

Q the Day Assessment Unit complaining of flu-like symptoms. She tells you
that she recently went on holiday to Kenya. What is the most appropriate
test for the diagnosis of malaria?

A Your answer:
> Thick and thin blood film for parasites 
Correct answer:
> Thick and thin blood film for parasites
The correct answer is thick and thin blood film for parasites. The
gold standard is thick and thin blood films in pregnancy rather than
a rapid diagnos c test. Serology is only useful in syphilis. See Royal
College of Obstetricians and Gynaecologists. The diagnosis and

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treatment of malaria in pregnancy. Green-top Guideline 45B.

London; RCOG: 2010 (h ps://www.rcog.org.uk/en/guidelines-
research-services/guidelines/gtg54b/).

A 28-year-old primigravida, presents at 36+3 weeks of gesta on in the

Q antenatal clinic with a breech presenta on. There are no obstetric or fetal
contraindica ons to external cephalic version (ECV). An ini al ECV without
tocolysis failed two days earlier. What is the most appropriate management
op on?

A Your answer:
> Another ECV with tocolysis 
Correct answer:
> Another ECV with tocolysis
The correct answer is another ECV with tocolysis. ECV should be
offered a er 37 weeks of gesta on in mul parous women and a er
36 weeks of gesta on in primiparous women. Another ECV can be
offered if the first one fails. The use of tocolysis increases the
success rate a er a failed ini al a empt. If a caesarean secton is
offered it needs to be a er 38+6 weeks of gesta on. Breech delivery
may not be the most appropriate management considering she is
primiparous. There is insufficient evidence to support the use of
postural management or Moxibus on as a method of promo ng
spontaneous version over ECV. See Royal College of Obstetricians
and Gynaecologists. External cephalic version (ECV) and reducing
the incidence of breech presenta on. Green-top Guideline 20a.
London: RCOG; 2010 (h ps://www.rcog.org.uk/en/guidelines-
research-services/guidelines/gtg20a/).

A 34-year-old primigravida presents to the maternity assessment unit with

Q a second episode of decreased fetal movements at 34+4 weeks of
gesta on. She is known to be low risk and has had an otherwise uneven ul
pregnancy. What is the most appropriate management op on?

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A Your answer:
> Perform a CTG and arrange a scan 
Correct answer:
> Perform a CTG and arrange a scan
The correct answer is to perform a CTG and arrange a scan.
Counselling of women in the antenatal period about the significance
of fetal movements and rela onship of this to s ll births is
increasingly being offered in UK. Delivery would not be warranted
unless further tes ng reveals an abnormality, e.g. an abnormal
Doppler scan or a pathological CTG. There is no evidence that any
formal defini on of reduced fetal movements is of greater value
than subjec ve maternal percep on in the detec on of fetal
compromise. Biophysical profiling has not shown to be of benefit.
See Unterscheider J, Horgan R, O'Donoghue K, Greene R. Reduced
fetal movements. The Obstetrician & Gynaecologist 2009;11:245–51
(h p://onlinelibrary.wiley.com/doi/10.1576/toag.11.4.245.27527/fu
ll) and Royal College of Obstetricians and Gynaecologists. Reduced
fetal movements. Green-top Guideline 57. London: RCOG; 2011
(h ps://www.rcog.org.uk/en/guidelines-research-
services/guidelines/gtg57/).

A woman presents for booking in the first trimester, she is taking lithium for
Q her mental health. How o en should her serum lithium levels be checked?

A Your answer:
> Every 4 weeks un l 36 weeks of gesta on 
Correct answer:
> Every 4 weeks un l 36 weeks of gesta on
The correct answer is every 4 weeks un l 36 weeks of gesta on.
Lithium is an important drug in maintaining mental health but
taking it in pregnancy is not without risks as the incidence of fetal
heart defects are increased. If it is not for the woman to stop taking
the drug prior to concep on, lithium levels should be monitored
every 4 weeks un l 36 weeks of gesta on, and then weekly un l
delivery. Lithium levels should be checked again within 24 hours of
delivery and the dose should be adjusted to maintain a level in the
lower part of the therapeu c range. See Na onal Ins tute for
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Health and Clinical Excellence. Antenatal and postnatal mental

health. CG45. London: NICE; 2007
(h ps://www.nice.org.uk/guidance/CG45).

A 25-year-old woman is found to have a platelet count of 110 x 10*9/l

Q when tested rou nely at 28 weeks of gesta on. Her platelet count at 12
weeks of gesta on was 352 x 10*9/l. She has no history of illness. What is
the most likely diagnosis from the list below?

A Your answer:
> Gesta onal thrombocytopenia 
Correct answer:
> Gesta onal thrombocytopenia
The correct answer is gesta onal thrombocytopenia. Gesta onal
thrombocytopaenia occurs in up to 1 in 20 pregnancies. If the count
is greater than 100 x 109/l no further inves ga ons are required but
other disorders should be considered. If the count falls below this,
further inves ga ons are indicated including blood film, coagula on
screen, renal and liver func on tests, an phospholipid an bodies
and an -DNA an bodies. See Pavord S, Fairlie F. Obstetric
haematology manual. In: Dewhurst’s textbook of obstetrics and
gynaecology, 7th edi on. Wiley-Blackwell. 2007.

Royal College of Obstetricians and Gynaecologists

© 2018

Registered charity no. 213280

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27 Sussex Place
Regent's Park
London NW1 4RG
UK

Tel +44 20 7772 6200

Fax +44 20 7723 0575

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A 32-year-old primigravid woman a ends the antenatal clinic complaining of

Q persistent mild pruritus due to atopic erup on of pregnancy. Which is the first line
treatment in reducing pruritus and providing relief of her symptoms?

Ultraviolet B phototherapy

Emollients

Oral an histamines

Oral prednisolone

Topical hydrocor sone

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At the evening handover of a busy labour ward, you are informed that a cord
Q prolapse has been diagnosed a er amniotomy with the presen ng part at –3
sta on. On CTG, the baseline is 115 bpm with 10 bpm variability and one variable
decelera on las ng less than 30 seconds over the last 10 minutes. The obstetric
emergency theatre is currently being used for a manual removal of the placenta.
What is the most appropriate management for this woman?

Ask a midwife to elevate the fetal presen ng part and arrange a category 1
sec on in the second theatre
Fill up the bladder via a urinary catheter and keep woman in a knee-chest
posi on un l the case in theatre is finished

Give tocolysis and wait for the emergency theatre to become free
Open the second emergency theatre for a category 1 sec on

Open the second emergency theatre for a category 2 sec on

You have been asked to review a postnatal woman with known type 1 insulin
Q dependent diabetes mellitus who was successfully delivered overnight. She is now
ea ng and drinking normally and the postdelivery capillary blood glucose readings
are all between 4 and 7 mmol/l. The plan is to stop the intravenous
insulin/dextrose sliding scale and recommence subcutaneous insulin. She wishes
to breas eed her baby. What is the most appropriate advice for the woman
regarding recommencing her subcutaneous insulin?

Con nue on the dose of insulin she was taking prior to her induc on

Increase her prepregnancy dose by 25%

Reduce her prepregnancy insulin dose by 25%

Reduce the dose of insulin she was taking prior to induc on by 25%

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Revert to her prepregnancy dose of insulin

An ST5 trainee performs an elec ve Caesarean sec on for a primigravida with a

Q breech presenta on. The woman's BMI is 23. She has had no previous abdominal
surgery. A straight transverse abdominal incision is made 3 cm below the level of
the anterior superior iliac spines. The subcutaneous ssue and rectus sheath are
opened in the midline and extended laterally with blunt finger dissec on. Blunt
dissec on is used to separate the rectus muscles and enter the peritoneum. Which
transverse abdominal incision is described above?

Cherney

Joel-Cohen

Kϋstner

Maylard

Pfannens el

A 35-year-old woman presents to the antenatal clinic in her first pregnancy at 28

Q weeks of gesta on with daily headaches. Her BMI was noted to be 36. The pain is
mainly at the back of her eyes, and gets worse on eye movements. She describes
her headaches as throbbing in nature. She also no ces transient visual
disturbances. Ophthalmological examina on revealed papilledema. Neurological
examina on was normal. Which of the following is the most appropriate
interven on?

Acetazolamide

Low molecular weight heparin

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Nifedepine

Propranolol

Sumatripan

A primigravida presents at the antenatal clinic with a monochorionic diamnio c

Q (MCDA) twin pregnancy at 24 weeks of gesta on. Ultrasound shows that twin 1
has oligohydramnios with absent end-diastolic flow in the umbilical artery (UA)
doppler. Twin 2 has polyhydramnios with posi ve end-diastolic flow in the UA
doppler. What would be the best management for this finding?

Prepara on for immediate delivery

Repeat UA doppler in one week

Urgent referral for amnio c septostomy

Urgent referral for laser abla on of the placental bed

Urgent referral for selec ve amnio-reduc on

A 28-year-old woman a ends for pre-pregnancy counselling. Her maternal

Q grandfather and her mother's brother have haemophilia A. Her husband is healthy
and there is no history of haemophilia in the family. What is the risk that any
daughter of hers will have haemophilia A?

0%

25%

50%

75%

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An 18-year-old woman is pregnant with a male fetus. She has cys c fibrosis and
Q her partner is a carrier. She is worried that the baby will inherit cys c fibrosis.
What is the likelihood that the baby will be affected?

0%

25%

50%

75%

100%

A 35-year-old woman presents at 16 weeks in her first pregnancy with a severe

Q throbbing headache las ng for the last 5 days, which is aggravated with eye
movements and associated with occasional blurred vision, nausea and
photophobia. The only abnormali es on examina on are bilateral papilloedema
and squint of the le eye, which turns inwards. A computer tomography scan
shows no abnormality. What is the most likely diagnosis?

Cerebral venous thrombosis

Idiopathic intracranial hypertension (IIH)

Migraine

Severe pre-eclampsia
Trigeminal neuralgia

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A 25-year-old woman with sickle cell disease is considering having a child with her
Q partner who has sickle cell trait. What is the probability that the child will have
sickle cell disease?

25%

33%

50%
75%

100%

This is the last ques on of this quiz. Press finish to submit your choice(s) and reveal the answer(s).

Royal College of Obstetricians and Gynaecologists

© 2018

Registered charity no. 213280

27 Sussex Place
Regent's Park
London NW1 4RG
UK

Tel +44 20 7772 6200

Fax +44 20 7723 0575

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A 32-year-old primigravid woman a ends the antenatal clinic complaining

Q of persistent mild pruritus due to atopic erup on of pregnancy. Which is
the first line treatment in reducing pruritus and providing relief of her
symptoms?

A Your answer:
> Emollients 
Correct answer:
> Emollients
The correct answer is emollients. The two most common skin
problems in pregnancy are atopic erup on of pregnancy and
polymorphic erup on of pregnancy. In about half of all women who

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complain of skin problems in pregnancy it is an exacerba on of a

pre-exis ng condi on. Atopic erup on of pregnancy may require
topical steroids and an histamines, but can o en be managed with
emollients. See Vaughan Jones S, Ambros-Rudolph C, Nelson-Piercy
C. Skin disease in pregnancy. BMJ 2014;348:26–30 [Abstract only]
(h p://www.bmj.com/content/348/bmj.g3489.long).

At the evening handover of a busy labour ward, you are informed that a
Q cord prolapse has been diagnosed a er amniotomy with the presen ng
part at –3 sta on. On CTG, the baseline is 115 bpm with 10 bpm variability
and one variable decelera on las ng less than 30 seconds over the last 10
minutes. The obstetric emergency theatre is currently being used for a
manual removal of the placenta. What is the most appropriate
management for this woman?

A Your answer:
> Open the second emergency theatre for a category 2 sec on 
Correct answer:
> Open the second emergency theatre for a category 2 sec on
The correct answer is to open the second emergency theatre for a
category 2 sec on. A category 2 caesarean sec on is appropriate for
women in whom the fetal heart rate pa ern is normal. However, if
the CTG becomes abnormal it should be re-categorised to category
1. See Royal College of Obstetricians and Gynaecologists. Umbilical
cord prolapse. Green-top Guideline 50. London: RCOG; 2014
(h ps://www.rcog.org.uk/en/guidelines-research-
services/guidelines/gtg50/).

You have been asked to review a postnatal woman with known type 1
Q insulin dependent diabetes mellitus who was successfully delivered
overnight. She is now ea ng and drinking normally and the postdelivery
capillary blood glucose readings are all between 4 and 7 mmol/l. The plan is
to stop the intravenous insulin/dextrose sliding scale and recommence

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11/21/2018 Obstetrics page 4 | StratOG

subcutaneous insulin. She wishes to breas eed her baby. What is the most
appropriate advice for the woman regarding recommencing her
subcutaneous insulin?

A Your answer:
> Reduce her prepregnancy insulin dose by 25% 
Correct answer:
> Reduce her prepregnancy insulin dose by 25%
The correct answer is to reduce her prepregnancy insulin dose by
25%. Once women with type 1 diabetes are ea ng normally,
subcutaneous insulin should be recommenced at a 25% lower dose
of her prepregnancy dose if she intends to breas eed. Breas eeding
is associated with increased energy expenditure. Nelson-Piercy C.
Handbook of obstetric medicine. Fourth edi on. CRC Press. 2010.

An ST5 trainee performs an elec ve Caesarean sec on for a primigravida

Q with a breech presenta on. The woman's BMI is 23. She has had no
previous abdominal surgery. A straight transverse abdominal incision is
made 3 cm below the level of the anterior superior iliac spines. The
subcutaneous ssue and rectus sheath are opened in the midline and
extended laterally with blunt finger dissec on. Blunt dissec on is used to
separate the rectus muscles and enter the peritoneum. Which transverse
abdominal incision is described above?

A Your answer:
> Joel-Cohen 
Correct answer:
> Joel-Cohen
The correct answer is Joel-Cohen. Pfannens el and Kustner are
curved incisions using sharp dissec on. Cherney and Maylard are
muscle cu ng incisions. Raghavan R, Arya P, Arya P, China S.
Abdominal incisions and sutures in obstetrics and gynaecology. The
Obstetrician & Gynaecologist 2014;16:13–18
(h p://onlinelibrary.wiley.com/doi/10.1111/tog.12063/full).

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A 35-year-old woman presents to the antenatal clinic in her first pregnancy

Q at 28 weeks of gesta on with daily headaches. Her BMI was noted to be 36.
The pain is mainly at the back of her eyes, and gets worse on eye
movements. She describes her headaches as throbbing in nature. She also
no ces transient visual disturbances. Ophthalmological examina on
revealed papilledema. Neurological examina on was normal. Which of the
following is the most appropriate interven on?

A Your answer:
> Acetazolamide 
Correct answer:
> Acetazolamide
The correct answer is acetazolamide. Idiopathic intracranial
hypertension (IIH) is a rare but important cause of headache in
pregnancy. A detailed history and examina on is essen al. IIH tends
to present in the first half of pregnancy and women with IIH are
o en overweight. The diagnosis is made using the modified Dandy
criteria. See Thirumalaikumar L, Ramalingam K, Heafield T.
Idiopathic intracranial hypertension in pregnancy. The Obstetrician
& Gynaecologist 2014;16:93–7
(h p://onlinelibrary.wiley.com/doi/10.1111/tog.12087/full).

A primigravida presents at the antenatal clinic with a monochorionic

Q diamnio c (MCDA) twin pregnancy at 24 weeks of gesta on. Ultrasound
shows that twin 1 has oligohydramnios with absent end-diastolic flow in
the umbilical artery (UA) doppler. Twin 2 has polyhydramnios with posi ve
end-diastolic flow in the UA doppler. What would be the best management
for this finding?

A Your answer:
> Urgent referral for laser abla on of the placental bed 
Correct answer:
> Urgent referral for laser abla on of the placental bed
The correct answer is urgent referral for laser abla on of the
placental bed. The twins have developed twin to twin transfusion
syndrome (TTTS) due to vascular placental anastomoses which are
almost universal in monochorionic twin pregnancies. Despite the
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anastomoses being almost universal TTTS only occurs in 10–15% of

pregnancies. It is more common in MCDA twins compared with
monochorionic monoamnio c twins, but the la er has a very high
risk of cord entanglement. The randomised trial comparing amnio-
reduc on and septostomy was stopped early. Although there were
be er outcomes in both groups significantly more babies (RR 1.66)
were alive without neurological deficit at 6 months of age in the
laser abla on group. The septostomy randomised trial was also
prematurely halted because there was no difference with the
control group. See Royal College of Obstetricians and
Gynaecologists. Management of monochorionic twin pregnancy.
Green-top Guideline 51. London: RCOG: 2008
(h ps://www.rcog.org.uk/en/guidelines-research-
services/guidelines/gtg51/).

