Q_Gynecology USMLE 2018 S_V

Gyne_1. Maternal physiology changes throughout pregnancy to cope with the additional demands of carrying a foetus. Which of the following changes best represents a normal pregnancy?

3. A 19-year-old woman in her frst pregnancy presents to the GUM clinic with an outbreak of primary herpes simplex infection on her labia. She is 33 weeks pregnant. What is the best advice regarding her herpes?

4. A 33-year-old woman presents to hospital with a 2-day history of itching on the soles of her feet and the palms of her hands. Her pregnancy has been straightforward and she has good fetal movements. Liver function tests reveal an alanine transaminase (ALT) of 64 IU/L and bile acids of 30 µmol/L. You suspect that she might have developed obstetric cholestasis. Which of the following bits of advice is true?

5. A 19-year-old woman is referred to your pre-conception clinic. She has SLE and wants to fall pregnant. She is currently not on any treatment and has no symptoms. As part of your general counselling you should talk about the risks associated with pregnancy. Which of the fllowing is not a particular risk to a woman with SLE?

6. A 24-year-old woman attends the antenatal clinic. She has had a glucose tolerance test which is abnormal. A diagnosis of gestational diabetes is mad The primary purpose of this appointment is to explain to her what gestational diabetes means to her and her baby. You explain to her that sugar control is important and there are specific glucose ranges that she should try to adhere to. Which of the following would be correct advice fr this woman?

7. A 24-year-old woman who is mv positive is in her first pregnancy. She is 39 weeks pregnant and is seen by you in the antenatal clinic. She has just transferred to your care, with no other previous antenatal car She reports that her pregnancy has been uncomplicate Her CD4 count is 180/mm3 and her viral load is 5500 copies/mL. She has come to fnd out what advice you have fr her delivery?

8. A 19-year-old woman is referred to your early pregnancy unit as she is having some vaginal bleeding. This is her frst pregnancy, she has regular menses and the date of her last menstrual period suggests she is 8 weeks gestation today. She is well apart from her bleeding and is naturally concerne A transvaginal ultrasound reveals an intrauterine gestational sac of 18 mm with a yolk sa What is the most likely explanation of these fndings?

9. A 50-year-old woman comes to your clinic with a 2-year history of no periods. Her GP has confrmed that her luteinizing hormone and fllicle-stimulating hormone levels are menopausal. Her night sweats and hot flushes are unbearable and are preventing her from going to work. She would like to start hormone replacement therapy (HRT) but is very worried about the side effects. Which of the following is incorrect?

10. A 24-year-old woman in her frst pregnancy presents to the labour ward in labour. She and her partner express an overwhelming desire to avoid a caesarean section. Her labour does not progress and after 9 hours her cervix is still only 3 cm dilate Unfortunately, the fetal heart slows to 60 beats and does not recover after 5 minutes. Your senior registrar explains the situation to the woman and recommends an immediate caesarean section. She refuses and her partner tells you to stop harassing them. You explain that their unborn child will die if this continues. What options do you have?

11. A quality improvement process that seeks to improve patient care and outcomes through systematic review of care against explicit criteria and the implementation of change. This is an accepted defnition of what?

12. A 39-year-old woman is seen in the gynaecology clinic having been diagnosed with polycystic ovarian syndrome (PCOS). She has lots of questions in particular about the associated long-term risks. Which of the fllowing is not a risk of PCOS?

13. A 54-year-old menopausal woman comes to your clinic desperate for hormone replacement therapy (HRT) as her vasomotor symptoms are very troubling. Her next door neighbour recently developed a deep vein thrombosis while on HRT. She is concerned about the risks of venous thromboembolism (VTE) and wants your advice. Which of the fllowing would you not advise?

14. A 19-year-old biochemistry student is seen in your clinic worried about her hormone levels. She has been told by her GP that her progesterone is low. You enter into a long discussion about the effects of progesterone on the body. Progesterone:?

15. A 19-year-old woman is giving birth to her first baby. She has been pushing for an hour and the feta] head has been on the perineum for 6 minutes. There seems to be a restriction due to resistance of her tissues. Her midwife carries out a right mediolateral episiotomy. Which of the following structures should not be cut with the episiotomy?

16. A mother comes to labour ward who is low risk, in labour at term. The unit is short staffed and there are not enough midwives to provide intermittent auscultation of the ftal heart. You decide to start continuous electronic monitoring (CTG). She is an epidemiologist and asks you about the CTG and how it will help her labour and prevent her baby suffering harm. Which of the following would you tell her? Continuous monitoring has a?

17. A 24-year-old woman is seen after her normal vaginal birth. The midwife who delivered the baby is concerned that there is a third degree tear. Having examined the woman the obstetrician confirms a third degree tear. The woman is taken to theatre to repair the external anal sphincter. Which of the following is not a risk factor for third degree tear?

18. A woman on the labour ward has just had a normal birth. At birth there was a lot of meconium present. The newborn did not respond initially but did after subsequent resuscitation. The midwife records the Apgar score as 5. Which of the following best describes the categories an Apgar score is created from?

19. A 16-year-old presents to the termination of pregnancy service 6 weeks into her second pregnancy requesting surgical termination (STOP). What is not required as part of her work-up fr the procedure?