A 28-year-old woman a ends for pre-pregnancy counselling. Her maternal

Q grandfather and her mother's brother have haemophilia A. Her husband is
healthy and there is no history of haemophilia in the family. What is the risk
that any daughter of hers will have haemophilia A?

A Your answer:
> 0% 
Correct answer:
> 0%
The correct answer is 0%. The pa ent’s mother must be a carrier.
She will have inherited the gene from her father. However the
pa ent’s grandmother must also be a carrier since the pa ent’s
uncle has the disease but her mother did not inherit the gene since
she is well. The pa ent has a 50% chance of being a carrier, but with
a healthy husband it is very unlikely any daughter of hers will have
the disease since she will only inherit an affected gene from her
mother unless her husband’s sperm has a new muta on.

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An 18-year-old woman is pregnant with a male fetus. She has cys c fibrosis
Q and her partner is a carrier. She is worried that the baby will inherit cys c
fibrosis. What is the likelihood that the baby will be affected?

A Your answer:
> 50% 
Correct answer:
> 50%
The correct answer is 50%. The woman is heterozygous so will
inevitably pass on the CF gene and there is a 50% chance of her
baby acquiring the gene from her partner. The child will be either a
carrier or affected.

A 35-year-old woman presents at 16 weeks in her first pregnancy with a

Q severe throbbing headache las ng for the last 5 days, which is aggravated
with eye movements and associated with occasional blurred vision, nausea
and photophobia. The only abnormali es on examina on are bilateral
papilloedema and squint of the le eye, which turns inwards. A computer
tomography scan shows no abnormality. What is the most likely diagnosis?

A Your answer:
> Idiopathic intracranial hypertension (IIH) 
Correct answer:
> Idiopathic intracranial hypertension (IIH)
The correct answer is idiopathic intracranial hypertension (IHH). IHH
is a diagnosis of exclusion in a pregnant woman with a headache. It
is more wommen in women, with a female:male ra o of 8:1. IHH is
also more comment in obese women, with an incidence of 19/100
000 compared with <1/100 000 in non-obese women. Rising obesity
rates will therefore lead to an increasing incidence of IHH. See
Thirumalaikumar L, Ramalingam K, Heafield T. Idiopathic intracranial
hypertension in pregnancy. The Obstetrician & Gynaecologist
2014;16:93–97
(h p://onlinelibrary.wiley.com/doi/10.1111/tog.12087/full).

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A 25-year-old woman with sickle cell disease is considering having a child

Q with her partner who has sickle cell trait. What is the probability that the
child will have sickle cell disease?

A Your answer:
> 50% 
Correct answer:
> 50%
The correct answer is 50%. Following screening, this couple is
iden fied as 'at risk'. They need counselling and advice about their
reproduc ve op ons, including the methods and risks of prenatal
screening and termina on of pregnancy. See Royal College of
Obstetricians and Gynaecologists. Management of sickle cell disease
in pregnancy. Green-top Guideline 61. London: RCOG; 201
(h ps://www.rcog.org.uk/en/guidelines-research-
services/guidelines/gtg61/)1.

Royal College of Obstetricians and Gynaecologists

© 2018

Registered charity no. 213280

27 Sussex Place
Regent's Park
London NW1 4RG
UK

Tel +44 20 7772 6200

Fax +44 20 7723 0575

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A recently delivered woman on the postnatal ward tells you that her baby has a
Q patent ductus arteriosus. She asks what the ductus arteriosus is connected to
when her baby was in utero. Where does the ductus arteriosus connects in a
fetus?

Middle cerebral artery to posterior communica ng artery

Pulmonary artery to aorta

Right and le atria

Umbilical artery to iliac artery
Umbilical vein to inferior vena cava

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A couple a end for pre-pregnancy gene c counselling because the partner is

Q known to have haemophilia A. They are seeking informa on about their future
baby's risk of inheri ng the condi on. Which of the following statements regarding
the heritability of haemophilia A is correct?

Approximately 50% of newly diagnosed pa ents have no family history

Daughters of males with haemophilia have a 50% chance of being carriers

Haemophilia cannot arise following a spontaneous muta on

Sons of males with haemophilia will inherit the disease

The background risk of carriership is approximately 1 in 50 000 women

A 26-year-old P1+0 woman booked under midwife-led care develops a confirmed

Q chickenpox infec on at 38+6 weeks of gesta on. She is a non-smoker and is
otherwise low risk. Clinically, the fetus appears appropriately grown for gesta on
and is in a cephalic presenta on. She previously had an uncomplicated normal
delivery of a 3.7 kg baby following induc on for postmaturity. What is the most
appropriate advice for her ongoing management?

Await the onset of spontaneous labour and give the newborn varicella
zoster immunoglobulin (VZIG)

Await the onset of spontaneous labour and give the newborn varicella
zoster immunoglobulin if delivered within 7 days following the onset of the
maternal rash

Give the mother varicella zoster immunoglobulin and await the onset of
spontaneous labour
Give the mother varicella zoster immunoglobulin and induce the following
day at 39 weeks of gesta on

Induce labour the following day at 39 weeks of gesta on and give the
newborn varicella zoster immunoglobulin

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A 19-year-old woman is 28 weeks into her first pregnancy. On rou ne blood tests,
Q her haemoglobin is 95 g/l. What is the best test to diagnose iron deficiency
anaemia?

Blood film

Serum ferri n
Serum iron levels

Serum soluble transferrin receptor

Total iron binding capacity

A primigravida presents at 41 weeks into an uncomplicated pregnancy. You arrange

Q induc on of labour. According to NICE guidelines (2008), what is the rate of
spontaneous vaginal delivery following induc on with prostaglandins alone?

31–40%
41–50%

51–60%

61–70%
71–80%

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A 35-year-old woman with persistent tachycardia has thyroid func on tests at 18

Q weeks of gesta on. The results are TSH <0.02 mU/l (normal range 0.4–5.0) and T4
of 67 pmol/l (normal range 10–20). What is the most likely cause for her
hyperthyroidism?

Graves disease

Hashimoto thyroidi s
Subacute thyroidi s

Thyrotropic ac vity of HCG

Toxic mul nodular goitre

You see a woman who is 35 weeks pregnant in your day assessment unit. She
Q presents with nausea, anorexia and generalised malaise. Her liver func on test
demonstrates an alanine transaminase (ALT) of 634. Which of the following
features is most useful in dis nguishing acute fa y liver of pregnancy (AFLP) from
HELLP syndrome?

Deranged renal func on

Epigastric pain

Hypertension

Hypoglycaemia

Proteinuria

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You see a woman who is 35 weeks pregnant in your day assessment unit. She
Q presents with itching. Your differen al diagnosis is obstetric cholestasis. Your ST1
asks you if she should prescribe vitamin K but is not sure how it works. Vitamin K is
responsible for manufacturing which of the following coagula on factors?

Factor V

Factor VIII

Factor X

Factor XI

Factor XII

You see a woman who is 35 weeks pregnant in your day assessment unit. She
Q presents with itching. Your differen al diagnosis is polymorphic erup on of
pregnancy. What clinical feature is most helpful in diagnosing this condi on?

Facial pigmenta on

Inflamed abdominal striae

Itching of palms of hands

Itching of soles of feet

Umbilical rash

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You see a woman who is 35 weeks pregnant in your day assessment unit. She
Q presents with itching causing insomnia of the palms of hands and soles of feet.
There are scratch marks but no rash. Her alanine transaminase is 78 IU/l (normal
range 10–35) and bile acids are 42 micromol/l (normal range 1–10). Which of the
following contracep ves should be avoided postnatally?

Condoms

Combined oral contracep ve pill

Depo Provera®

Levonorgestrel-releasing intrauterine system

Progestogen only pill

This is the last ques on of this quiz. Press finish to submit your choice(s) and reveal the answer(s).

Royal College of Obstetricians and Gynaecologists

© 2018

Registered charity no. 213280

27 Sussex Place
Regent's Park
London NW1 4RG
UK

Tel +44 20 7772 6200

Fax +44 20 7723 0575

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11/21/2018 Obstetrics page 5 | StratOG

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A recently delivered woman on the postnatal ward tells you that her baby
Q has a patent ductus arteriosus. She asks what the ductus arteriosus is
connected to when her baby was in utero. Where does the ductus
arteriosus connects in a fetus?

A Your answer:
> Pulmonary artery to aorta 
Correct answer:
> Pulmonary artery to aorta
The correct answer is the pulmonary artery to the aorta. An
understanding of fetal circula on and congenital heart defects is
important to an obstetrician. It gives them the ability to discuss any

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problems with their pa ents and is required to understand changes

seen on ultrasound and the effect on the fetus and baby. There are
many resources on the internet e.g. the Atlas of Cardiac Anatomy
(h p://www.vhlab.umn.edu/atlas/index.shtml) produced by the
University of Minnesota (accessed 2 July 2015).

A couple a end for pre-pregnancy gene c counselling because the partner

Q is known to have haemophilia A. They are seeking informa on about their
future baby's risk of inheri ng the condi on. Which of the following
statements regarding the heritability of haemophilia A is correct?

A Your answer:
> Approximately 50% of newly diagnosed pa ents have no family 
history
Correct answer:
> Approximately 50% of newly diagnosed pa ents have no family
history
The correct answer is approximately 50% of newly diagnosed
pa ents have no family history. Daughters of affected males will
always be carriers but sons will never inherit the disease (the
affected gene is on the paternal X chromosome, which never goes
to the sons). Haemophilia can arise as a spontaneous muta on and
the risk of being a carrier is 1 in 20 000. See Mumford A. Gene c
counselling and pre-natal diagnosis. In: Pavord S, Hunt B (editors).
The obstetric haematology manual. Cambridge University Press.
2010. p 194–199.

A 26-year-old P1+0 woman booked under midwife-led care develops a

Q confirmed chickenpox infec on at 38+6 weeks of gesta on. She is a non-
smoker and is otherwise low risk. Clinically, the fetus appears appropriately
grown for gesta on and is in a cephalic presenta on. She previously had an
uncomplicated normal delivery of a 3.7 kg baby following induc on for
postmaturity. What is the most appropriate advice for her ongoing
management?

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A Your answer:

> Await the onset of spontaneous labour and give the newborn
varicella zoster immunoglobulin if delivered within 7 days
following the onset of the maternal rash

Correct answer:
> Await the onset of spontaneous labour and give the newborn
varicella zoster immunoglobulin if delivered within 7 days
following the onset of the maternal rash
The correct answer is await the onset of spontaneous labour and
give the newborn varicella zoster immunoglobulin if delivered
within 7 days following the onset of the maternal rash. VZIG has no
effect once chickenpox has developed. If the woman presents within
24 hours (at over 20 weeks of gesta on) it is worth prescribing
acyclovir. The baby is at most risk if delivered within a week of the
development of the infec on. A er 7 days the maternal an bodies
will protect the baby. See Royal College of Obstetricians and
Gynaecologists. Chickenpox in pregnancy. Green-top Guideline 13.
London: RCOG; 2007 (h ps://www.rcog.org.uk/en/guidelines-
research-services/guidelines/gtg13/).

A 19-year-old woman is 28 weeks into her first pregnancy. On rou ne blood

Q tests, her haemoglobin is 95 g/l. What is the best test to diagnose iron
deficiency anaemia?

A Your answer:
> Serum ferri n 
Correct answer:
> Serum ferri n
The correct answer is serum ferri n. Although an approxima on of
iron deficiency can be assessed by the mean corpuscular volume,
serum ferri n will give an accurate test of iron stores. See Bri sh
Commi ee for Standards in Haematology. UK guidelines on the
management of iron deficiency in pregnancy. London: BCSH: 2011
(h p://www.bcshguidelines.com/documents/UK_Guidelines_iron_d
eficiency_in_pregnancy.pdf).

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A primigravida presents at 41 weeks into an uncomplicated pregnancy. You

Q arrange induc on of labour. According to NICE guidelines (2008), what is
the rate of spontaneous vaginal delivery following induc on with
prostaglandins alone?

A Your answer:
> 61–70% 
Correct answer:
> 61–70%
The correct answer is 61–70%. Induc on of labour should only be
offered to women in specific circumstances since there is an
increased risk of caesarean sec on. See Na onal Ins tute for Health
and Clinical Excellence. Induc on of labour. Clinical guideline 70.
London: NICE. 2008 (h ps://www.nice.org.uk/guidance/cg70).

A 35-year-old woman with persistent tachycardia has thyroid func on tests

Q at 18 weeks of gesta on. The results are TSH <0.02 mU/l (normal range
0.4–5.0) and T4 of 67 pmol/l (normal range 10–20). What is the most likely
cause for her hyperthyroidism?

A Your answer:
> Graves disease 
Correct answer:
> Graves disease
The correct answer is Graves disease. 95% of cases of
hyperthyroidism in pregnancy are due to Graves disease. Thyroxine
produc on increases in pregnancy due to an increase in thyroxine
binding globulin to maintain a steady free thyroxine level (both T3
and T4). In assessing thyroid func on in pregnancy, free T3 and T4
levels reflect thyroid func on rather than total T3 and T4 levels. In
monitoring hypo- and hyperthyroid disease the TSH level may take
longer to return to normal so free T3 and T4 levels are a more
accurate reflec on. Hyperthyroidism is common in women of
reproduc ve years and is seen in approximately 1 in 500
pregnancies. See Nelson-Piercy C. Handbook of obstetric medicine,
4th edi on. CRC Press. 2010.

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You see a woman who is 35 weeks pregnant in your day assessment unit.
Q She presents with nausea, anorexia and generalised malaise. Her liver
func on test demonstrates an alanine transaminase (ALT) of 634. Which of
the following features is most useful in dis nguishing acute fa y liver of
pregnancy (AFLP) from HELLP syndrome?

A Your answer:
> Hypoglycaemia 
Correct answer:
> Hypoglycaemia
The correct answer is hypoglycaemia. Liver disorders are common in
pregnancy, but rarely cause long term problems. AFLP is a rare but
serious condi on which will share many common features with
HELLP. However hypoglycaemia is common in AFLP and can be
severe, but is extremely unlikely in HELLP. See Nelson-Piercy C.
Handbook of obstetric management, 4th edi on. CRC Press. 2010.

You see a woman who is 35 weeks pregnant in your day assessment unit.
Q She presents with itching. Your differen al diagnosis is obstetric cholestasis.
Your ST1 asks you if she should prescribe vitamin K but is not sure how it
works. Vitamin K is responsible for manufacturing which of the following
coagula on factors?

A Your answer:
> Factor X 
Correct answer:
> Factor X
The correct answer is factor X. Vitamin K is required for
manufacturing coagula on factors II, VII, IX, X. See Royal College of
Obstetricians and Gynaecologists. Obstetric cholestasis. Green-top
Guideline 43. London: RCOG; 2011
(h ps://www.rcog.org.uk/en/guidelines-research-
services/guidelines/gtg43/).

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You see a woman who is 35 weeks pregnant in your day assessment unit.
Q She presents with itching. Your differen al diagnosis is polymorphic
erup on of pregnancy. What clinical feature is most helpful in diagnosing
this condi on?

A Your answer:
> Inflamed abdominal striae 
Correct answer:
> Inflamed abdominal striae
The correct answer is inflamed abdominal striae. Polymorphic
erup on of pregnancy classically affects the abdominal striae,
sparing the umbilicus. The differen al diagnosis is intrahepa c
cholestasis of pregnancy, atopic erup on of pregnancy and
pemphigoid gesta onis. See Nelson-Piercy C. Handbook of obstetric
management, 4th edi on. CRC Press 2010 and Maharajan A, Aye C,
Ratnavel R, Burova E. Skin erup ons specific to pregnancy: an
overview. The Obstetrician & Gynaecologist 2013;15:233–40
(h p://onlinelibrary.wiley.com/doi/10.1111/tog.12051/full).

You see a woman who is 35 weeks pregnant in your day assessment unit.
Q She presents with itching causing insomnia of the palms of hands and soles
of feet. There are scratch marks but no rash. Her alanine transaminase is 78
IU/l (normal range 10–35) and bile acids are 42 micromol/l (normal range
1–10). Which of the following contracep ves should be avoided
postnatally?

A Your answer:
> Combined oral contracep ve pill 
Correct answer:
> Combined oral contracep ve pill
The correct answer is the combined oral contracep ve pill.
Estrogen-containing contracep ves should be avoided in women
who have had obstetric cholestasis. See Royal College of
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Obstetricians and Gynaecologists. Obstetric cholestasis. Green-top

Guideline 43. London: RCOG; 2011
(h ps://www.rcog.org.uk/en/guidelines-research-
services/guidelines/gtg43/).

Royal College of Obstetricians and Gynaecologists

© 2018

Registered charity no. 213280

27 Sussex Place
Regent's Park
London NW1 4RG
UK

Tel +44 20 7772 6200

Fax +44 20 7723 0575

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A maternity unit wishes to reduce unnecessary admissions for suspected preterm

Q labour. A member of staff inves gates whether there is a more suitable bedside
test for the predic on of preterm labour than the one already in use. Which of the
following sta s cal parameters of any new test used is most likely to achieve the
desired goal?

Increased odds ra o of a posi ve test

Increased posi ve predic ve value of the test

Increased rela ve risk of a posi ve test

Increased sensi vity of the test
Increased specificity of the test

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A 27-year-old primigravida books at the antenatal clinic. She has a heritable

Q thrombophilia and wishes to discuss the implica ons for her pregnancy. Which
heritable thrombophilia produces the greatest risk for venous thromboembolism
in pregnancy?

An thrombin III deficiency

Factor V Leiden homozygosity

Protein C deficiency

Protein S deficiency
Prothrombin muta on heterozygosity

A 28-year-old woman had a primary postpartum haemorrhage 2 hours previously

Q a er delivering a 4.1 kg baby. You are asked to review her as she appears confused
and agitated. There is no sign of ongoing bleeding. Her pulse is recorded as 123
beats per minute, her blood pressure is 89/45 mmHg and her booking weight was
71 kg. Approximately how much blood has this woman lost?

1000–1499 ml

1500–1999 ml
2000–2499 ml

2500–2999 ml

3000–3499 ml

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A pregnant woman with severe von Willebrand’s disease a ends the antenatal
Q clinic. She is nonsensi sed Rh-nega ve. What is the recommend management
regarding rou ne antenatal an -D prophylaxis?

Administer half the dose of an -D intramuscularly

Administer intramuscular an -D in four divided doses

Administer intravenous an -D

Administer oral an -D

Do not administer an -D

A mul parous woman is seen in antenatal clinic at 34 weeks of gesta on following

Q a scan for placental localisa on. The scan shows the placenta is anterior with the
leading edge encroaching on the internal os. Which of the following is the
strongest predisposing risk factor for developing placenta praevia?

Maternal age of more than 40 years

Maternal smoking

Previous caesarean delivery

Previous myomectomy

Previous surgical management of miscarriage

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A 21-year-old primigravida is admi ed for induc on at 35 weeks of gesta on. She

Q presents with reduced fetal movements and the fetus is thought to be small for
gesta onal age. An ultrasound scan shows that the es mated weight is below the
10th cen le and there is reduced end diastolic flow. Which condi on is this baby
most at risk of?

Acute renal failure

Hepatosplenomegaly
Meconium ileus

Pneumonia

Polycythaemia

A 22-year-old primigravid woman presents at 32 weeks of gesta on with signs and

Q symptoms of acute appendici s. The cardiotocography (CTG) is reassuring. What is
the best laparotomy incision for appendicectomy?

Lanz
Low transverse

Lower midline

Over the area of maximal tenderness

Upper midline

A 30-year-old woman, Para 0, is referred for a growth scan. The pregnancy has
Q been uncomplicated so far. The ultrasonographer reports that the es mated fetal
weight is on the 5th cen le for gesta on, there is normal liquor and the umbilical
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artery Doppler waveform is normal but the fetal head circumference is less than
the 1st cen le for gesta on. What is the most likely infec ve cause?

Cytomegalovirus

Epstein–Barr virus

Rubella

Syphilis

Toxoplasmosis

A 35-year-old woman presents 4 days following a normal delivery. She complains

Q of a severe headache, which has been ge ng worse, and weakness on her le
side. What is the most appropriate inves ga on?

Cranial ultrasound

CT scan

MR venogram
Positron emission tomography scan

Skull x-ray

A school teacher is at 26 weeks of gesta on in her first pregnancy. One of her

Q pupils has chickenpox. The lesions have crusted over. She cannot recall having
chickenpox as a child and wants to know if she is now infected with chickenpox.
How long does it usually take for the lesions to crust over from onset of the rash?

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11/21/2018 Obstetrics page 6 | StratOG

3 days

4 days

5 days

6 days

7 days

This is the last ques on of this quiz. Press finish to submit your choice(s) and reveal the answer(s).

Royal College of Obstetricians and Gynaecologists

© 2018

Registered charity no. 213280

27 Sussex Place
Regent's Park
London NW1 4RG
UK

Tel +44 20 7772 6200

Fax +44 20 7723 0575

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Your result 100 %

A maternity unit wishes to reduce unnecessary admissions for suspected

Q preterm labour. A member of staff inves gates whether there is a more
suitable bedside test for the predic on of preterm labour than the one
already in use. Which of the following sta s cal parameters of any new test
used is most likely to achieve the desired goal?

A Your answer:
> Increased specificity of the test 
Correct answer:
> Increased specificity of the test

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11/21/2018 Obstetrics page 6 | StratOG

The correct answer is increased specificity of the test. In this clinical

context it is important to be able to iden fy women who are not at
risk of progressing to preterm labour with a degree of certainty to
be able to discharge them home. Specificity refers to the ability of
the test to correctly iden fy pa ents who do not have the disease
(preterm labour).

A 27-year-old primigravida books at the antenatal clinic. She has a heritable

Q thrombophilia and wishes to discuss the implica ons for her pregnancy.
Which heritable thrombophilia produces the greatest risk for venous
thromboembolism in pregnancy?

A Your answer:
> Factor V Leiden homozygosity 
Correct answer:
> Factor V Leiden homozygosity
The correct answer is Factor V Leiden homozygosity.

A 28-year-old woman had a primary postpartum haemorrhage 2 hours

Q previously a er delivering a 4.1 kg baby. You are asked to review her as she
appears confused and agitated. There is no sign of ongoing bleeding. Her
pulse is recorded as 123 beats per minute, her blood pressure is 89/45
mmHg and her booking weight was 71 kg. Approximately how much blood
has this woman lost?

A Your answer:
> 2000–2499 ml 
Correct answer:
> 2000–2499 ml
The correct answer is 2000–2499 ml. This describes a class III
haemorrhage, i.e. 30–40% of circula ng volume lost (pulse
>120<140, BP decreased, agitated and confused mental state).

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11/21/2018 Obstetrics page 6 | StratOG

A pregnant woman with severe von Willebrand’s disease a ends the

Q antenatal clinic. She is nonsensi sed Rh-nega ve. What is the recommend
management regarding rou ne antenatal an -D prophylaxis?

A Your answer:
> Administer intravenous an -D 
Correct answer:
> Administer intravenous an -D
The answer is administer intravenous an -D.

Qureshi H, Massey E, Kirwan D, Davies T, Robson S, White J, et al.

BCSH guideline for the use of an -D immunoglobulin for the
preven on of haemoly c disease of the fetus and newborn.
Transfus Med 2014;24:8–20.
(h p://onlinelibrary.wiley.com/doi/10.1111/tme.12091/full)

A mul parous woman is seen in antenatal clinic at 34 weeks of gesta on

Q following a scan for placental localisa on. The scan shows the placenta is
anterior with the leading edge encroaching on the internal os. Which of the
following is the strongest predisposing risk factor for developing placenta
praevia?

A Your answer:
> Maternal age of more than 40 years 
Correct answer:
> Maternal age of more than 40 years
The answer is maternal age of more than 40 years, as it is associated
with a ninefold risk of placental praevia.

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Jolly M, Sebire N, Harris J, Robinson S, Regan L. The risks associated

with pregnancy in women aged 35 years or older. Hum Reprod
2000;15:2433–7.
(h ps://academic.oup.com/humrep/ar cle/15/11/2433/635079/The-
risks-associated-with-pregnancy-in-women-aged)

A 21-year-old primigravida is admi ed for induc on at 35 weeks of

Q gesta on. She presents with reduced fetal movements and the fetus is
thought to be small for gesta onal age. An ultrasound scan shows that the
es mated weight is below the 10th cen le and there is reduced end
diastolic flow. Which condi on is this baby most at risk of?

A Your answer:
> Polycythaemia 
Correct answer:
> Polycythaemia
The correct answer is polycythaemia.

A 22-year-old primigravid woman presents at 32 weeks of gesta on with

Q signs and symptoms of acute appendici s. The cardiotocography (CTG) is
reassuring. What is the best laparotomy incision for appendicectomy?

A Your answer:
> Lower midline 
Correct answer:
> Lower midline
The correct answer is lower midline.

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11/21/2018 Obstetrics page 6 | StratOG

Weston P, Moroz P. Appendici s in pregnancy: how to manage

and whether to deliver. The Obstetrician and Gynaecologist
2015;17:105–10.
(h ps://stratog.rcog.org.uk/sites/default/files/Weston_et_al-
2015-The_Obstetrician_%26_Gynaecologist_1.pdf)

A 30-year-old woman, Para 0, is referred for a growth scan. The pregnancy

Q has been uncomplicated so far. The ultrasonographer reports that the
es mated fetal weight is on the 5th cen le for gesta on, there is normal
liquor and the umbilical artery Doppler waveform is normal but the fetal
head circumference is less than the 1st cen le for gesta on. What is the
most likely infec ve cause?

A Your answer:
> Cytomegalovirus 
Correct answer:
> Cytomegalovirus
The answer is cytomegalovirus.

van Zuylen WJ, Hamilton ST, Naing Z, Hall B, Shand A, Rawlinson WD.
Congenital cytomegalovirus infec on: Clinical presenta on,
epidemiology, diagnosis and preven on. Obstet Med 2014;7:140–6.
(h ps://academic.oup.com/humrep/ar cle/15/11/2433/635079/The-
risks-associated-with-pregnancy-in-women-aged)

A 35-year-old woman presents 4 days following a normal delivery. She

Q complains of a severe headache, which has been ge ng worse, and
weakness on her le side. What is the most appropriate inves ga on?

A Your answer:
> MR venogram 
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Correct answer:
> MR venogram
The answer is MR venogram.

A school teacher is at 26 weeks of gesta on in her first pregnancy. One of

Q her pupils has chickenpox. The lesions have crusted over. She cannot recall
having chickenpox as a child and wants to know if she is now infected with
chickenpox. How long does it usually take for the lesions to crust over from
onset of the rash?

A Your answer:
> 5 days 
Correct answer:
> 5 days
The answer is 5 days. When the lesions have crusted over, the
individual is no longer infec ous.

Royal College of Obstetricians and Gynaecologists. Chickenpox in

pregnancy. GTG13. London: RCOG Press; 2015.
(h ps://www.rcog.org.uk/globalassets/documents/guidelines/gtg13.pdf)

Royal College of Obstetricians and Gynaecologists

© 2018

Registered charity no. 213280

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11/21/2018 Obstetrics page 6 | StratOG

27 Sussex Place
Regent's Park
London NW1 4RG
UK

Tel +44 20 7772 6200

Fax +44 20 7723 0575

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A 44-year-old woman with a BMI of 48 and gesta onal diabetes presents at 30

Q weeks of gesta on complaining of lethargy associated with a sore throat and is
found to have a temperature of 39.6°C. A venous blood gas reveals a haemoglobin
of 89 g/l. Which of the aspects of her history is not a risk factor for severe sepsis?

Age
Anaemia

BMI
Gesta onal diabetes
Sore throat

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A primigravid woman presents to the antenatal diabe c clinic at 28 weeks of

Q gesta on. She has just been diagnosed with gesta onal diabetes on a 75-g 2-hour
oral glucose tolerance test. The fas ng plasma glucose was 7.2 mmol/l. The scan
has revealed polyhydramnios and a baby that is large for gesta onal age. What is
the most appropriate treatment for this woman?

Immediate treatment with glibenclamide

Immediate treatment with insulin and/or me ormin

Self-monitoring of blood glucose and clinic review in 2 weeks

Self-monitoring of blood glucose and clinic review in 4 weeks

Self-monitoring of blood glucose with a further clinic appointment in 2

weeks with the plan to commence me ormin if blood glucose targets are
not met

A pregnant woman who is known to have poorly controlled epilepsy is found dead
Q at her home at 22 weeks of gesta on. According to the MBRRACE 2014 report,
what is the most likely cause of her death?

Cerebrovascular accident

Eclamp c seizure

Overdose of an convulsant medica on

Status epilep cus

Sudden unexplained death in pregnancy

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A woman with a spinal cord transec on presents in labour at term. She is having
Q regular, strong uterine contrac ons but does not experience any pain. What is the
level of her spinal cord injury?

L1

L2

T8

T10

T12

This is the last ques on of this quiz. Press finish to submit your choice(s) and reveal the answer(s).

Royal College of Obstetricians and Gynaecologists

© 2018

Registered charity no. 213280

27 Sussex Place
Regent's Park
London NW1 4RG
UK

Tel +44 20 7772 6200

Fax +44 20 7723 0575

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A 44-year-old woman with a BMI of 48 and gesta onal diabetes presents at

Q 30 weeks of gesta on complaining of lethargy associated with a sore throat
and is found to have a temperature of 39.6°C. A venous blood gas reveals a
haemoglobin of 89 g/l. Which of the aspects of her history is not a risk
factor for severe sepsis?

A Your answer:
> Age 
Correct answer:
> Age
The answer is her age.

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Royal College of Obstetrics and Gynaecology. Bacterial Sepsis in

Pregnancy. GTG64a. London: RCOG Press; 2015
(h ps://www.rcog.org.uk/en/guidelines-research-
services/guidelines/gtg64a/).

A primigravid woman presents to the antenatal diabe c clinic at 28 weeks

Q of gesta on. She has just been diagnosed with gesta onal diabetes on a 75-
g 2-hour oral glucose tolerance test. The fas ng plasma glucose was 7.2
mmol/l. The scan has revealed polyhydramnios and a baby that is large for
gesta onal age. What is the most appropriate treatment for this woman?

A Your answer:
> Immediate treatment with insulin and/or me ormin 
Correct answer:
> Immediate treatment with insulin and/or me ormin
The answer is immediate treatment with insulin and/or me ormin.

Na onal Ins tute for Health and Care Excellence. 1.2 Gesta onal
diabetes. In: Diabetes in Pregnancy: Management from
Preconcep on to the Postnatal Period.NG3. London: NICE; 2015.
(h ps://www.nice.org.uk/guidance/ng3/chapter/1-
recommenda ons#gesta onal-diabetes-2)

A pregnant woman who is known to have poorly controlled epilepsy is

Q found dead at her home at 22 weeks of gesta on. According to the
MBRRACE 2014 report, what is the most likely cause of her death?

A Your answer:
> Sudden unexplained death in pregnancy 
Correct answer:
> Sudden unexplained death in pregnancy
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The answer is sudden unexplained death in pregnancy.

MBRRACE-UK. Saving Lives, Improving Mothers' Care. Lessons learned to inf

maternity care from the UK and Ireland Confiden al Enquiries into Materna
Morbidity 2009-2012. Oxford: MBRRACE; 2014.
(h ps://www.npeu.ox.ac.uk/downloads/files/mbrrace-
uk/reports/Saving%20Lives%20Improving%20Mothers%20Care%20report%

A woman with a spinal cord transec on presents in labour at term. She is

Q having regular, strong uterine contrac ons but does not experience any
pain. What is the level of her spinal cord injury?

A Your answer:
> T10 
Correct answer:
> T10
The answer is T10.

Dawood R, Iatrikes EAP, Ribes-Pastor P, Ashworth F. Pregnancy

and spinal cord injury. The Obstetrician and Gynaecologist.
2014;16:99–107. (h ps://stratog-
live.rcog.org.uk/sites/default/files/Dawood_et_al-2014-
The_Obstetrician_%26_Gynaecologist_5_0.pdf)

Royal College of Obstetricians and Gynaecologists

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© 2018

Registered charity no. 213280

27 Sussex Place
Regent's Park
London NW1 4RG
UK

Tel +44 20 7772 6200

Fax +44 20 7723 0575

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A 35-year-old woman undergoes extensive laparoscopic surgery in the lithotomy

Q posi on. She presents a er 3 days with unresolved weakness of right hip
extension and right knee flexion. There is associated sensory impairment below
the right knee. Damage to which nerve is the most likely cause?

Femoral

Ilio-inguinal

Lateral cutaneous of the thigh

Obturator

Scia c

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You have been reviewing the NICE guidelines on urinary incon nence. You have
Q been asked to perform an audit on management of urinary incon nence in your
department. What is the main purpose of audit?

Changing prac ce
Collec ng data

Providing pa ent feedback

Improving quality
Reducing costs

A 47-year-old woman seeks advice about con nuing the combined oral
Q contracep ve pill (COCP). She is normotensive and a non-smoker with a BMI of 25.
She has no other medical history and no significant family history. She is
concerned that the COCP may give her addi onal health risks. Which of the
following malignancies would you advise she may have a small addi onal risk of
developing due to taking the COCP?

Breast cancer

Colorectal cancer

Endometrial cancer
Lung cancer

Ovarian cancer

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A 65-year-old had a hysterectomy for endometrial cancer. She recovered well but
Q complained of dribbling urine 2 days later and was given a course of an bio cs for
a presumed UTI. On review at 4 weeks she complains of con nued urinary
incon nence. She has no dysuria, no sensa on of urgency, needs to wear a pad at
night, and intermi ently voids good volumes of urine with normal flow. Urinalysis
is nega ve. What the most likely diagnosis?