20. A 19-year-old comes to you for some pre-conception advice. Some members of her fmily and her partner's fmily have a sickle cell anaemia. She reveals that her sister and his sister are both affecte Tests have shown that they are both carriers. What is the chance that if their child was a boy he would have sickle cell anaemia?

21. A 40-year-old woman comes to your clinic alone wanting an effective form of contraception. She has two children fom a previous marriage and has recently started a new relationship. She says that she does not want any frther children. She has regular heavy periods, no menopausal symptoms and she is otherwise well with no past medical history. A recent ultrasound showed a normal sized uterus and pipelle biopsy revealed normal secretory endometrial tissue. What is the most appropriate form of contraception?

22. A 42-year-old man undergoes semen analysis as part of the investigation of subfertility with his wife. What result would most likely contribute to their subfertility?

23. A woman is undergoing surgery to enhance the cosmetic appearance of her labia. A bleeding vessel is encountered at the labia majora which cannot be controlled through pressure alone. The surgeon believes it to be a branch of the posterior labial artery. The posterior labial artery is a branch of which artery?

24. A 54-year-old woman with a history of signifcant ischaemic heart disease undergoes vaginal hysterectomy fr symptomatic uterine prolapse. She develops signifcant surgical site bleeding which is repaired at reoperation the same day. Her postoperative haemoglobin is 6.4 g/dL. Later the same day she develops chest pain. Her observations, blood gas and cardiac enzymes are within normal limits. An electrocardiogram (ECG) shows sinus rhythm without ST changes. She is charted for thromboprophylaxis. What is the most likely cause of the chest pain?

25. A 74-year-old woman has an annual health check up with her private insurer. They arrange an ultrasound scan that shows a cyst on her right ovary. It is multiloculated and has solid components. She is post-menopausal and otherwise well. A doctor has sent fr a CA 125 which comes back as 120 U/mL. What is her risk of malignancy index score (RMI)?

26. A 60-year-old woman is undergoing abdominal hysterectomy fr a fibroid uterus. During suture ligation of the right uterine pedicle, iatrogenic injury to the ureter is confirmed. Which of the following statements is correct?

27. A 21-year-old woman with dysmenorrhorea, dyspareunia and dyschezia has been scheduled fr a laparoscopy to investigate possible endometriosis. You are asking fr her consent and you describe the risks of laparoscopy, which include bleeding and damage to blood vessels, viscera and nerves. Which of the following is not at risk when inserting a lateral port?

28. A 32-year-old female has a 5-year-old child with cystic fibrosis by her ex-husband. She has remarried and wants more children. She wants to know the risk of her and the new (Caucasian) husband having an affected child. What is the risk?

29. A 3-day-old neonate is noted by ward staff to have had a seizure. Which of the following statements concerning neonatal convulsions is correct?

31. A 30-year-old lady attends clinic for advice concerning her future cancer risk. She has been appropriately treated for CIN II. She is an ex-smoker and takes the combined oral contraceptive pill. Two of her paternal aunts died of ovarian carcinoma at the ages of 40 and 48. Which of the following is the most important predisposing factor to ovarian cancer in this patient?

Diag_1. A nulliparous woman is seen at the antenatal clinic 27 weeks into her first pregnancy. Routine screening with a 75 g oral glucose tolerance test for gestational diabetes mellitus (GDM) is performed. Which of the following would confirm a diagnosis of GDM?

2. A 34-year-old woman attends antenatal clinic fr a routine ultrasound scan. Abnormalities of placentation are detected and a magnetic resonance imaging (MRI) scan is organized by the fetal medicine consultant. The MRI report shows: 'The placenta is in the lower anterior uterine wall with evidence of invasion to the posterior wall of the bladder'. What is the most likely diagnosis?

3. A 21-year-old woman attends the labour ward with per vaginal bleeding of 100 mL. She is 32 weeks pregnant and has had one normal delivery in the past. An important history to note is that of an antepartum haemorrhage in her last pregnancy and she smokes 10 cigarettes a day. Her 20-week anomaly ultrasound revealed a posterior fundal placenta. She admits she and her partner had intercourse last night and is concerned by terrible abdominal pains. What is the most likely diagnosis?

4. A 38-year-old woman in her frst pregnancy is 36 weeks pregnant. She presents to the labour ward feeling dizzy with a mild headache and flashing lights. Her past medical history includes systemic lupus erythematosus (SLE), renal stones and malaria. Her blood pressure is 158/99 mmHg with 2+ protein in her urine. Her platelets are 55 x 109/L, Hb 10.1 g/dL, bilirubin 62 µmol/L, ALT 359 IU/L, urea 2.3 mmol/L and creatinine 64 µmol/L. What is the most likely diagnosis?

5. A 24-year-old woman who is 32 weeks pregnant presents to the labour ward with a terrible headache that has not improved despite analgesic. It started 2 days ago and came on suddenly. She has stayed in bed as it hurts to be in sunlight and she vomited twice this morning. Her past medical history includes a macroprolactinoma (which has been removed) and occasional migraines. She is haemodynamically stable with no focal neurology or papilledema. You arrange for her to have a CT of her head as an emergency, which adds no further infrmation to aid your diagnosis. There are red cells on lumbar puncture but no organisms are isolate What is the most likely diagnosis?