Fistula

Occult underlying stress incon nence

Overac ve bladder syndrome

Overflow incon nence

Urinary tract infec on

A woman has been recommended to undergo hysterectomy and bilateral salpingo-

Q oophorectomy for benign disease. You discuss the risks and benefits of an open
versus a laparoscopic procedure. Which sort of injury is more common at
laparoscopic hysterectomy compared to an open procedure?

Bowel

Nerve

Ovary

Urinary tract

Vascular

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A 46-year-old para 2 woman is referred to your gynaecology clinic complaining of

Q regular but heavy menstrual bleeding which is affec ng her quality of life. Which
of the following associated features indicates the need for endometrial biopsy?

BMI greater than 30

Dysmenorrhoea

Failure of previous medical therapy

Iron deficiency anaemia

Uterus enlarged on vaginal examina on

A 55-year-old woman is due to come in for total abdominal hysterectomy and

Q bilateral salpingo-oophorectomy for a large mucinous ovarian cyst. She takes
sequen al HRT for menopausal symptoms. What is the approximate overall risk of
serious complica ons from abdominal hysterectomy?

1 opera on in every 100

2 opera ons in every 100

3 opera ons in every 100

4 opera ons in every 100

5 opera ons in every 100

You are asked to review a 55-year-old woman with overac ve bladder symptoms.
Q She has responded poorly to bladder training and is on oxybutynin therapy. Her
main complaint is nocturia, which is badly affec ng her quality of life. What is the
best treatment for her con nuing symptoms?

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Darifenacin

Desmopressin

Mirabegrone

Tolterodine

Transdermal oxybutynin

This analysis below is taken from a meta-analysis of ovula on rates in women with
Q polycys c ovarian syndrome (PCOS) taking me ormin compared with clomifene
ovula on induc on therapy. Subgroup analysis was also carried out using a cut-off
BMI level of 30 kg/m2.

View larger version

(h ps://stratog.rcog
Reproduced with permission from Tang T et al. Cochrane Database Syst Rev 2012;
.org.uk/sites/default
(5):CD003053
/files/Cochrane_CD
(h003053_analysis3.3.
p://onlinelibrary.wiley.com/doi/10.1002/14651858.CD003053.pub5/full)
png)
Which statement of the following best describes the above findings?

Me ormin is equally as effec ve as clomifene in the obese group (BMI >

30)

Me ormin is less effec ve than clomifene in the non-obese group (BMI

<30)

Me ormin is less effec ve than clomifene in the obese group (BMI >30)
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Me ormin is equally as effec ve as clomifene in the non-obese group (BMI

< 30)

Me ormin is more effec ve than clomifene in the obese group (BMI >30)

This is the last ques on of this quiz. Press finish to submit your choice(s) and reveal the answer(s).

Royal College of Obstetricians and Gynaecologists

© 2018

Registered charity no. 213280

27 Sussex Place
Regent's Park
London NW1 4RG
UK

Tel +44 20 7772 6200

Fax +44 20 7723 0575

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Your result 100 %

A 35-year-old woman undergoes extensive laparoscopic surgery in the

Q lithotomy posi on. She presents a er 3 days with unresolved weakness of
right hip extension and right knee flexion. There is associated sensory
impairment below the right knee. Damage to which nerve is the most likely
cause?

A Your answer:
> Scia c 
Correct answer:
> Scia c

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The correct answer is the scia c nerve. See Kuponiyi O,

Alleemudder DI, Latunde-Dada A, Eedarapalli P. Nerve injuries
associated with gynaecological surgery. The Obstetrician &
Gynaecologist 2014;16:29–36
(h p://onlinelibrary.wiley.com/doi/10.1111/tog.12064/full).

You have been reviewing the NICE guidelines on urinary incon nence. You
Q have been asked to perform an audit on management of urinary
incon nence in your department. What is the main purpose of audit?

A Your answer:
> Improving quality 
Correct answer:
> Improving quality
The correct answer is improving quality. Clinical audit is a quality
improvement process that seeks to improve pa ent care and
outcomes through systema c review of care against explicit criteria
and the implementa on of change. Aspects of the structure,
processes and outcomes of care are selected and systema cally
evaluated against explicit criteria. Where indicated, changes are
implemented at an individual, team or service level and further
monitoring is used to confirm improvement in healthcare delivery.
See Royal College of Obstetricians and Gynaecologists.
Understanding audit. Clinical Governance Advice 5. London: RCOG;
2003 (h ps://www.rcog.org.uk/en/guidelines-research-
services/guidelines/clinical-governance-advice-5/).

A 47-year-old woman seeks advice about con nuing the combined oral
Q contracep ve pill (COCP). She is normotensive and a non-smoker with a
BMI of 25. She has no other medical history and no significant family
history. She is concerned that the COCP may give her addi onal health
risks. Which of the following malignancies would you advise she may have a
small addi onal risk of developing due to taking the COCP?

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11/21/2018 Gynaecology page 1 | StratOG

A Your answer:
> Breast cancer 
Correct answer:
> Breast cancer
The correct answer is breast cancer. COCP use provides a protec ve
effect against ovarian and endometrial cancer that con nues for 15
years or more a er stopping the pill. Women can be advised that
there may be a small addi onal risk of developing breast cancer if
they use COCP, which reduces to no risk 10 years a er stopping the
pill. See Faculty of Sexual & Reproduc ve Healthcare. Contracep on
for women aged over 40 years. Clinical Guidance. London: FSRH;
2010 (h p://www.fsrh.org/pdfs/Contracep onOver40July10.pdf).

A 65-year-old had a hysterectomy for endometrial cancer. She recovered

Q well but complained of dribbling urine 2 days later and was given a course
of an bio cs for a presumed UTI. On review at 4 weeks she complains of
con nued urinary incon nence. She has no dysuria, no sensa on of
urgency, needs to wear a pad at night, and intermi ently voids good
volumes of urine with normal flow. Urinalysis is nega ve. What the most
likely diagnosis?

A Your answer:
> Fistula 
Correct answer:
> Fistula
The correct answer is fistula. In the developed world the majority of
urinary tract fistulae occur following hysterectomy (both vaginal and
abdominal) and caesarean sec on. This is usually due to failure to
dissect the bladder free of the cervix and upper vagina. Leakage
star ng in the immediate postopera ve period suggests direct
damage. Leakage that starts 1-2 weeks postopera vely is due to
avascular necrosis. See Monaghan JM, Lopes T, Naik R. Bonney's
gynaecological surgery. Wiley-Blackwell. 2004.

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A woman has been recommended to undergo hysterectomy and bilateral

Q salpingo-oophorectomy for benign disease. You discuss the risks and
benefits of an open versus a laparoscopic procedure. Which sort of injury is
more common at laparoscopic hysterectomy compared to an open
procedure?

A Your answer:
> Urinary tract 
Correct answer:
> Urinary tract
The correct answer is urinary tract injury. Laparoscopic surgery
involves risks to bowel, urinary tract and major blood vessels. These
risks are higher in women who are obese or significantly
underweight, however the risks of laparotomy are significantly
greater in the morbidly obese. Urinary tract injury and vaginal cuff
dehiscence are more common in the laparoscopic approach with an
odds ra o of 2.61 for urinary tract injury. Royal College of
Obstetricians and Gynaecologists. Preven ng entry-related
gynaecological laparoscopic injuries. Green-top Guideline 49.
London: RCOG; 2008. (h ps://www.rcog.org.uk/en/guidelines-
research-services/guidelines/gtg49/)

A 46-year-old para 2 woman is referred to your gynaecology clinic

Q complaining of regular but heavy menstrual bleeding which is affec ng her
quality of life. Which of the following associated features indicates the need
for endometrial biopsy?

A Your answer:
> Failure of previous medical therapy 
Correct answer:
> Failure of previous medical therapy
The correct answer is failure of previous medical therapy. An
endometrial biopsy should be taken if there is persistent
intermenstrual bleeding or if treatment is ineffec ve in women over
45. An ultrasound is the first line diagnos c tool for iden fying
structural abnormali es and should be performed if the uterus is
palpable abdominally, vaginal examina on reveals a pelvic mass or if
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drug treatment fails. See Na onal Ins tute for Health and Clinical
Excellence. Heavy menstrual bleeding. London: NICE; 2013
(h ps://www.nice.org.uk/guidance/QS47).

A 55-year-old woman is due to come in for total abdominal hysterectomy

Q and bilateral salpingo-oophorectomy for a large mucinous ovarian cyst. She
takes sequen al HRT for menopausal symptoms. What is the approximate
overall risk of serious complica ons from abdominal hysterectomy?

A Your answer:
> 4 opera ons in every 100 
Correct answer:
> 4 opera ons in every 100
The correct answer is 4 opera ons in every 100. The overall risk of
serious complica ons from abdominal hysterectomy is
approximately four women in every 100 (common). See Na onal
Ins tute of Health and Clinical Excellence. Venous
thromboembolism: reducing the risk. Clinical Guideline 92. London:
NICE; 2010 (h ps://www.nice.org.uk/guidance/CG92) and Royal
College of Obstetricians and Gynaecologists. Abdominal
hysterectomy for benign condi ons. Consent Advice 4. London:
RCOG; 2009 (h ps://www.rcog.org.uk/en/guidelines-research-
services/guidelines/consent-advice-4/).

You are asked to review a 55-year-old woman with overac ve bladder

Q symptoms. She has responded poorly to bladder training and is on
oxybutynin therapy. Her main complaint is nocturia, which is badly affec ng
her quality of life. What is the best treatment for her con nuing symptoms?

A Your answer:
> Desmopressin 
Correct answer:
> Desmopressin

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The correct answer is Desmopressin. The use of desmopressin may

be considered specifically to reduce nocturia in women with UI or
OAB who find it a troublesome symptom. Use par cular cau on in
women with cys c fibrosis and avoid in those over 65 years with
cardiovascular disease or hypertension. See Na onal Ins tute for
Health and Clinical Excellence. Urinary incon nence in women.
CG171. London: NICE; 2013.
(h p://www.nice.org.uk/guidance/CG171)

This analysis below is taken from a meta-analysis of ovula on rates in

Q women with polycys c ovarian syndrome (PCOS) taking me ormin
compared with clomifene ovula on induc on therapy. Subgroup analysis
was also carried out using a cut-off BMI level of 30 kg/m2.

View larger version

(h ps://stratog.rcog
Reproduced with permission from Tang T et al. Cochrane Database Syst Rev
.org.uk/sites/default
2012;(5):CD003053
/files/Cochrane_CD
(h003053_analysis3.3.
p://onlinelibrary.wiley.com/doi/10.1002/14651858.CD003053.pub5/full
) png)
Which statement of the following best describes the above findings?

A Your answer:
> Me ormin is less effec ve than clomifene in the obese 
group (BMI >30)
Correct answer:
> Me ormin is less effec ve than clomifene in the obese
group (BMI >30)
The correct answer is that me ormin is less effec ve than clomifene
in the obese group (BMI >30). Me ormin is less effec ve than
clomifene in the obese group (BMI >30 kg/m2) as the OR = 0.43
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(95% CI 0.36–0.51) in favour of clomifene. See Tang T, Lord JM,

Norman RJ, Yasmin E, Balen AH. Insulin-sensi sing drugs
(me ormin, rosiglitazone, pioglitazone, D-chiro-inositol) for women
with polycys c ovary syndrome, oligo amenorrhoea and subfer lity.
Cochrane Database Syst Rev 2012;(5):CD003053
(h p://onlinelibrary.wiley.com/doi/10.1002/14651858.CD003053.p
ub5/full). Correct interpreta on of sta s cs is essen al in modern
clinical prac ce. This ques on aims to assess your ability to interpret
a Forest plot.

Royal College of Obstetricians and Gynaecologists

© 2018

Registered charity no. 213280

27 Sussex Place
Regent's Park
London NW1 4RG
UK

Tel +44 20 7772 6200

Fax +44 20 7723 0575

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A 23-year-old primigravid woman presents at the emergency department at 6

Q weeks of gesta on with threatened miscarriage. On examina on, her vital signs
were normal and her abdomen was so with minimal tenderness on deep
palpa on. On speculum examina on, there was a small amount of brown (old)
blood in the vagina. A transvaginal ultrasound scan showed an intrauterine
gesta on sac measuring 18 mm x 15 mm x 12 mm. No yolk sac or fetal pole was
visible. What would be the best management plan for her?

Arrange a da ng scan at 12 weeks of gesta on

Arrange a repeat scan a er 7 days

Arrange serial β-HCG levels

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Arrange serum progesterone level

Arrange surgical management of miscarriage

A 23-year-old woman whose mother died at the age of 56 of cervical cancer comes
Q to see you. She wants to know how to reduce her own risk of cervical cancer. What
is the single most important piece of advice you could give her?

To a end regularly for cervical screening

To avoid sexual promiscuity
To stop smoking

To stop smoking

To undergo prophylac c risk-reducing bilateral salpingo-oophorectomy

A 48-year-old woman presents 1 week a er a total abdominal hysterectomy. She

Q has persistent weakness of hip flexion and paraesthesia over the anterior and
medial aspects of her le thigh. Damage to which nerve is the most likely cause?

Femoral
Genito-femoral

Ilio-inguinal

Lateral cutaneous of the thigh

Obturator

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A 16-year-old girl presents to the gynaecology outpa ent clinic with primary
Q amenorrhea. She is 148 cm tall and weighs 54 kg (BMI 24.7). Breast development
is assessed as Tanner stage 2 and her pubic hair is noted to be sparse. Further
examina on iden fies cubitus valgus. She has no other dysmorphic features. What
is the most likely diagnosis?

Congenital adrenal hyperplasia

Down syndrome
Mayer-Rockitansky-Kusterhauser syndrome

Tes cular feminisa on

Turner syndrome

A 22-year-old medical student presents with a request for contracep on. Her
Q menstrual cycle is irregular and she complains of acne and hirsu sm. Previous
inves ga on has diagnosed polycys c ovary syndrome (PCOS). She wishes to have
a combined oral contracep ve with the best risk profile and most impact on her
androgenic symptoms. Which one of the following is the best available op on to
recommend for her?

Cilest® (ethinyl estradiol/norges mate)

Loestrin® (ethinyl estradiol/levonorgestrol)

Marvelon® (ethinyl estradiol/desogestrel)

Microgynon® (ethinyl estradiol/norethisterone)

Yasmin® (ethinyl estradiol/drosperinone)

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A 68-year-old woman with postmenopausal bleeding is a ending for a diagnos c

Q hysteroscopy under general anaesthe c. You discuss the complica ons with her.
What is the incidence of serious complica ons during hysteroscopy?

1 in 50

1 in 100
1 in 500

1 in 1000

1 in 5000

A 36-year old woman undergoes laparoscopic resec on of deep infiltra ng

Q endometriosis. You advise her regarding the risk of injury to her ureters during the
surgery and the fact that this may be a direct injury or a thermal injury related to
electrocautery. If she does receive a thermal injury, when would you expect her to
present?

1–2 days post surgery

5–7 days post surgery

10–14 days post surgery

3–4 weeks post surgery

5–6 weeks post surgery

You see a 48-year-old woman op ng for a hysterectomy for management of her

Q heavy menstrual bleeding. While obtaining her consent for the opera on you
explain to her that haemorrhage requiring transfusion is a 'common' procedural
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risk. What is the numerical ra o for a complica on when it is quoted as 'common'?

1/1 to 1/10

1/10 to 1/100

1/100 to 1/1000
1/1000 to 1/10 000

Less than 1/10 000

You prescribe hormone replacement therapy (HRT) for vasomotor instability in a

Q healthy 51-year-old woman who has no significant past medical or family history.
During her appointment you counsel her regarding the risks of estrogen and
progestogen HRT. How many es mated addi onal cases of breast cancer are there
per 1000 women using HRT for five years?

3 cases per 1000 women

6 cases per 1000 women

9 cases per 1000 women

12 cases per 1000 women

14 cases per 1000 women

You see a 45-year-old nulliparous woman at your gynaecology clinic who is a

Q carrier for the BRCA2 muta on. She wishes to discuss surgery to reduce her cancer
risk. What is the approximate average cumula ve risk of her developing ovarian-
type cancer by the age of 70?

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10%

25%

40%

55%

70%

This is the last ques on of this quiz. Press finish to submit your choice(s) and reveal the answer(s).

Royal College of Obstetricians and Gynaecologists

© 2018

Registered charity no. 213280

27 Sussex Place
Regent's Park
London NW1 4RG
UK

Tel +44 20 7772 6200

Fax +44 20 7723 0575

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A 23-year-old primigravid woman presents at the emergency department at

Q 6 weeks of gesta on with threatened miscarriage. On examina on, her vital
signs were normal and her abdomen was so with minimal tenderness on
deep palpa on. On speculum examina on, there was a small amount of
brown (old) blood in the vagina. A transvaginal ultrasound scan showed an
intrauterine gesta on sac measuring 18 mm x 15 mm x 12 mm. No yolk sac
or fetal pole was visible. What would be the best management plan for
her?

A Your answer:
> Arrange a repeat scan a er 7 days 
Correct answer:
> Arrange a repeat scan a er 7 days
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The correct answer is arrange a repeat scan a er 7 days. For an

embryonic pregnancy, if the mean gesta onal sac diameter is less
than 25.0 mm with a transvaginal ultrasound scan and there is no
visible fetal pole, a second scan a er a minimum of 7 days should be
performed before making a diagnosis of miscarriage. Once a
gesta on sac has been iden fied, there is no role for tes ng of
serum β-HCG or serum progesterone level. See Na onal Ins tute for
Health and Clinical Excellence. Ectopic pregnancy and miscarriage:
diagnosis and ini al management in early pregnancy of ectopic
pregnancy and miscarriage. CG154. London: NICE; 2012.
(h ps://www.nice.org.uk/guidance/cg154)

A 23-year-old woman whose mother died at the age of 56 of cervical cancer

Q comes to see you. She wants to know how to reduce her own risk of
cervical cancer. What is the single most important piece of advice you could
give her?

A Your answer:
> To a end regularly for cervical screening 
Correct answer:
> To a end regularly for cervical screening
The correct asnwer is to a end regularly for cervical screening. The
incidence of cervical carcinoma has dras cally reduced in countries
with screening programmes. Only 1% of abnormal smears progress
to malignancy over a long period of me. Most women with cervical
cancer have not had a smear in the last 5 years and many of then
have never had a smear. See Centres for Disease Control and
Preven on. Gynecologic cancers. Accessed online July 2015
(h p://www.cdc.gov/cancer/cervical/basic_info/preven on.htm).

A 48-year-old woman presents 1 week a er a total abdominal

Q hysterectomy. She has persistent weakness of hip flexion and paraesthesia
over the anterior and medial aspects of her le thigh. Damage to which
nerve is the most likely cause?

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A Your answer:

> Femoral

Correct answer:
> Femoral
The correct answer is the femoral nerve. Gynaecological surgery,
especially abdominal hysterectomy, is the most common cause of
iatrogenic femoral nerve injury, and injury to the femoral nerve is
the most common nerve injury in gynaecological prac ce. This is
usually caused by compression of the nerve against the pelvic
sidewall by a retractor blade. See Kuponiyi O, Alleemudder DI,
Latunde-Dada A, Eedarapalli P. Nerve injuries associated with
gynaecological surgery. The Obstetrician & Gynaecologist
2014;16:29–36
(h p://onlinelibrary.wiley.com/doi/10.1111/tog.12064/full).

A 16-year-old girl presents to the gynaecology outpa ent clinic with

Q primary amenorrhea. She is 148 cm tall and weighs 54 kg (BMI 24.7). Breast
development is assessed as Tanner stage 2 and her pubic hair is noted to be
sparse. Further examina on iden fies cubitus valgus. She has no other
dysmorphic features. What is the most likely diagnosis?

A Your answer:
> Turner syndrome 
Correct answer:
> Turner syndrome
The correct answer is Turner syndrome. The karyotype is 45 XO in
Turner syndrome. It is the most common cause of gonadal
dysgenesis. These pa ents may have addi onal renal and cardiac
anamolies. Some women may menstruate due to mosaicism, but
premature ovarian failure is more common. See Bondy CA, and for
The Turner Syndrome Consensus Study Group. Care of girls and
women with Turner syndrome: a guideline of the Turner Syndrome
Study Group. J Clin Endocrinol Metab 2007;92:10–25
(h p://press.endocrine.org/doi/abs/10.1210/jc.2006-1374?
url_ver=Z39.88-
2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3Dpubmed).

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A 22-year-old medical student presents with a request for contracep on.

Q Her menstrual cycle is irregular and she complains of acne and hirsu sm.
Previous inves ga on has diagnosed polycys c ovary syndrome (PCOS). She
wishes to have a combined oral contracep ve with the best risk profile and
most impact on her androgenic symptoms. Which one of the following is
the best available op on to recommend for her?

A Your answer:
> Yasmin® (ethinyl estradiol/drosperinone) 
Correct answer:
> Yasmin® (ethinyl estradiol/drosperinone)
The correct answer is Yasmin® (ethinyl estradiol/drosperinone).
From the given list, Yasmin is more beneficial in terms of
management of acne and hirsui sm associated with PCOS. Women
with PCOS may also be given Marvelon or Mercilon as
contracep on. Yasmin contains 3 mg of drosperinone, which has
some an androgenic proper es. Diane e is also useful as it
contains cyproterone acetate, which is also an an androgenic agent.
Care must be taken for women with high body mass index. See
Swingler R, Awala A, Gordon U. Hirsu sm in young women. The
Obstetrician & Gynaecologist 2009;11:101–7
(h p://onlinelibrary.wiley.com/doi/10.1576/toag.11.2.101.27483/fu
ll).

A 68-year-old woman with postmenopausal bleeding is a ending for a

Q diagnos c hysteroscopy under general anaesthe c. You discuss the
complica ons with her. What is the incidence of serious complica ons
during hysteroscopy?

A Your answer:
> 1 in 500 
Correct answer:
> 1 in 500
The correct is 1 in 500. Uterine perfora on is uncommon, but a
small postmenopausal uterus is an independent risk factor,
especially if the cervical os is stenosed. The overall risk is reported
as 0.76%. See Shakir F, Diab Y. The perforated uterus. The
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Obstetrician & Gynaecologist 2013;15:256–61

(h p://onlinelibrary.wiley.com/doi/10.1111/tog.12056/abstract)
and Rock JA, Jones HW. Te Linde’s Opera ve Gynaecology. Lippinco
Williams and Wilkins. 2011.

A 36-year old woman undergoes laparoscopic resec on of deep infiltra ng

Q endometriosis. You advise her regarding the risk of injury to her ureters
during the surgery and the fact that this may be a direct injury or a thermal
injury related to electrocautery. If she does receive a thermal injury, when
would you expect her to present?

A Your answer:
> 10–14 days post surgery 
Correct answer:
> 10–14 days post surgery
The correct answer is 10–14 days a er surgery. Thermal injuries to
the ureter may result in delayed necrosis and/or fistula forma on
that will typically present clinically between 10 and 14 days
postopera vely. See Minas V, Gul N, Aust T, Doyle M, Rowlands D.
Urinary tract injuries in laparoscopic gynaecological surgery;
preven on, recogni on and management. The Obstetrician &
Gynaecologist 2014;16:19–28
(h p://onlinelibrary.wiley.com/doi/10.1111/tog.12073/abstract).

You see a 48-year-old woman op ng for a hysterectomy for management of

Q her heavy menstrual bleeding. While obtaining her consent for the
opera on you explain to her that haemorrhage requiring transfusion is a
'common' procedural risk. What is the numerical ra o for a complica on
when it is quoted as 'common'?

A Your answer:
> 1/10 to 1/100 
Correct answer:

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> 1/10 to 1/100

The correct answer is 1/10 to 1/100. See Royal College of
Obstetricians and Gynaecologists. Obtaining valid consent for
complex gynaecological surgery. Clinical Governance Advice 6b.
London: RCOG; 2010 (h ps://www.rcog.org.uk/en/guidelines-
research-services/guidelines/clinical-governance-advice-6b/).

You prescribe hormone replacement therapy (HRT) for vasomotor

Q instability in a healthy 51-year-old woman who has no significant past
medical or family history. During her appointment you counsel her
regarding the risks of estrogen and progestogen HRT. How many es mated
addi onal cases of breast cancer are there per 1000 women using HRT for
five years?

A Your answer:
> 6 cases per 1000 women 
Correct answer:
> 6 cases per 1000 women
The correct answer is 6 addi onal cases per 1000 women.
Combined (estrogen and progesterone) HRT is associated with a
higher risk of breast cancer than estrogen-only HRT or bolone.
There are some discrepancies between the Million Women Study
(MWS) and Women's Health Ini a ve (WHI) study. Many of the
discrepencies can be explained by the popula ons studies. The WHI
study group was 16 000 women aged 50-79, 45% of whom had a
BMI of 30 or more. The MWS looked at 1 084 110 women aged 50-
64, only 18% of whom had a BMI of 30 or more See the Bri sh
Na onal Formulary. Hormone replacement therapy. Accessed online
February 2016
(h ps://www.medicinescomplete.com/mc/bnf/current/PHP78400-
sex-hormones.htm?
q=hormone%20replacement%20therapy&t=search&ss=text&p=1#_
hit).

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You see a 45-year-old nulliparous woman at your gynaecology clinic who is

Q a carrier for the BRCA2 muta on. She wishes to discuss surgery to reduce
her cancer risk. What is the approximate average cumula ve risk of her
developing ovarian-type cancer by the age of 70?

A Your answer:
> 10% 
Correct answer:
> 10%
The correct answer is 10%. BRCA1 and BRCA2 are highly penetrant
genes that account for 95% of families with both breast and ovarian
cancer. The cumula ve risk of ovarian cancer is lower in women
with BRCA2 at 11%, compared with BRCA1 where the risk is 39%.
See Devlin LA, Morrison PJ. Inherited gynaecological cancer
syndromes. The Obstetrician & Gynaecologist 2008;10:9–15
(h p://onlinelibrary.wiley.com/doi/10.1576/toag.10.1.009.27371/a
bstract) and Antoniou A, Pharoah PD, Narod S, Risch HA, Ey ord JE,
Hopper JL et al. Average risks of breast and ovarian cancer
associated with BRCA1 or BRCA2 muta ons detected in case Series
unselected for family history: a combined analysis of 22 studies. Am
J Hum Genet 2003;72:1117–30
(h p://www.ncbi.nlm.nih.gov/pmc/ar cles/PMC1180265/).

Royal College of Obstetricians and Gynaecologists

© 2018

Registered charity no. 213280

27 Sussex Place
Regent's Park
London NW1 4RG
UK

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Tel +44 20 7772 6200

Fax +44 20 7723 0575

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A 42-year-old para 2 woman is referred to your gynaecology clinic complaining of

Q regular but heavy menstrual bleeding that is affec ng her quality of life. Which of
the following inves ga ons is most appropriate at the first clinic visit?

Full blood count (FBC)

Gonadotrophin assay

Thyroid func on tests (TFTs)

Thyroid func on tests (TFTs)
Transvaginal ultrasound (TVS)

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You have informed a 45-year-old that she has stage 3c ovarian cancer. She is keen
Q to know about her prognosis. What is the 5-year survival rate in UK for ovarian
cancer?

20–25%

30–35%
40–45%

50–55%
60–65%

A 16-year-old girl a ends the gynaecology clinic for heavy periods and confides
Q that she is being forced to undergo female genital mu la on (FGM) by her
parents. What is the es mated number of children at risk of FGM in the UK?

500

5000

10 000

20 000
50 000

A 40-year-old woman presents with severe pelvic pain. She has had a
Q myomectomy in the past through a ver cal abdominal incision to the level of the
umbilicus. To inves gate her pelvic pain, she undergoes a diagnos c laparoscopy
using the Palmer point of entry. Where is Palmer’s point?

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3 cm below the le costal margin in the midaxillary line

3 cm below the le costal margin in the midclavicular line

3 cm below the right costal margin in the midaxillary line

3 cm below the right costal margin in the midclavicular line

3 cm below xiphisternum in the midline

A 36-year-old woman presents to the early pregnancy assessment unit with a

Q history of mild bleeding for 3 days and lower abdominal pain. She has had two
vaginal deliveries in the past. She has factor V Leiden deficiency, which was
diagnosed during her first pregnancy. Her last menstrual period was 7 weeks ago
and this is an unplanned pregnancy. She has no other significant medical or
surgical history. She lives with her husband and children. On ultrasound scan, she
was found to have an intrauterine gesta onal sac with a fetal pole measuring 8
mm. No fetal heart beat was seen and was confirmed by two ultrasonographers.
What is the best ini al management for this woman?

Book a repeat scan in 7–10 days

Counsel her regarding expectant management of miscarriage

Discuss medical management of miscarriage and prescribe oral

administra on of 600 micrograms of misoprostol
Discuss medical management of miscarriage and prescribe oral
administra on of 200 mg mifepristone

Prescribe an bio cs for 7 days and discuss expectant management of

miscarriage

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A 46-year-old fit and healthy woman has urodynamically confirmed stress urinary

Q incon nence. She has undergone pelvic floor muscle training without
improvement. On examina on she is noted to have a POPQ grade 1 anterior
vaginal wall prolapse. In view of the effect of her urinary symptoms on her quality
of life she is reques ng defini ve treatment. What is the most appropriate surgical
interven on for her?

Anterior colporrhaphy

Ar ficial urinary sphincter

Intramural bulking agent

Laparoscopic colposuspension

Synthe c mid-urethral tape

A 26-year-old-woman presents to the emergency gynaecology clinic reques ng

Q emergency contracep on (EC). She had unprotected sex 6 days ago. She is not
currently using any contracep on, having not had a partner for a year. She has a
regular 28 day menstrual cycle, which can be heavy. The first day of her last period
was 15 days ago. What emergency contracep on op on, if any, would you advise?

A copper bearing intrauterine device

A Mirena® coil

It is too late for emergency contracep on

Levonelle®

Ulipristal acetate

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A 27-year-old woman has had three successive first trimester miscarriages.

Q Inves ga ons show that she has an phospholipid syndrome. Which treatment
op on will improve the chance of a successful pregnancy?

Aspirin and heparin

Cor costeroids and intravenous immunoglobulin

Human chorionic gonadotrophin

Me ormin
Progesterone

A 17-year-old girl presents with a 12 hour history of lower abdominal pain. She
Q had unprotected intercourse a week ago, which was 6 days a er her last period.
Her pulse is 110 beats per minute, her blood pressure is 110/70 mmHg, her
temperature 37.8°C and she is tender over her lower abdomen, especially in the
right iliac fossa where there is rebound tenderness. There is cervical excita on. Her
Hb is 137g/l (normal 115–165) and her white cell count 17.6 x 10*9/l (normal 4–
11). What is the most likely diagnosis?

Acute appendici s

Acute pelvic inflammatory disease

Ectopic pregnancy
Pelvic endometriosis

Ruptured corpus luteum

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A 65-year-old postmenopausal woman a ends the clinic having been found to

Q have a 4.9 cm simple cyst arising from the right ovary. There is no other
abnormality on scan. Her Ca 125 is 29. She is asymptoma c and the cyst was
picked up on inves ga on for haematuria. What is the most appropriate
management?

Aspira on of the cyst under ultrasound guidance

Laparoscopic aspira on of the cyst

Repeat scan and Ca 125 test in 4 months

Right oophorectomy

Right ovarian cystectomy

This is the last ques on of this quiz. Press finish to submit your choice(s) and reveal the answer(s).

Royal College of Obstetricians and Gynaecologists

© 2018

Registered charity no. 213280

27 Sussex Place
Regent's Park
London NW1 4RG
UK

Tel +44 20 7772 6200

Fax +44 20 7723 0575

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A 42-year-old para 2 woman is referred to your gynaecology clinic

Q complaining of regular but heavy menstrual bleeding that is affec ng her
quality of life. Which of the following inves ga ons is most appropriate at
the first clinic visit?

A Your answer:
> Full blood count (FBC) 
Correct answer:
> Full blood count (FBC)
The correct answer is a full blood count (FBC). All women presen ng
with heavy menstrual bleeding should have FBC performed. An
ultrasound scan is not indicated unless the uterus is palpable

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abdominally, an adnexal mass is palpable or medical treatment fails.

See Na onal Ins tute for Health and Clinical Excellence. Heavy
menstrual bleeding. CG44. NICE; 2007
(h p://www.nice.org.uk/guidance/cg44).

You have informed a 45-year-old that she has stage 3c ovarian cancer. She is
Q keen to know about her prognosis. What is the 5-year survival rate in UK for
ovarian cancer?

A Your answer:
> 40–45% 
Correct answer:
> 40–45%
The correct answer is 40–45%. As with the majority of cancers,
rela ve survival for ovarian cancer is improving. Much of the
increase occurred during the 1980s and 1990s, and appears to be
leveling off in the 2000s. The significant increase in 1-year survival is
likely to be the result of greater use of pla num-based
chemotherapy. One-year rela ve survival rates for ovarian cancer
increased from 42% in England and Wales in 1971–1975 to 72.3% in
England in 2005–2009. The 5-year survival rate for advanced ovarian
cancer in 2005–2009 was 43%. See Cancer Research UK. Ovarian
cancer survival sta s cs. Accessed online July 2015
(h p://www.cancerresearchuk.org/cancer-
info/cancerstats/types/ovary/survival/#trends).