6. A 44-year-old women who is 18 weeks pregnant presents to your clinic with a 2-day history of a viral illness. She is extremely anxious and is in floods of tears. She recently had some soft cheese in a restaurant and after an internet search she is convinced she has a particular infection. What infction is she concerned about?

7. A 26-year-old woman is 37 weeks pregnant and consults you about a rash that started on her abdomen and has now spread all over her body. Interestingly her umbilicus is spare The rash is very itchy and nothing is helping. The rash is her frst problem in this pregnancy. Of interest, her mother has pemphigoid and her sister has psoriasis. What is the most likely cause of her rash?

8. A 42-year-old woman is in her first pregnancy. She conceived with in vitro fertilization (IVF) and has had a straightfrward pregnancy so fr. At 25 weeks' gestation she is seen in clinic with a blood pressure of 142/94 mmHg and protein + in her urine. A protein creatinine ratio (PCR) comes back as 19. She says that her blood pressure is often up at the doctor's. With the information you have to hand what is the most likely diagnosis?

9. A 24-year-old woman attends accident and emergency 4 weeks after having a positive urinary pregnancy test. She has had 3 days of painless vaginal bleeding and is passing clots. Over the past 2 days the bleeding has settle. An ultrasound scan shows an empty uterus. What is the correct diagnosis?

10. An 18-year-old woman presents to accident and emergency having fainted at work. She is complaining of pain in the lower abdomen. A serum beta hCG perfrmed in the emergency department is 3020 mlU/mL. The on-call gynaecologist performs transvaginal ultrasonography in the resuscitation area which shows free fluid in the Pouch of Douglas and no visible intrauterine pregnancy. Her pulse is 120 bpm and blood pressure 90/45 mmHg. What is the most likely diagnosis?

11. A 26-year-old woman presents to accident and emergency with left-sided lower abdominal pain and a single episode of vaginal spotting the day befre. A urinary beta hCG is positive, and her last period was 6 weeks ago. A transvaginal ultrasound shows two gestational sacs. What is the most likely diagnosis?

12. A 59-year-old woman attends the gynaecology clinic complaining of worsening pain during penetrative sexual intercourse. She went through the menopause 9 years before, with very few problems, and did not require hormone replacement therapy (HRT). She has been with the same partner for 4 years since the death of her husband with whom she had four children. What is the most likely diagnosis?

13. A 19-year-old woman is referred to accident and emergency with a fluctuant lower right abdominal pain which started over the course of the morning, associated with vomiting. There is rebound tenderness on examination. She is afebrile. Serum beta human chorionic gonadotrophin (hCG) is negative. An ultrasound shows free fluid in the peritoneal cavity but no other pathology to account fr the pain. White cells are 14 * 109/L and the C-reative protein (CRP) is 184 mg/L. What is the most likely diagnosis?

14. A 38-year-old nulliparous woman has had an uncomplicated pregnancy. She has laboured very quickly and is 10 cm dilate The fetal heart falls to 60 fr 4 minutes. She is pushing effectively and the head is 1 cm below the ischial spines. You prepare for forceps delivery in the room. She has had no analgesia so you quickly insert a pudendal nerve block and deliver the baby 4 minutes later in good condition. Which of the following is not a branch of the pudendal nerve?

15. A 39-year-old woman is 6 days post-partum and has come back to hospital with shortness of breath. She is struggling to breath at rest, has a respiratory rate of 28, pulse 115, BP 105/60 mmHg, temperature 37.4 On examination she has an audible wheeze and cough. Investigations reveal a P02 of 9.5 kPa on arterial blood gas and a PC02 3.7 kPa, pH 7.36, base excess -3.4. A chest x-ray shows some upper lobe diversion and bilateral diffuse shadowing with an enlarged heart. Her haemoglobin is 8.9 g/dL, white blood count 11.1 x 109/L and C-reactive protein 21 mg/L. What is the most likely cause of her symptoms?

16. A 17-year-old girl is seen in accident and emergency 14 days after an emergency caesarean delivery of a healthy infnt, her frst. Her neighbours became concerned and called the polic She had been seen prostrate in the garden chanting verses from the Bible and shouted at them accusing them of being spies when they asked if she was ok. They say her problem has worsened over the past fortnight. What is the most likely diagnosis?

17. A 34-year-old woman develops a signifcant post-partum haemorrhage and hypotensive shock following vaginal delivery of a healthy infant at term. The labour was uncomplicated. She recovers well with volume replacement and oxytocin and returns to the post-natal war She is unable to breast fed on the ward and 2 months later has neither started breastfeeding nor resumed her periods and is increasingly fatigue What is the most likely diagnosis?

18. A 30-year-old French woman delivers a live female infant by spontaneous vaginal delivery at term. In the eleventh week of pregnancy she developed a flu-like illness which resolved spontaneously a week later. Her newborn child has severe hydrocephalus and chorioretinitis. Four days after birth, she develops severeconvulsions and efforts to revive her are unsuccessful. Which pathogen is most likely to be responsible?

19. A 32-year-old woman has a routine cervical smear at her GP practice The result returns as severe dyskaryosis. Following colposcopy and cervical biopsy, formal histological examination reveals cervical intraepithelial neoplasia 3 (CIN 3). Which of the following pathogens is the most likely to have caused this disease?

20. A 15-year-old girl attends the paediatric gynaecology clinic with primary amenorrhoea and features of secondary breast development. She has intermittent abdominal bloating and is extremely worried that she is 'not like other girls'. On speculum examination of the vagina, which is normal externally, a bulging red disc is seen 3 cm proximal to the introitus. What is the most likely diagnosis?

21. A 19-year-old woman undergoes surgical evacuation of the retained products of conception (ERPC). Histological examination of the sample shows genetically abnormal placenta with a mixture of large and small villi with scalloped outlines, trophoblastic hyperplasia. What is the most likely diagnosis?

22. A 16-year-old girl attends the gynaecology clinic complaining of vaginal itching and lumpy labia. On examination the area is covered with vulval warts. Which is the causative pathogen for vulval warts?

23. An 18-year-old woman attends clinic seeking contraceptive advice. She is currently using condoms only and is keen to start taking the combined oral contraceptive pill (COCP). Her sister used to take it but told her there were lots of problems with it. Her aunt has bowel cancer and she has no other past medical history. Appropriate counselling should cover all of the following except:?

24. A 41-year-old woman is about to undergo her frst cycle of IVF. As part of the consultation, she is counselled about the maternal and fetal risks involved with IVF-conceived pregnancies. All of the fllowing occur in such pregnancies except:?

25. A 35-year-old woman is seen in the assisted conception unit. She has been trying to conceive for 4 years. In this period she has been having regular intercourse. Her periods have been irregular and recently she has had no periods at all. Her BMI is 19.5 kg/m2, she has had an appendectomy and is otherwise well. Her biochemistry comes back as fllows: luteinizing hormone (LH) 0.5 IU/L, follicle-stimulating hormone (FSH) 1.0 IU/L, prolactin 490 mIU/L, thyroxine (T4) 12, thyroid stimulating hormone (TSH) 4.2 mIU/L, oestradiol 60 pmol/L. What is the most likely cause of her subfertility?

26. An 18-year-old girl is seen in the colposcopy clinic after having had persistent post-coital bleeding. She has been sexually active since the age of 14 and has no past medical history. She is studying for her A-levels and has been doing a lot of reading. She is concerned that she might have cervical cancer. Which of the following is not a risk fctor fr cervical cancer?

27. In a busy gynaecology clinic you are assessing a 22-year-old woman who has not had a period for 18 months. She is not pregnant and previously had regular periods. She has had two surgical terminations of pregnancies (STOP), an underactive thyroid gland and an appendectomy. Clinical examination is unremarkable with a BMI kg/m2 of 20. Biochemical investigations reveal a T4 of 17 pmol/L, TSH 4.6 kg/m2, prolactin of 570 mU/L, and testosterone of 42 ng/dL. LH and FSH are normal. Vaginal ultrasound shows a normal sized uterus and the left ovary contain four cysts. Which of the answers listed below is the most likely cause?

28. A 17-year-old girl comes to clinic with her mother as she has not started having periods yet and they are worried. On examination she is of short stature, with a slightly widened neck and has no secondary sexual characteristics and there is no obvious abnormality of the external genitale. What is the most likely diagnosis frm this limited infrmation?

29. A 22-year-old woman presents to the GUM clinic with an offensive smelling discharge. She is sexually active and is in a monogamous relationship. She describes no pain or soreness just an offensive smelling discharge. After examination and taking swabs for the second time she is diagnosed with bacterial vaginosis. Which of the fllowing organisms is not likely to be the cause?

30. A 58-year-old woman presents to the clinic with post-menopausal bleeding. A pipelle biopsy confrms adenocarcinoma of the endometrium. Further imaging of the pelvis shows that there is spread of the tumour outside of the uterus into the left adnexa. There is no other spread. What is the most likely stage of the tumour?

31. A 62-year-old woman presents to accident and emergency with shortness of breath. Examination reveals reduced breath sounds and a swollen, distended abdomen. Chest x-ray demonstrates a left-sided pleural effusion. On further questioning the woman has had a poor appetite for the last 6 months and recently had some vaginal bleeding. An ultrasound revealed large quantities of ascites, which were drained. Analysis of the ascites shows a high protein content. What is the most likely diagnosis?

32. Following surgery to place a tension-free transobturator tape for stress incontinence, a 54-yearold woman loses some sensation in part of her labia anterior to the anus. Damage has most likely been caused to which nerve?

33. Two days after undergoing posterior exenteration for recurrence of cervical adenocarcinoma a 53-year-old woman develops a tachypnoea, tachycardia of 125 bpm and a fever of 39° Blood cultures have grown methicillin-resistant Staphylococcus aureus (MRSA). She requires intravenous vasopressors. What is the most appropriate diagnosis?

34. A 39-year-old woman attends the gynaecology clinic complaining of long-standing pelvic pain. Routine bimanual examination and abdominal ultrasonography do not detect any abnormality. At diagnostic laparoscopy, multiple tiny dark brown nodular lesions are noted covering the surface of the uterus, tubes and left ovary, as well as in the Pouch of Douglas. Which fnding is most likely from histological examination of the excised lesions?