A 16-year-old girl a ends the gynaecology clinic for heavy periods and
Q confides that she is being forced to undergo female genital mu la on
(FGM) by her parents. What is the es mated number of children at risk of
FGM in the UK?

A Your answer:
> 20 000 
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Correct answer:
> 20 000
The correct answer is 20 000. It is es mated that 20 000 girls in the
UK are at risk of FGM, usually through travelling abroad to facilitate
the procedure. It is important that the safeguarding team are
informed when a woman who has undergone FGM themselves
delivers a female child. See Royal College of Obstetricians and
Gynaecologists. Female genital mu la on and its management.
Green-top Guideline 53. London: RCOG; 2009
(h ps://www.rcog.org.uk/en/guidelines-research-
services/guidelines/gtg53/).

A 40-year-old woman presents with severe pelvic pain. She has had a
Q myomectomy in the past through a ver cal abdominal incision to the level
of the umbilicus. To inves gate her pelvic pain, she undergoes a diagnos c
laparoscopy using the Palmer point of entry. Where is Palmer’s point?

A Your answer:
> 3 cm below the le costal margin in the midclavicular line 
Correct answer:
> 3 cm below the le costal margin in the midclavicular line
The correct answer is 3 cm below the le costal margin in the
midclavicular line. Palmer’s point should be used if there is a high
suspicion of adhesions. Adhesions are found in up to 50% of women
following midline laparotomy but are rarely found in the le upper
quadrant. The usual trocar and cannulae can be inserted under
direct vision or following dissec on of any adhesions seen. If there
are two failed a empts at insuffla on then u lising Palmer’s point
or the open Hasson technique should be used. See Royal College of
Obstetricians and Gynaecologists. Preven ng entry related
gynaecological laparoscopic injuries. Green-top Guideline 49.
London: RCOG; 2008. (h ps://www.rcog.org.uk/en/guidelines-
research-services/guidelines/gtg49/)

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A 36-year-old woman presents to the early pregnancy assessment unit with

Q a history of mild bleeding for 3 days and lower abdominal pain. She has had
two vaginal deliveries in the past. She has factor V Leiden deficiency, which
was diagnosed during her first pregnancy. Her last menstrual period was 7
weeks ago and this is an unplanned pregnancy. She has no other significant
medical or surgical history. She lives with her husband and children. On
ultrasound scan, she was found to have an intrauterine gesta onal sac with
a fetal pole measuring 8 mm. No fetal heart beat was seen and was
confirmed by two ultrasonographers. What is the best ini al management
for this woman?

A Your answer:
> Counsel her regarding expectant management of miscarriage 
Correct answer:
> Counsel her regarding expectant management of miscarriage
The correct answer is counsel her regarding expectant management
of miscarriage. Expectant management should be offered as first
line management for all women with a confirmed diagnosis of
miscarriage, taking into account if she is at increased risk of
haemorrhage (e.g. late first trimester), has risks associated with
haemorrhage (e.g. unable to have a blood transfusion), evidence of
infec on, or her personal wishes. Mifepristone is not indicated in
management of a non viable pregnancy. See Na onal Ins tute for
Health and Clinical Excellence. Ectopic pregnancy and miscarriage.
CG154. NICE; 2012 (h p://www.nice.org.uk/guidance/CG154).

A 46-year-old fit and healthy woman has urodynamically confirmed stress

Q urinary incon nence. She has undergone pelvic floor muscle training
without improvement. On examina on she is noted to have a POPQ grade 1
anterior vaginal wall prolapse. In view of the effect of her urinary symptoms
on her quality of life she is reques ng defini ve treatment. What is the
most appropriate surgical interven on for her?

A Your answer:
> Synthe c mid-urethral tape 
Correct answer:
> Synthe c mid-urethral tape

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The correct answer is synthe c mid-urethral tape. All women with

stress urinary incon nence should be referred for pelvic floor
exercises in the first instance. If conserva ve management fails, the
first line management is a synthe c mid-urethral tape procedure.
Anterior colporrhaphy is not indicated since her prolapse is only
stage 1 and is therefore asymptoma c, and it does not treat stress
incon nence. See Na onal Ins tute for Health and Clinical
Excellence. The management of urinary incon nence in women.
Clinical Guideline 171. NICE; 2013
(h p://www.nice.org.uk/guidance/CG171).

A 26-year-old-woman presents to the emergency gynaecology clinic

Q reques ng emergency contracep on (EC). She had unprotected sex 6 days
ago. She is not currently using any contracep on, having not had a partner
for a year. She has a regular 28 day menstrual cycle, which can be heavy.
The first day of her last period was 15 days ago. What emergency
contracep on op on, if any, would you advise?

A Your answer:
> A copper bearing intrauterine device 
Correct answer:
> A copper bearing intrauterine device
The correct answer is a copper bearing intrauterine device. The
choice of EC depends on the length of me since unprotected sexual
intercourse. All forms are not effec ve a er 6 days except for the
copper-bearing intrauterine device, and only in the circumstance
that it is within 5 days of the earliest es mated date of ovula on.
See Faculty of Sexual and Reproduc ve Healthcare. Emergency
contracep on. Clinical Guidance. London: FSRH; 2011
(h p://www.fsrh.org/pages/Clinical_Guidance_2.asp).

A 27-year-old woman has had three successive first trimester miscarriages.

Q Inves ga ons show that she has an phospholipid syndrome. Which
treatment op on will improve the chance of a successful pregnancy?

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A Your answer:

> Aspirin and heparin

Correct answer:
> Aspirin and heparin
The correct answer is aspirin and heparin. An phospholipid
syndrome is present in 15% of women with recurrent miscarriage.
Without treatment, the live birth rate has been reported to be as
low as 10%. Cor costeroids and intravenous immunoglobulin are
associated with significant maternal and fetal morbidity. Despite the
associa on between PCOS and miscarriage that is a ributed to
insulin resistance and hyperinsulinaemia, a meta-analysis of 117
randomised controlled trials showed no reduc on in the rate of
miscarriage in those women prescribed me ormin. See Royal
College of Obstetricians and Gynaecologists. Inves ga on and
treatment of couples with recurrent miscarriage. Green-top
Guideline 17. London: RCOG; 2011
(h ps://www.rcog.org.uk/en/guidelines-research-
services/guidelines/gtg17/).

A 17-year-old girl presents with a 12 hour history of lower abdominal pain.

Q She had unprotected intercourse a week ago, which was 6 days a er her
last period. Her pulse is 110 beats per minute, her blood pressure is 110/70
mmHg, her temperature 37.8°C and she is tender over her lower abdomen,
especially in the right iliac fossa where there is rebound tenderness. There
is cervical excita on. Her Hb is 137g/l (normal 115–165) and her white cell
count 17.6 x 10*9/l (normal 4–11). What is the most likely diagnosis?

A Your answer:
> Acute appendici s 
Correct answer:
> Acute appendici s
The correct answer is acute appendici s. The white count and mild
pyrexia suggest an infec on and the localisa on to the right iliac
fossa makes this more likely to be appendici s.

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A 65-year-old postmenopausal woman a ends the clinic having been found

Q to have a 4.9 cm simple cyst arising from the right ovary. There is no other
abnormality on scan. Her Ca 125 is 29. She is asymptoma c and the cyst
was picked up on inves ga on for haematuria. What is the most
appropriate management?

A Your answer:
> Repeat scan and Ca 125 test in 4 months 
Correct answer:
> Repeat scan and Ca 125 test in 4 months
The correct answer is repeat scan and Ca 125 test in 4 months. The
risk of malignancy index (RMI) is zero since the cyst is simple and it
measures less than 5 cm. Therefore, monitoring for 12 months is all
that is required. See Royal College of Obstetricians and
Gynaecologists. Ovarian cysts in postmenopausal women. Green-top
Guideline 34. London: RCOG; 2003
(h ps://www.rcog.org.uk/en/guidelines-research-
services/guidelines/gtg34/).

Royal College of Obstetricians and Gynaecologists

© 2018

Registered charity no. 213280

27 Sussex Place
Regent's Park
London NW1 4RG
UK

Tel +44 20 7772 6200

Fax +44 20 7723 0575

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11/21/2018 Gynaecology page 3 | StratOG

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History
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A 67-year-old woman is referred to the rapid access clinic with a 2 day history of
Q postmenopausal bleeding, which has since resolved. She is otherwise fit and well.
The endometrial thickness is 7 mm on transvaginal ultrasound scan, the
endometrium appears polypoidal at hysteroscopy and histology on an endometrial
sample is reported as showing irregular and ghtly packed glands with large and
vesicular nuclei containing prominent nucleoli. What is the most appropriate
management for this woman?

Bilateral oophorectomy
Combined estrogen and progestogen hormone replacement therapy

Expectant management
Hysterectomy
Inser on of a levonorgestrel-releasing intrauterine system
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A 40-year-old woman has regular heavy menstrual bleeding. The history and
Q inves ga ons indicate that pharmacological treatment is appropriate. Her GP has
tried tranexamic acid without success. What is the most appropriate next
pharmaceu cal treatment?

Etamsylate

Gonadotrophin-releasing hormone analogues

Injected long ac ng progestogens
Levonorgestrel-releasing intrauterine system (LNG-IUS)

Norethisterone 15 mg daily from day 5 to day 26 of cycle

A 23-year-woman had an ultrasound scan that was sugges ve of a missed

Q miscarriage. She underwent evacua on of the uterus and products of concep on
were sent for histology. The histology report confirmed that this had been a par al
molar pregnancy. What are the most likely gene c features of the par al molar
pregnancy?

46 XY

46 YY
46 YYY

69 XYY

69 YYY

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You see a 38-year-old woman with a 2.5 cm malignant tumour on her cervix and
Q no extracervical disease on imaging. She is fit and healthy. What is her best
treatment op on?

Radical hysterectomy

Radical hysterectomy and bilateral pelvic lymphadenectomy

Radical trachelectomy

Radical trachelectomy and bilateral pelvic lymphadenectomy

Radiotherapy

A 55-year-old woman is seen in the pre-assessment clinic. She is due to undergo

Q full staging surgery for ovarian cancer as recommended by the MDT. Her only
current medica ons are clopidogrel and thyroxine. If the benefits of stopping
clopidogrel outweigh the risks, how long should clopidogrel be stopped prior to
surgery?

1 day

3 days

5 days
7 days

14 days

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A 45-year-old woman is due to have a total abdominal hysterectomy and bilateral

Q salpingo oopherectomy for chronic pelvic pain. You receive a le er from her GP
informing you that her recent cervical smear has shown borderline changes in
endocervical cells. What arrangement will you make, if any, prior to her
admission?

Endometrial sampling

HPV tes ng
No change in her management

Referral to colposcopy

Repeat cervical cytology

A 46-year-old nulliparous woman has been referred by her GP having been treated
Q for heavy regular menstrual bleeding with cyclical progestogens for a period of 6
months. The treatment has failed to improve her symptoms. What is the most
appropriate next line of management?

Endometrial biopsy
Levonorgestrel intrauterine system

Non-steroidal an -inflammatory drugs

Pelvic ultrasound

Tranexamic acid

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A 25-year-old woman with a bicornuate uterus a ends the emergency

Q gynaecology unit reques ng emergency contracep on (EC). She has been on
holiday and forgot to take her contracep ve pill for 3 days in the first week of the
calendar pack and had unprotected sexual intercourse (UPSI) four days ago. She is
in good health. Which of the following is the recommended EC?

Copper IUCD

Mirena IUS

Levonorgestrel (LNG)

Mifepristone
Ulipristal acetate (UA)

A 30-year-old mul parous woman with a suspected borderline le ovarian tumour

Q is awai ng laparotomy, frozen sec on and conserva ve or complete staging
surgery. She wants to know the accuracy of frozen sec on. How many cases
diagnosed as borderline ovarian tumours on frozen sec on would be later
reclassified as invasive tumours?

One-tenth of cases

One-fi h of cases

One-quarter of cases
One-third of cases

One-half of cases

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A 63-year-old woman with a history of postmenopausal bleeding returns to the

Q gynaecology clinic. Recent endometrial biopsy shows complex hyperplasia without
atypia. She wants to know what the risk is of these abnormal cells progressing to
cancer. What is the risk of her complex hyperplasia progressing to endometrial
cancer over 10 years?

4%

8%

12%

16%

20%

This is the last ques on of this quiz. Press finish to submit your choice(s) and reveal the answer(s).

Royal College of Obstetricians and Gynaecologists

© 2018

Registered charity no. 213280

27 Sussex Place
Regent's Park
London NW1 4RG
UK

Tel +44 20 7772 6200

Fax +44 20 7723 0575

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11/21/2018 Gynaecology page 4 | StratOG

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11/21/2018 Gynaecology page 4 | StratOG

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Progress 72% complete

Gynaecology page 4
Assessment Total A empts: 5 Highest Score: 100 %
History
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Your result 100 %

A 67-year-old woman is referred to the rapid access clinic with a 2 day

Q history of postmenopausal bleeding, which has since resolved. She is
otherwise fit and well. The endometrial thickness is 7 mm on transvaginal
ultrasound scan, the endometrium appears polypoidal at hysteroscopy and
histology on an endometrial sample is reported as showing irregular and
ghtly packed glands with large and vesicular nuclei containing prominent
nucleoli. What is the most appropriate management for this woman?

A Your answer:
> Hysterectomy 
Correct answer:
> Hysterectomy

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11/21/2018 Gynaecology page 4 | StratOG

The correct answer is hysterectomy. The endometrial sample has

features that are diagnos c of complex atypical hyperplasia. Atypical
hyperplasia is a premalignant condi on and will progress to
malignancy in 29% of cases. It can co-exist with an invasive
carcinoma. Less aggressive abnormali es are complex hyperplasia
which will progress to malignancy in only 4% of women, but will
persist in 22%. The majority of simple hyperplasias will regress
spontaneously although 3% progress to complex atypical
hyperplasia. Current advice is that these women should be offered a
hysterectomy, especially with the risk of co-exis ng carcinoma. In
younger women high doses of progestagens have been used with
success, and there have been reported pregnancies following
treatment. See Palmer JE, Perunovic B, Tidy JA. Endometrial
hyperplasia. The Obstetrician & Gynaecologist 2008;10:211–6
(h p://onlinelibrary.wiley.com/doi/10.1576/toag.10.4.211.27436/a
bstract).

A 40-year-old woman has regular heavy menstrual bleeding. The history

Q and inves ga ons indicate that pharmacological treatment is appropriate.
Her GP has tried tranexamic acid without success. What is the most
appropriate next pharmaceu cal treatment?

A Your answer:
> Levonorgestrel-releasing intrauterine system (LNG-IUS) 
Correct answer:
> Levonorgestrel-releasing intrauterine system (LNG-IUS)
The correct answer is levonorgestrel-releasing intrauterine system
(LNG-IUS). The LNG-IUS is first line treatment in women complaining
of heavy menstrual bleeding and NICE recommends it's use before
tranexamic acid. See Na onal Ins tute for Health and Clinical
Excellence. Heavy menstrual bleeding. CG44. NICE; 2007
(h p://www.nice.org.uk/guidance/CG44).

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11/21/2018 Gynaecology page 4 | StratOG

A 23-year-woman had an ultrasound scan that was sugges ve of a missed

Q miscarriage. She underwent evacua on of the uterus and products of
concep on were sent for histology. The histology report confirmed that this
had been a par al molar pregnancy. What are the most likely gene c
features of the par al molar pregnancy?

A Your answer:
> 69 XYY 
Correct answer:
> 69 XYY
The correct answer is 69 XYY. Complete moles are usually diploid
and all chromosomes are of paternal origin. Par al molar
pregnancies are usually triploid, with the addi onal set of
chromosomes of maternal origin. Incidence varies worldwide,
ranging from 2 in 1000 pregnancies in Japan to 0.6–1.1 per 1000 in
Europe and North America. See Royal College of Obstetricians and
Gynaecologists. Gesta onal trophoblas c disease. Green-top
Guideline 38. London: RCOG; 2010
(h ps://www.rcog.org.uk/en/guidelines-research-
services/guidelines/gtg38/).

You see a 38-year-old woman with a 2.5 cm malignant tumour on her cervix
Q and no extracervical disease on imaging. She is fit and healthy. What is her
best treatment op on?

A Your answer:
> Radical hysterectomy and bilateral pelvic 
lymphadenectomy

Correct answer:
> Radical hysterectomy and bilateral pelvic
lymphadenectomy
The correct answer is radical hysterectomy and bilateral pelvic
lymphadenectomy. Radical surgery is recommended in stage 1B1
disease if there is no contraindica on to surgery. Radical
trachelectomy can only be offered for fer lity sparing in tumours

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less than 2 cm. See Sco sh Intercollegiate Guidelines Network.