35. A 29-year-old female presents with dysuria and vaginal discharge which has deteriorated over the past week. She is in a steady relationship and uses the oral contraceptive pill. Her partner is asymptomatic. She has a temperature of 37.5° Vaginal examination reveals tenderness with an inflamed cervix and a purulent discharge, culture of which reveals Gram negative diplococci. What is the likely diagnosis?

36. A 40-year-old female solicitor attends her general practitioner's surgery and complains of postcoital bleeding of two months duration. She does not experience pain during intercourse and has not had any vaginal discharge other than the post-coital bleeding. She is still having regular periods. Which of the following is the most likely diagnosis in this case?

37. A 19-year-old female presents with heavy irregular menstrual bleeding and has a BMI of 35. Which of the following is the most likely diagnosis?

38. A 14-year-old white British girl presents with heavy, irregular menstrual bleeding. Her periods began 6 months ago and have never been regular. She is not sexually active, takes no medication, and is otherwise well. What is the most likely cause fr her menorrhagia?

39. An 18-year-old fmale presents with a fur-month history of secondary amenorrhoea fllowed by a week of intermittent light vaginal bleeding. She has gained approximately one stone in weight over this time. Which of the following is the likely diagnosis?

40. An 18-year-old girl presents with heavy irregular periods, postcoital bleeding and deep dyspareunia fr the last six months. Which of the following is the likely diagnosis?

41. A 19-year-old female presents with a four month history of secondary amenorrhoea. She has lost approximately 8 kg over this time and has a BMI of 17.4 kg/m2. Which of the following is the most likely diagnosis?

42. A 36-year-old Afro-Caribbean woman presents having suffered her furth miscarriage. She has a history of venous thrombosis. She is positive fr the lupus anticoagulant. What is the likely diagnosis?

43. A 35-year-old woman has had fur previous live births. Sixteen weeks into her ffth pregnancy she presents with diffuse lower abdominal pain. On examination she is tender in the suprapubic are She has a fundal height of 25 cm and there is a frm mass related to the uterus. She has urinary fequency but no dysuria. Only one fetal heart is heared. What is the most likely diagnosis?

Paraclinic_1. A nervous 42-year-old woman presents herself to your antenatal clinic very worried that she has missed the right time to have her combined test fr Down's syndrome screening. She is now 17 weeks pregnant and is very concerned about her ag You counsel her about the appropriate alternative, the quadruple test and arrange to have this don What assays make up the quadruple test?

2. A 29-year-old woman is seen at her booking visit and has blood taken fr screening. Which of these is the most appropriate set of booking tests?

3. A 37-year-old woman in her furth ongoing pregnancy presents to the labour ward at 34 weeks' gestation complaining of a sharp pain in her chest, worse on inspiration. An arterial blood gas shows: pH 7.51, P02 8.0 kPa, PC02 4.61 kPa, base excess 0.9. What is the most appropriate investigation?

4. A 32-year-old woman in her third pregnancy is 37 weeks pregnant and has an extended breech baby on ultrasound. After discussion in the antenatal clinic, which of the following is not an absolute contraindication to an external cephalic version (ECV)?

6. A 25-year-old woman in her frst pregnancy has a pathological CTG. Her cervix is 5 cm dilatated. Which of the following might increase the risk to the fetus if the doctor performed a fetal blood sample?

7. A 49-year-old comes to the urogynaecology clinic with a history of leaking urine fr the last year. There are associated stress symptoms and some urge symptoms. Interestingly she says that it seems to come from inside the vagina as well. She had a hysterectomy last year for endometrial cancer and had quite a prolonged recovery. She has a BMI of 30 kg/m2, does not smoke and is otherwise ft and well. You are suspicious that she might have a vesicovaginal fstula secondary to her operation. What is the most appropriate frst line investigation?

8. A 26-year-old woman is otherwise ft and well has been trying to conceive for over 2 years. On questioning she has regular periods and has been having regular intercourse. There are no abnormalities on clinical examination. What would be your frst line investigations for her subfertility?

10. A 21-year-old comes to the clinic with a history of intermenstrual bleeding for the last 6 weeks. She has regular periods and does not experience post-coital bleeding. She is not on the oral contraceptive pill and has no other past medical history. What is the most appropriate frst line investigation?

11. A 57-year-old woman has been referred by her GP under the 2-week suspected cancer referral approach with vaginal bleeding. She has been post-menopausal for the last 4 years and she has been taking Ellested. Duet to treat her vasomotor symptoms. Two weeks ago, after reading about the risks associated with hormone replacement therapy (HRT) she stopped taking any medication. This is the frst unscheduled bleeding she has ever ha She had a normal smear 2 years ago and is otherwise well. What would be your frst line investigation?

12. A 13-year-old girl presents with menorrhagia and is fund to have von Willebrand's disease. Which of the following coagulation parameters would be most expected to be abnormal?

14. A 60-year-old postmenopausal woman complains of recent onset of vaginal bleeding. She has a past history of diabetes mellitus fr which she takes metfrmin 500 mg b She underwent the menopause 10 years previously and took continuous combined HRT fr two years. Digital vaginal examination is normal. What is the single most appropriate frst line investigation fr this woman?

Emergency_1. A 24-year-old Jehovah's Witness is brought to accident and emergency with a Glasgow coma scale (GCS) score of 3, BP 90/30 mmHg and pulse 110 bpm. Her husband reports that her last menstrual period was 8 weeks ago and she complained this morning of lower abdominal pain and vaginal spotting. Ultrasonography suggests a ruptured ectopic pregnancy. As part of the resuscitative measures employed before emergency laparotomy, a transfusion of group 0- negative blood is prepared. Her husband interrupts and says that as a Jehovah's Witness she would absolutely refuse all blood products even at risk of death, and has previously signed an advance directive stating this. What is the most appropriate option?

2. An unbooked 26-week pregnant woman sees you at the hospital to request a termination of pregnancy. She says that if she leaves here today without a termination she will try and do it herself by stabbing her abdomen. Your consultant arranges an urgent psychiatric review which fnds no grounds under which to detain this woman in regards to her mental health. Under these circumstances, if a termination was performed, which part of the Abortion Act would it fall under?

3. A 46-year-old women in her ffth IVF cycle is admitted to the emergency department 4 days after egg collection. She is complaining of a swollen abdomen and shortness of breath. She is reviewed and a diagnosis of ovarian hyperstimulation syndrome (OHSS) is made. Which of the following is not a clinical feature/complication of OHSS?

4. A 19-year-old girl presents at the antenatal clinic. She is approximately six weeks pregnant and the pregnancy was unplanned. She has a two-year history of grand mal epilepsy fr which she takes carbamazepine. She has had no fts for approximately six months. She wants to continue with her pregnancy if it is safe to do so. She is worried about the anticonvulsant therapy and its effects on the baby. She asks how she should be managed. Which of the following management plans is the most appropriate in this case?

Management_1. A 33-year-old nulliparous woman is 29 weeks pregnant. She was referred to the rapid access breast clinic for investigation of a solitary breast lump. Sadly, a biopsy of this lump revealed a carcinoma. After much counselling from the oncologists and her obstetricians a decision is reached on her further treatment. What option below may be available to her?

2. A 38-year-old woman with type 2 diabetes attends the maternal medicine clinic. She has a body mass index (BMI) of 48 and is currently controlling her sugars with insulin. You have a long discussion about her weight. What should not be routinely offered to this woman?

3. Weeks showed Aof 30-year-old a minor, unprovoked nulliparous a low-lying painless placenta. Woman is 29 weeks vaginal Her ftus bleedis pregnant. Of moving well about aShe teaspoonful. Presented and continuous Her to hospital anomalywith scana at history 20 cardiotocography (CTG) is reassuring. What is the most appropriate management?

4. A 28-year-old pregnant woman attends accident and emergency with a history of clear vaginal loss. She is 18 weeks pregnant and so far has had no problems. Her past medical history includes a large cone biopsy of the cervix and she is allergic to penicillin. She is worried because the fluid continues to come and there is now some blood. On examination it is apparent that her membranes have rupture What is the most appropriate initial management?

5. A 32-year-old woman in her second pregnancy presents at 36 weeks gestation with a history of a passing gush of blood stained fluid from the vagina an hour ago, followed by a constant trickle since. The admitting obstetrician reviews her history and weekly antenatal ultrasound scans have shown a placenta praevia. What is the most appropriate management? She has a firm, posterior cervix and has not been experiencing any contractions?

6. A 30-year-old woman attends the antenatal clinic asking to be sterilized at the time of her elective caesarean. She is 34 weeks into her second pregnancy having had her frst child 2 years ago via an emergency caesarean section. She is not sure that she wants any more children. Furthermore, she does not wish to try fr a vaginal birth. She has tried the contraceptive pill in the past but does not like the side effects. You talk to her about other options, including the sterilization she is requesting. What is the best management option for this woman?

7. A 41-year-old multipara attends the antenatal clinic at 36 weeks gestation complaining of lower abdominal cramps and fatigue when mobilizing. Clinical examination is unremarkable save for a grade I pansystolic murmur, loudest over the furth intercostal space in the midaxillary line. What is the most appropriate management?

8. A 32-year-old HIV positive woman who booked fr antenatal care at 28 weeks gestation arrives on the delivery suite at 37 weeks with painfl regular contractions and a cervix dilated to 4 cm. Ultrasonography confrms a breech singleton pregnancy with a reactive fetal heart rat What is the most appropriate management option?

9. A 41-year-old multiparous woman attends accident and emergency at 32 weeks gestation complaining of sudden onset shortness of breath. A CTPA demonstrates a large saddle embolus. What is the most appropriate treatment regimen?

11. You are the FYI covering the antenatal war A 27-year-old nulliparous woman who is 36 weeks and 5 days pregnant has been admitted to your ward with suspected pre-eclampsia The emergency buzzer goes off in her room. You are the first to attend and find your patient flat on the bed having a generalized seizure what do you do?