Management of cervical cancer. Guideline 99. Edinburgh: SIGN;
2008 (h p://www.sign.ac.uk/assets/sign99.pdf).

A 55-year-old woman is seen in the pre-assessment clinic. She is due to

Q undergo full staging surgery for ovarian cancer as recommended by the
MDT. Her only current medica ons are clopidogrel and thyroxine. If the
benefits of stopping clopidogrel outweigh the risks, how long should
clopidogrel be stopped prior to surgery?

A Your answer:
> 7 days 
Correct answer:
> 7 days
The correct answer is 7 days. You should assess the risks and
benefits of stopping pre-exis ng an platelet therapy 1 week before
surgery. Consider involving the mul disciplinary team in the
assessment. See: Na onal Ins tute for Health and Clinical
Excellence. Venous thromboembolism: reducing the risk. CG92.
London: NICE; 2010 (h p://www.nice.org.uk/guidance/CG92).

A 45-year-old woman is due to have a total abdominal hysterectomy and

Q bilateral salpingo oopherectomy for chronic pelvic pain. You receive a le er
from her GP informing you that her recent cervical smear has shown
borderline changes in endocervical cells. What arrangement will you make,
if any, prior to her admission?

A Your answer:
> Referral to colposcopy 
Correct answer:
> Referral to colposcopy

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The correct answer is referral to colposcopy. All women being

considered for hysterectomy who have an uninves gated abnormal
test result or symptoms a ributable to cervical cancer should have
diagnos c colposcopy and an appropriate biopsy. See: NHS Cancer
Screening Programmes. Colposcopy and Programme Management.
Guidelines for the NHS Cervical Screening Programme. Second
edi on. Sheffield: NHS Cancer Screening Programmes; 2010
(h p://www.cancerscreening.nhs.uk/cervical/publica ons/nhscsp2
0.pdf).

A 46-year-old nulliparous woman has been referred by her GP having been

Q treated for heavy regular menstrual bleeding with cyclical progestogens for
a period of 6 months. The treatment has failed to improve her symptoms.
What is the most appropriate next line of management?

A Your answer:
> Endometrial biopsy 
Correct answer:
> Endometrial biopsy
The correct answer is endometrial biopsy. Endometrial biopsy
should be performed if a women over 45 years of age fails to
respond to first line treatment. See: Na onal Ins tute for Health
and Clinical Excellence. Heavy menstrual bleeding. CG44. London:
NICE; 2007 (h p://www.nice.org.uk/guidance/CG44).

A 25-year-old woman with a bicornuate uterus a ends the emergency

Q gynaecology unit reques ng emergency contracep on (EC). She has been
on holiday and forgot to take her contracep ve pill for 3 days in the first
week of the calendar pack and had unprotected sexual intercourse (UPSI)
four days ago. She is in good health. Which of the following is the
recommended EC?

A Your answer:
> Ulipristal acetate (UA) 
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Correct answer:
> Ulipristal acetate (UA)
The correct asnwer is ulipristal acetate (UA). The Mirena coil is not
licensed for EC. LNG is recommended only within 72 hours of UPSI.
A copper IUCD can be used within 5 days of first UPSI in a cycle but
is not indicated in the presence of a uterine anomaly. Mifepristone
is not licensed for EC in the UK. UA is licensed for use within 120
hours of UPSI so is the recommended choice. See Faculty of Sexual
and Reproduc ve Health Care. Emergency contracep on. London:
FSRH; 2011
(h p://www.fsrh.org/pdfs/CEUguidanceEmergencyContracep on11
.pdf).

A 30-year-old mul parous woman with a suspected borderline le ovarian

Q tumour is awai ng laparotomy, frozen sec on and conserva ve or
complete staging surgery. She wants to know the accuracy of frozen
sec on. How many cases diagnosed as borderline ovarian tumours on
frozen sec on would be later reclassified as invasive tumours?

A Your answer:
> One-third of cases 
Correct answer:
> One-third of cases
The correct answer is one-third of cases. Approximately one-third of
cases reported as borderline tumours on frozen sec on are later
reclassified as invasive tumours. For the older women with no
fer lity concerns, if frozen sec on is reported as a borderline
tumour then complete staging should be undertaken. See Bagade P,
Edmondson R, Nayar A. Management of borderline ovarian
tumours. The Obstetrician & Gynaecologist 2012;14:115–20
(h p://onlinelibrary.wiley.com/doi/10.1111/j.1744-
4667.2012.00102.x/abstract).

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A 63-year-old woman with a history of postmenopausal bleeding returns to

Q the gynaecology clinic. Recent endometrial biopsy shows complex
hyperplasia without atypia. She wants to know what the risk is of these
abnormal cells progressing to cancer. What is the risk of her complex
hyperplasia progressing to endometrial cancer over 10 years?

A Your answer:
> 4% 
Correct answer:
> 4%
The correct answer is 4%. It is important to be able to counsel
pa ents appropriately regarding their risk of malignancy and not to
confuse complex hyperplasia with complex atypical hyperplasia. See
Palmer JE, Perunovic B, Tidy JA. Endometrial hyperplasia. The
Obstetrician & Gynaecologist 2008;10:211–6
(h p://onlinelibrary.wiley.com/doi/10.1576/toag.10.4.211.27436/a
bstract).

Royal College of Obstetricians and Gynaecologists

© 2018

Registered charity no. 213280

27 Sussex Place
Regent's Park
London NW1 4RG
UK

Tel +44 20 7772 6200

Fax +44 20 7723 0575

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11/21/2018 Gynaecology page 4 | StratOG

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11/21/2018 Gynaecology page 5 | StratOG

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Progress 72% complete

Gynaecology page 5
Assessment Total A empts: 2 Highest Score: 100 %
History
View last results (/quiz/latest/305554/299350) View highest
result (/quiz/highest/305554/299350) Retake quiz
(/quiz/retake/299350)

A 36-year-old parous woman was diagnosed with stage 3 endometriosis. She was
Q on GnRH (gonadotrophin releasing hormone) analogue for 12 months.
Subsequently she had laparoscopic excision of recto-vaginal endometriosis. She
con nues to be in pain despite medical and surgical management. What is the
next most appropriate management op on for her?

Aromatase inhibitors
Danazol

Long term GnRH

Progesterone only pills
Tibolone

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A 51-year-old woman a ends your clinic with history of severe vasomotor

Q symptoms (hot flushes, night sweats). She has a family history of breast cancer and
would like to avoid hormone replacement therapy (HRT). Which non-hormonal
medica on is most likely to control her symptoms?

Citalopram

Metaprolol
Nifedipine

Phentolamine
Venlafaxine

A 26-year-old woman has been admi ed with late onset severe ovarian
Q hypers mula on syndrome (OHSS) 10 days a er embryo transfer in an IVF cycle.
She reports generalised abdominal pain and sickness for 2 days. Abdominal
examina on revealed significant ascites, whilst abdominal ultrasound showed
bilateral enlarged ovaries with a maximal diameter of 10 cm. Which of the
following combina on of blood results is commonly observed on admission?

Haematocrit decreased, fibrinogen increased, albumin increased

Haematocrit increased, fibrinogen decreased, albumin decreased

Haematocrit increased, fibrinogen decreased, albumin increased

Haematocrit increased, fibrinogen increased, albumin decreased

Haematocrit increased, fibrinogen increased, albumin increased

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A 48-year-old woman undergoes a total abdominal hysterectomy and bilateral

Q salpingo-oophrectomy and omental biopsy for an ovarian tumour. Pathology
confirms a serous borderline ovarian tumour. Which of the following is a feature of
borderline ovarian tumours?

Absence of stromal invasion

Complex histological architecture

Mito c figures

Peritoneal implants

Raised serum CA125

A 23-year-old woman undergoes laparoscopic cystectomy of a right

Q endometrioma, densely adherent to the pelvic side wall. She is discharged home
soon a er the surgery but presents 36 hours later with right flank pain. Which
inves ga on would you arrange to confirm and locate any ureteric injury?

Computerised tomography intravenous urogram

Magne c resonance imaging

Renogram

Transurethral cystoscopy and sten ng

Ultrasonography

A 24-year-old woman in her first pregnancy a ends the antenatal clinic. Her
Q community midwife has referred her to a Consultant clinic as she disclosed having
had female genital mu la on (FGM) at 8 years of age. Which one of the following
countries is this woman LEAST likely to originate from?
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Egypt

Eritrea

Nigeria

Somalia
Sudan

Your consultant asks you to prescribe a 3 month course of ulipristal acetate to a

Q woman with fibroids prior to having a hysterectomy. To which class of drugs does
ulipristal acetate belong?

Aromatase inhibitor

Gonadotrophin releasing hormone (GnRH) antagonist

Progestogen antagonist

Prostaglandin

Selec ve estrogen receptor modulator (SERM)

A 15-year-old girl a ends sexual health clinic reques ng termina on of pregnancy.

Q She is 7 weeks pregnant. Her boyfriend is also 15-years-old and studies in the
same school. She has not informed anyone of this pregnancy. What is your most
likely immediate ac on?

Encourage her to inform her parents

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Inform specialist youth worker

Inform the GP

Inform the school head teacher

Reject the request without parental consent

A 25-year-old woman develops a wound infec on a er a straight forward elec ve

Q subtotal hysterectomy. What is the single most likely causa ve organism?

Escherichia coli

Haemophilus influenzae

Methicillin resistant Staphylococcal aureus

Staphylococcal aureus

Streptococcus milleri

A 37-year-old woman is undergoing a diagnos c laparoscopy for inves ga on of

Q pelvic pain. Following inser on of the laparoscope through the umbilical port you
find bowel adherent to the anterior abdominal wall in the midline. You are worried
that bowel may be adherent under the umbilicus. What is the recommended
course of ac on?

Con nue with procedure as Palmer’s test was normal

Convert to laparotomy

Remove port and reinsert at Palmer’s point

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Seek surgical advice

Visualise the primary trocar site from a secondary port site

This is the last ques on of this quiz. Press finish to submit your choice(s) and reveal the answer(s).

Royal College of Obstetricians and Gynaecologists

© 2018

Registered charity no. 213280

27 Sussex Place
Regent's Park
London NW1 4RG
UK

Tel +44 20 7772 6200

Fax +44 20 7723 0575

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A 36-year-old parous woman was diagnosed with stage 3 endometriosis.

Q She was on GnRH (gonadotrophin releasing hormone) analogue for 12
months. Subsequently she had laparoscopic excision of recto-vaginal
endometriosis. She con nues to be in pain despite medical and surgical
management. What is the next most appropriate management op on for
her?

A Your answer:
> Aromatase inhibitors 
Correct answer:
> Aromatase inhibitors

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The correct answer is aromatase inhibitors. Aromatase inhibitors are

recommended in women with rectovaginal endometriosis which is
refractory to medical or surgical treatment. It can be prescribed in
combina on with hormones or GnRH analogues. See Dunselman
GAJ, Vermeulen N, Becker C, Calhaz-Jorge C, D’Hooghe T, De Bie B.
ESHRE guideline: management of women with endometriosis. Hum
Reprod 2014;29:400–12
(h p://humrep.oxfordjournals.org/content/early/2014/01/15/humr
ep.det457.full.pdf+html).

A 51-year-old woman a ends your clinic with history of severe vasomotor

Q symptoms (hot flushes, night sweats). She has a family history of breast
cancer and would like to avoid hormone replacement therapy (HRT). Which
non-hormonal medica on is most likely to control her symptoms?

A Your answer:
> Venlafaxine 
Correct answer:
> Venlafaxine
The correct answer is Venlafaxine. Selec ve serotonin and
noradrenaline reuptake inhibitors are the drugs used most
commonly to alleviate vasomotor symptoms. The most convincing
data relates to venlafaxine, although this was a short study. See
Royal College of Obstetricians and Gynaecologists. Alterna ves to
HRT for the management of symptoms of the menopause. Scien fic
Impact Paper 6. London: RCOG; 2010
(h ps://www.rcog.org.uk/en/guidelines-research-
services/guidelines/sip6/).

A 26-year-old woman has been admi ed with late onset severe ovarian
Q hypers mula on syndrome (OHSS) 10 days a er embryo transfer in an IVF
cycle. She reports generalised abdominal pain and sickness for 2 days.
Abdominal examina on revealed significant ascites, whilst abdominal

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ultrasound showed bilateral enlarged ovaries with a maximal diameter of

10 cm. Which of the following combina on of blood results is commonly
observed on admission?

A Your answer:
> Haematocrit increased, fibrinogen increased, albumin decreased 
Correct answer:
> Haematocrit increased, fibrinogen increased, albumin decreased
The correct answer is haematocrit increased, fibrinogen increased,
albumin decreased. Severe OHSS is usually associated with an
increased capillary permeability resul ng in a reduc on of
intravascular volume and haemoconcentra on (increase
haematocrit), and a shi of fluid into the third compartment (a
reduc on of serum albumin concentra ons). The woman is at risk of
developing thrombosis (increase fibrinogen levels). See Prakash A,
Mathur R. Ovarian hypers mula on syndrome. The Obstetrician &
Gynaecologist 2013;15:31–5
(h p://onlinelibrary.wiley.com/doi/10.1111/j.1744-
4667.2012.00153.x/abstract).

A 48-year-old woman undergoes a total abdominal hysterectomy and

Q bilateral salpingo-oophrectomy and omental biopsy for an ovarian tumour.
Pathology confirms a serous borderline ovarian tumour. Which of the
following is a feature of borderline ovarian tumours?

A Your answer:
> Absence of stromal invasion 
Correct answer:
> Absence of stromal invasion
The correct asnwer is absence of stromal invasion. Borderline
tumours are o en found following primary surgery in younger
women. They show higher prolifera ve ac vity than benign
tumours, but do not show stromal invasion. They cons tute 10–15%
of ovarian neoplasms. Serous borderline tumours are the most
common and are o en (30%) bilateral. See Bagade P, Edmondson R,
Nayar A. Management of borderline ovarian tumours. The

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Obstetrician & Gynaecologist 2012;14:115–20

(h p://onlinelibrary.wiley.com/doi/10.1111/j.1744-
4667.2012.00102.x/abstract).

A 23-year-old woman undergoes laparoscopic cystectomy of a right

Q endometrioma, densely adherent to the pelvic side wall. She is discharged
home soon a er the surgery but presents 36 hours later with right flank
pain. Which inves ga on would you arrange to confirm and locate any
ureteric injury?

A Your answer:
> Computerised tomography intravenous urogram 
Correct answer:
> Computerised tomography intravenous urogram
The correct answer is computerised tomography intravenous
urogram. Endometriosis increases the risk of injury to the urinary
tract. An acute injury usually presents within 48 hours with diffuse
abdominal pain, distension and ileus. The chemical peritoni s has
more subtle symptoms compared with peritoni s secondary to
faeces or infec on. A CT scan with contrast will usually demonstrate
a uroperitoneum and may show direct evidence of the injury. MRI is
useful in late presenta ons where a fistula is suspected. See Minas
V, Gul N, Aust T, Doyle M, Rowlands D. Urinary tract injuries in
laparoscopic gynaecological surgery; preven on, recogni on and
management. The Obstetrician & Gynaecologist 2014;16:19–28
(h p://onlinelibrary.wiley.com/doi/10.1111/tog.12073/full).

A 24-year-old woman in her first pregnancy a ends the antenatal clinic. Her
Q community midwife has referred her to a Consultant clinic as she disclosed
having had female genital mu la on (FGM) at 8 years of age. Which one of
the following countries is this woman LEAST likely to originate from?

A Your answer:
> Nigeria 
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Correct answer:
> Nigeria
The correct answer is Nigeria. The prevalence of FGM varies by
country. The type of FGM also varies and the more severe types are
commonest in Somalia. Somalia has the highest incidence at 98–
100% of girls and this is usually type III. Royal College of
Obstetricians and Gynaecologists. Female genital mu la on and its
management. Green-top Guideline 53. London: RCOG; 2009
(h ps://www.rcog.org.uk/en/guidelines-research-
services/guidelines/gtg53/).

Your consultant asks you to prescribe a 3 month course of ulipristal acetate

Q to a woman with fibroids prior to having a hysterectomy. To which class of
drugs does ulipristal acetate belong?

A Your answer:
> Progestogen antagonist 
Correct answer:
> Progestogen antagonist
The correct answer is progestogen antagonist. Ulipristal acetate has
been used as a drug for emergency contracep on. It has recently
been licensed for use in reducing the size of fibroids prior to surgery
and it does this by inducing apoptosis in the cells. See the Bri sh
Na onal Formulary
(h ps://www.medicinescomplete.com/about/)for more details.