12. A 19-year-old woman in her frst pregnancy is admitted to the labour ward with a 4-hour history of lower abdominal pain - she is 22 weeks pregnant. She has not had any vaginal bleeding but describes a possible history of rupture of her membranes. Her past medical history includes an appendectomy and a large cone biopsy of her cervix. On examination she has palpable lower abdominal tenderness, her cervix is 2 cm dilated, she has an offensive vaginal discharge and her temperature is 38.9° Her white cell count is 19.0 * 109/L and her C-reactive protein is 188 mg/L. There are no signs of cardiovascular compromise. How would you manage this woman?

13. A 24-year-old multiparous woman is 23 weeks pregnant. She has not had chicken pox before. She goes to a collect her 3-year-old son from a birthday party and comes into contact with a child with an infective chicken pox infection. She is naturally very anxious. What is the best course of management?

14. A 24-year-old type 1 diabetic woman has just had her frst baby delivered by caesarean section at 35 weeks due to fetal macrosomia and poor blood sugar control. The operation is straightforward with no complications. She has an insulin sliding scale running when you review her on the ward 12 hours postoperatively. She has begun to eat and drink. How would you manage her insulin requirements?

15. A 24-year-old woman in her frst pregnancy has a signifcantly raised glucose tolerance test at 28 weeks gestation: 4.6 fasting 12.1 at one hour 9.1 at 2 hours (µmol/L). She is given the diagnosis of GDM. You are asked to counsel her about the effects of gestational diabetes on pregnancy. Which of the following is not an additional effect of having GDM?

16. A 51-year-old woman in her 12th week of an assisted-conception triplet pregnancy presents to accident and emergency with severe nausea and vomiting. She has mild lower abdominal and back pains. Urine dipstick shows blood -ve, protein -ve, ketones ++++, glucose +. What is the most appropriate management plan?

17. A 31-year-old woman is seen in the termination of pregnancy (TOP) clinic requesting a termination. She is 5 weeks pregnant in her frst pregnancy. She is otherwise well but does have some lower abdominal pain on the right hand side. On examination her abdomen is soft and non-tender. An ultrasound reveals a small sac in the uterus which might be a pseudosac. What would be your next management step?

18. A 28-year-old woman with a history of pelvic inflammatory disease is 6 weeks into her third pregnancy. She previously had two terminations. She presents with lower abdominal pain and per virginal bleeding. Her beta hCG is 1650 mIU/mL, progesterone 11 nmol/1. An ultrasound reveals a small mass in her left fllopian tube with no intrauterine pregnancy seen. There is no free fluid in the Pouch of Douglas. She is diagnosed with an ectopic pregnancy and is clinically stable but scared of surgery. How would you manage this case?

19. A 24-year-old woman attends her GP complaining of deep dyspareunia and post-coital bleeding. She has crampy lower abdominal pain. Of note, she has been treated in the past fr gonorrhoea on more than one occasion. On speculum examination there is no visible discharge, but the cervix bleeds easily on contact. What is the most appropriate management?

20. A 24-year-old woman who is 9 weeks pregnant is brought to accident and emergency by ambulance with left iliac fossa pain and a small vaginal bleed. An abdominal ultrasound scan performed at the bedside demonstrates a corneal pregnancy and free fluid in the pelvis. Her observations are: pulse 119 bpm, blood pressure 74/40 mmHg, respiratory rate 24/minute. What is the most appropriate defnitive management?

21. A 32-year-old woman with paranoid schizophrenia is admitted for antenatal assessment at 36 weeks' gestation with twins. Her pregnancy is complicated by intrauterine growth restriction and impaired placental flow. She has had no psychotic symptoms in this pregnancy. Her obstetricians recommend an early caesarean section and argue it is in the best interests of the mother and her babies and to prevent further fetal insult. She has repeatedly said that despite the significant risks, which she understands, she refuses caesarean delivery. What is the most appropriate action?

22. A 16-year-old Muslim woman attends accident and emergency department with her father. She complains of a 1-day history of left iliac fssa pain and mild vaginal spotting. A urinary beta hCG test is positive. As part of your assessment the patient consents to a vaginal examination. She insists you do not tell her father that she is pregnant, and you consider her to be competent in her judgement. Her father becomes angry and says you must not perform a vaginal examination. How should you proceed?

23. A 32-year-old woman is rushed to accident and emergency as the viction of a high speed vehicle collision. She is 35 weeks pregnant and unconscious. There is evidence of blunt abdominal trauma and she is showing signs of grade 3 hypovolaemic shock. The consultant obstetrician on call immediately attends the resus call and recommends immediate perimortem caesarean delivery in a resuscitative effort to improve the management of her shock. Her husband has been brought into resus by the police, and insists that she would refuse caesarean section under any circumstances. What is the most appropriate management?

24. A 59-year-old woman has been admitted fr a hysterectomy fr endometrial cancer. She has not yet given her consent and the rest of the team is in theatre. You have perfrmed a hysterectomy befre so feel confdent in taking her through what will happen and the risks involve The General Medical Council (GMC) says that you should tailor your discussion to all of the options except which of the following?

25. A 15-year-old girl attends the gynaecology clinic with her boyfiend, also 15, requesting the morning after pill 4 months after being circumcised during a family trip to Somali She understands your advice and the implications of her decisions to engage in sexual activity, is using condoms regularly and refuses to inform her parents. What is the most appropriate management?