A 15-year-old girl a ends sexual health clinic reques ng termina on of

Q pregnancy. She is 7 weeks pregnant. Her boyfriend is also 15-years-old and
studies in the same school. She has not informed anyone of this pregnancy.
What is your most likely immediate ac on?

A Your answer:
> Encourage her to inform her parents 
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Correct answer:
> Encourage her to inform her parents
The correct answer is encourage her to inform her parents. Fraser
guidelines relate to a case in 1984 – Gillick v West Norfolk – and
provide a framework for dealing with children under the age of 16.
It revolves around whether a child is capable of making a reasonable
assessment of the advantages and disadvantages of treatment and
thus their ability to consent to treatment. In his guidance Fraser
stated that a doctor could prescribe contracep ves "provided he is
sa sfied in the following criteria:
1. That the girl (although under the age of 16 years of age) will
understand his advice
2. That he cannot persuade her to inform her parents or to allow
him to inform the parents that she is seeking contracep ve
advice
3. That she is very likely to con nue having sexual intercourse with
or without contracep ve treatment
4. That unless she receives contracep ve advice or treatment her
physical or mental health, or both, are likely to suffer
5. That her best interests require him to give her contracep ve
advice, treatment, or both, without the parental consent."
The same guidelines relate to termina on of pregnancy. See Royal
College of Obstetricians and Gynaecologists. The care of women
reques ng induced abor on. Evidence-based Clinical Guideline 7.
London: RCOG; 2011 (h ps://www.rcog.org.uk/en/guidelines-
research-services/guidelines/the-care-of-women-reques ng-
induced-abor on/).

A 25-year-old woman develops a wound infec on a er a straight forward

Q elec ve subtotal hysterectomy. What is the single most likely causa ve
organism?

A Your answer:
> Staphylococcal aureus 
Correct answer:
> Staphylococcal aureus

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The correct answer is Staphylococcal aureus. All wounds are

colonised with bacteria. This does not mean all wounds will become
infected. If there is an infec on it is likely to be from skin flora which
have colonised the wound and thus Staphylococcal aureus is the
most likely bacteria.

A 37-year-old woman is undergoing a diagnos c laparoscopy for

Q inves ga on of pelvic pain. Following inser on of the laparoscope through
the umbilical port you find bowel adherent to the anterior abdominal wall
in the midline. You are worried that bowel may be adherent under the
umbilicus. What is the recommended course of ac on?

A Your answer:
> Visualise the primary trocar site from a secondary port site 
Correct answer:
> Visualise the primary trocar site from a secondary port site
The correct answer is visualise the primary trocar site from a
secondary port site. If there are adhesions within the abdomen it is
advisable to check the umbilical port by inspec ng it through a
preferably 5 mm scope via a secondary port. If damage has occurred
seek surgical advice. See Royal College of Obstetricians and
Gynaecologists. Preven ng entry-related gynaecological
laparoscopic injuries. Green-top Guideline 49. London: RCOG; 2008.
(h ps://www.rcog.org.uk/en/guidelines-research-
services/guidelines/gtg49/)

Royal College of Obstetricians and Gynaecologists

© 2018

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Registered charity no. 213280

27 Sussex Place
Regent's Park
London NW1 4RG
UK

Tel +44 20 7772 6200

Fax +44 20 7723 0575

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11/21/2018 Gynaecology page 6 | StratOG

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A 23-year-old woman has been referred to the gynaecology clinic by her GP a er

Q being on the combined oral contracep ve pill (COCP) for 3 months. She has been
on 20 micrograms of ethinyl oestradiol and 150 micrograms of desogestrel. She is
experiencing irregular vaginal bleeding, which is interfering with her lifestyle. She
has been taking the pills as prescribed and has not missed a dose. The pregnancy
test in the clinic is nega ve. She reports no symptoms of abdominal pain. A
cervical smear was performed 5 months ago and was normal. What is the best
management op on?

Add extra progesterone cover for 5 days per month during the pill-free
interval
Advise that this is normal and review in a further 3 months
Change to a COCP with 30 micrograms of ethinyl estradiol and reassess
a er 3 months
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Change to a progesterone-only formula on and reassess a er 3 months

Stop the pill and monitor her symptoms before trying alterna ve hormonal
contracep on

A medical student asks for clarifica on on the relevance of the following

Q documenta on from an examina on of a woman with prolapse:
> Aa: 0; Ba: 0; C: -3; D: -4; Bp: -5; Ap: -3
Which of the following is a standard quan fying tool for the measurement of
pelvic organ prolapse?

AFS score

Baden–Walker halfway scoring system

Bristol Female Lower Urinary Tract Symptoms (BFLUTS) ques onnaire

King's College Health Ques onnaire (KHQ)

Pelvic Organ Prolapse Quan fica on System (POP–Q)

A 32-year-old woman had normal vaginal delivery 6 months ago. She complains of
Q stress urinary incon nence on coughing and sneezing. Abdominal and pelvic
examina ons were unremarkable and stress incon nence was demonstrable.
What is the most appropriate strategy to manage her stress incon nence?

No ac on required as symptoms are likely to improve with me

Pelvic floor muscle training

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Ring pessary

Tension-free vaginal tape

Urodynamics

A 65-year-old woman is referred to the gynaecology outpa ent department with

Q le -sided lower abdominal discomfort. A bimanual examina on reveals discomfort
in her le iliac fossa. She is concerned that she may have ovarian cancer. What is
the most appropriate radiological inves ga on for this woman?

Colour flow Doppler

Computed tomography

Magne c resonance imaging

Positron emission tomography

Transvaginal ultrasound

A 30-year-old woman was diagnosed with polycys c ovary syndrome presents with
Q primary subfer lity of 4 years. Her BMI is 20. Her partner’s semen analysis is
sa sfactory (WHO criteria 2010). Hysterosalpingography has confirmed bilateral
tubal patency. What is the most appropriate first-line treatment for this couple?

In vitro fer liza on (IVF)

Intracytoplasmic sperm injec on (ICSI)

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Intrauterine insemina on (IUI)

Ovula on induc on with clomifene citrate

Ovula on induc on with gonadotrophins and intrauterine insemina on

A group of trainees are preparing a tutorial session on laparoscopic

Q hysterectomies. They plan to review the risks of urinary tract damage associated
with laparoscopic hysterectomy in order to provide informa on about the risks
and diagnosis of urinary tract injury. What important informa on as part of the
tutorial needs to be included:

Damage to the ureter at the vesico–ureteric junc on is the most common

urinary tract injury

MRI is subop mal to diagnose vesico–vaginal fistula because of poor ssue

contrast in the area

The most common site of bladder injury is in the midline above the
interureteric bar
Thermal injuries usually present within 72 hours with uroperitoneum or
vesico–vaginal fistula

Trauma c bladder injury is prevented by catheterisa on

An ST3 is asked to review a previously fit woman. She is 6 hours postopera ve

Q following a laparoscopic hysterectomy. She looks pale and is confused and
agitated. Her pulse is 120 beats per minute, respiratory rate is 40 breaths per
minute and her blood pressure is 60/40 mmHg. She has a urine output of 5 ml per
hour. Her weight is 70 kg. Approximately what percentage of her blood volume has
she lost?

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10–15%

20–25%

30–35%

40–45%

50–55%

A 52-year-old postmenopausal woman wishes to discuss the op on of hormone

Q replacement therapy (HRT). She is par cularly concerned about the risk of breast
cancer. Which study focuses mainly on the risk of breast cancer associated with
HRT?

The Cochrane Collabora on Systema c Review 2012

The Heart and Estrogen/Proges n Replacement Study (HERS) I & II

The Million Women Study

The Women's Health Ini a ve Study

The Women's Hormone Interven on Secondary Preven on Study

A 57-year-old postmenopausal women is referred by her GP following the

Q incidental finding of an endometrial polyp on a transvaginal scan during the
inves ga on of lower abdominal pain. She is otherwise asymptoma c. What is the
incidence of atypical hyperplasia in this case?

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0.6%

1.2%

2%

3.1%

4.3%

A 28-year-old nulliparous woman presents with symptoms of overac ve bladder

Q (OAB) with urgency urinary incon nence. Her urinalysis is nega ve and a bladder
diary shows a day me frequency of 12–14 and a nocturnal frequency of of 2. She
is very concerned as it affects her quality of life. What is the prevalence of OAB in
adult females?

5–8%

9–12%

13–16%
17–20%

21–24%

This is the last ques on of this quiz. Press finish to submit your choice(s) and reveal the answer(s).

Royal College of Obstetricians and Gynaecologists

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© 2018

Registered charity no. 213280

27 Sussex Place
Regent's Park
London NW1 4RG
UK

Tel +44 20 7772 6200

Fax +44 20 7723 0575

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A 23-year-old woman has been referred to the gynaecology clinic by her GP

Q a er being on the combined oral contracep ve pill (COCP) for 3 months.
She has been on 20 micrograms of ethinyl oestradiol and 150 micrograms
of desogestrel. She is experiencing irregular vaginal bleeding, which is
interfering with her lifestyle. She has been taking the pills as prescribed and
has not missed a dose. The pregnancy test in the clinic is nega ve. She
reports no symptoms of abdominal pain. A cervical smear was performed 5
months ago and was normal. What is the best management op on?

A Your answer:
> Advise that this is normal and review in a further 3 months 
Correct answer:
> Advise that this is normal and review in a further 3 months
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The answer is to advise that this is normal and review in a further 3

months.

Faculty of Sexual and Reproduc ve Healthcare. Problema c Bleeding With

Contracep ves. London: FSRH; 2015.
(h p://www.fsrh.org/pdfs/CEUGuidanceProblema cBleedingHormonalCon

A medical student asks for clarifica on on the relevance of the following

Q documenta on from an examina on of a woman with prolapse:
> Aa: 0; Ba: 0; C: -3; D: -4; Bp: -5; Ap: -3
Which of the following is a standard quan fying tool for the measurement
of pelvic organ prolapse?

A Your answer:
> Pelvic Organ Prolapse Quan fica on System (POP–Q) 
Correct answer:
> Pelvic Organ Prolapse Quan fica on System (POP–Q)
The answer is POP-Q.

Royal College of Obstetricians and Gynaecologists; Bri sh Society

of Urogynaecology. Post-Hysterectomy Vaginal Vault Prolapse.
GTG 46. RCOG/BSUG; 2015.
(h ps://www.rcog.org.uk/en/guidelines-research-
services/guidelines/gtg46/)

A 32-year-old woman had normal vaginal delivery 6 months ago. She

Q complains of stress urinary incon nence on coughing and sneezing.
Abdominal and pelvic examina ons were unremarkable and stress
incon nence was demonstrable. What is the most appropriate strategy to
manage her stress incon nence?
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A Your answer:
> Pelvic floor muscle training 
Correct answer:
> Pelvic floor muscle training
The answer is pelvic floor muscle training. You should offer a trial of
supervised pelvic floor muscle training of at least 3 months'
dura on as first-line treatment to women with stress or mixed
urinary incon nence.

Na onal Ins tute for Health and Care Excellence. Urinary

Incon nence in Women: Management. CG171. NICE; 2013.
(h ps://www.nice.org.uk/guidance/cg171)

A 65-year-old woman is referred to the gynaecology outpa ent department

Q with le -sided lower abdominal discomfort. A bimanual examina on
reveals discomfort in her le iliac fossa. She is concerned that she may have
ovarian cancer. What is the most appropriate radiological inves ga on for
this woman?

A Your answer:
> Transvaginal ultrasound 
Correct answer:
> Transvaginal ultrasound
The answer is transvaginal ultrasound. Ultrasound is a well-
established test to assess postmenopausal cysts, achieving a
sensi vity of 89% and a specificity of 73%.

Royal College of Obstetricians and Gynaecologists. Ovarian Cysts

in Postmenopausal Women. GTG34. London: RCOG; 2003.
(h ps://www.rcog.org.uk/en/guidelines-research-
services/guidelines/gtg34/)

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A 30-year-old woman was diagnosed with polycys c ovary syndrome

Q presents with primary subfer lity of 4 years. Her BMI is 20. Her partner’s
semen analysis is sa sfactory (WHO criteria 2010). Hysterosalpingography
has confirmed bilateral tubal patency. What is the most appropriate first-
line treatment for this couple?

A Your answer:
> Ovula on induc on with clomifene citrate 
Correct answer:
> Ovula on induc on with clomifene citrate
The answer is ovula on induc on with clomifene citrate.

Na onal Ins tute for Health and Care Excellence. Fer lity
Problems: Assessment and Treatment. CG156. NICE; 2013.
(h ps://www.nice.org.uk/guidance/cg156)
Gorthi S, Balen A, Tang T. Current issues in ovula on
induc on. The Obstetrician & Gynaecologist 2012;14:188–96.
(h ps://stratog.rcog.org.uk/sites/default/files/Gorthi_et_al-
2012-The_Obstetrician_%26_Gynaecologist_5_0.pdf)

A group of trainees are preparing a tutorial session on laparoscopic

Q hysterectomies. They plan to review the risks of urinary tract damage
associated with laparoscopic hysterectomy in order to provide informa on
about the risks and diagnosis of urinary tract injury. What important
informa on as part of the tutorial needs to be included:

A Your answer:
> The most common site of bladder injury is in the midline above 
the interureteric bar

Correct answer:
> The most common site of bladder injury is in the midline above
the interureteric bar
The answer is that the most common site of bladder injury is in the
midline above the interureteric bar.

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Minas V, Gul N, Augt T, Doyle M, Rowlands D. Urinary tract

injuries in laparoscopic gynaecological surgery; preven on,
recogni on and management. The Obstetrician and
Gynaecologist 2014;16:19–28.
(h ps://stratog.rcog.org.uk/sites/default/files/Minas_et_al-
2014-The_Obstetrician_%26_Gynaecologist_1.pdf)

An ST3 is asked to review a previously fit woman. She is 6 hours

Q postopera ve following a laparoscopic hysterectomy. She looks pale and is
confused and agitated. Her pulse is 120 beats per minute, respiratory rate is
40 breaths per minute and her blood pressure is 60/40 mmHg. She has a
urine output of 5 ml per hour. Her weight is 70 kg. Approximately what
percentage of her blood volume has she lost?

A Your answer:
> 30–35% 
Correct answer:
> 30–35%
The answer is 30–35%.

Advanced Life Support Group. Managing Obstetric Emergencies

and Trauma: The MOET Course Manual. 3rd edi on. Cambridge:
Cambridge University Press; 2016.

A 52-year-old postmenopausal woman wishes to discuss the op on of

Q hormone replacement therapy (HRT). She is par cularly concerned about
the risk of breast cancer. Which study focuses mainly on the risk of breast
cancer associated with HRT?

A Your answer:
> The Million Women Study 
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Correct answer:
> The Million Women Study
The answer is The Million Women Study. Women aged 50–64 years
in the UK a ending the NHS breast screening programme were
invited to take part in this study, and this was subsequently followed
by the comple on of a ques onnaire. A significant increased risk of
breast cancer was seen in the women on combined HRT (estrogen
and progestogens) compared with estrogen only and bolone.

Bakour S, Williamson J. The latest evidence on using hormone

replacement therapy in menopause. The Obstetrician &
Gynaecologist 2015;17:20–8.
(h p://onlinelibrary.wiley.com/doi/10.1111/tog.12155/epdf)

A 57-year-old postmenopausal women is referred by her GP following the

Q incidental finding of an endometrial polyp on a transvaginal scan during the
inves ga on of lower abdominal pain. She is otherwise asymptoma c.
What is the incidence of atypical hyperplasia in this case?

A Your answer:
> 1.2% 
Correct answer:
> 1.2%
The answer is 1.2%.

O fy M, Fuller J, Ross J, Shaikh H, Johns J. Endometrial

pathology in the postmenopausal woman – an evidence based
approach to management. The Obstetrician & Gynaecologist
2015;17:29–38.
(h ps://stratog.rcog.org.uk/sites/default/files/O fy_et_al-2015-
The_Obstetrician_%26_Gynaecologist_1.pdf)

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A 28-year-old nulliparous woman presents with symptoms of overac ve

Q bladder (OAB) with urgency urinary incon nence. Her urinalysis is nega ve
and a bladder diary shows a day me frequency of 12–14 and a nocturnal
frequency of of 2. She is very concerned as it affects her quality of life.
What is the prevalence of OAB in adult females?

A Your answer:
> 13–16% 
Correct answer:
> 13–16%
The answer is 13–16%. See Iewin DE, Milson I, Hunskaar S, Reilley K,
Kopp Z, Herschorn S et al. Popula on-based survey of urinary
incon nence, overac ve bladder, and other lower urinary tract
symptoms in five countries: results of EPIC study. Eur Urol
2006;50:1306–14 [Abstract]
(h p://www.sciencedirect.com/science/ar cle/pii/S0302283806011
16X).

Royal College of Obstetricians and Gynaecologists

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Regent's Park
London NW1 4RG
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Tel +44 20 7772 6200

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