26. A 34-year-old woman with long-standing menorrhagia attends accident and emergency having fainted at home. She is on the third day of her period, which has been unusually heavy this month. She insists she cannot be pregnant as she has not had sexual intercourse fr a year. She is haemodynamically stable. A point-of care test venous full blood count in the emergency department shows: Hb 5.2 g/dL, WCC 8.9 .109/L, Hct 0.41% L, MCV 80 f. What should the initial management be?

27. A 66-year-old post-menopausal woman is referred to you urgently by her general practioner (GP). She had been complaining of some lower abdominal pain. An ultrasound arranged by the GP shows a 4 cm simple left ovarian cyst. A CA 125 comes back as 29 U/ml (normal 0-35 U/ml). What is the most appropriate management?

28. A 79-year-old woman attends your clinic with some vaginal bleeding. Her last period was 16 years ago. She has had two children both via caesarean section, has a normal smear history and is currently sexually active. On examination the vagina appears mildly atrophic with some raw areas near the cervix. What is the most important next step in her management?

29. At laparoscopy a 21-year-old woman is found to have severe endometriosis. There are multiple adhesions and both ovaries are adherent to the pelvic side wall. The sigmoid colon is adherent to a large rectovaginal nodule. The nodule is excised and the bowel and ovaries free Which of the following medications would be appropriate to help treat her endometriosis?

30. A 54-year-old woman comes to your clinic complaing of hot flushes and night sweats that are unbearable. Her last mentrual period was 14 months ago. She has had a levonorgestrel releasing intrauterine system (Mirena) in situ for 2 years as treatment for extremely heavy periods. What treatment would you consider for her symptoms?

31. A 41-year-old mother of two presents to the GP with long-standing heavy menstrual bleeding which has become worse over the past year. She is otherwise well and has no signifcant medical history. She requests treatment to alleviate the impact of her heavy bleeding on her social lif Pelvic examination reveals a normal sized uterus. What is the most appropriate frst line treatment?

32. A 42-year-old woman is seen in the gynaecology clinic. She has been suffering from severe premenstrual symptoms all her life. They have now significantly affected her relationship and her husband is filing for divorce. She comes to your clinic in tears regarding the future of her children. She demands a hysterectomy and bilateral salpingoophrectomy. After taking her history you talk about other less radical treatments. Which management option is inappropriate?

33. A 22-year-old woman is seen in accident and emergency with lower abdominal pain and some vaginal discharge. She has had PID once in the past and was treated for it. She is otherwise well. Her temperature is 36.9°c, pulse 90, blood pressure 105/66 mmHg. She is passing good volumes of urine. On clinical examination she has diffuse lower abdominal tenderness. There are no signs of peritonism on examing her abdomen. On vaginal examination she has adnexal tenderness and an offensive discharge. Her CRP is 28 mg/L and her white blood count is 12.2 x109/L. Her pregnancy test is negative. She is reviewed by your senior and is diagnosed with PI What would be an appropriate antibiotic regime?

34. A 24-year-old woman is in her frst pregnancy. She has no signifcant medical history. She is 40 weeks and 2 days pregnant and has been contracting fr 4 days. She is not coping with the pain. She has been given intramuscular pethidine. On examination she is found to be 4 cm dilated (fetus in the occipito-posterior position) having been the same 4 hours previously. What analgesia would you recommend?

35. A 36-year-old woman is 41 weeks pregnant and is established in spontaneous labour. She is contracting three times every 10 minutes and has ruptured her membranes. She is draining signifcant meconium stained liquor. Her cervix is 7 cm dilate Her midwife has started continuous electronic fetal monitoring using a cardiotocograph (CTG). The baseline rate has been 155, with variability of 2 beats per minute, for the past 60 minutes. There are no accelerations and no decelerations. What is the most appropriate management?

36. A multiparous woman is admitted to the labour ward with regular painful contractions. On examination she is 9 cm dilated with intact membranes and is coping well with labour pains. Forty minutes later her membranes rupture while she is being examined and you see the umbilical cord hanging from her vagina. You inform the woman what has happened. She is now fully dilated, the fetal position is Direct occipitoanterior, and the presenting part is below the ischial spines. What do you do next?

37. A 34-year-old para O has been admitted fr a post-dates induction of labour at 42 weeks. She has received 4 mg PGE2 (prostaglandin) vaginally. After 72 hours her cervix is 5 cm dilate Four hours later she is still 5 cm dilate On abdominal examination the fetus appears to be a normal size. The fetal head position is left occipito-transverse, and the station is -1. There is no moulding but a mild caput. She is contracting two times in every 10 minutes and has an epidural in situ. You are asked to review and make a management plan. What would be the most appropriate plan?

38. A 29-year-old woman comes to the labour ward complaining that her baby has not been moving for 72 hours. She is 36 weeks pregnant. Otherwise her pregnancy has been complicated with gestational diabetes for which she is taking insulin. On examination you fail to pick up the fetal heart. You confrm the diagnosis of an intrauterine death. The scan shows no liquor and the baby is transvers After a long discussion you explain tha

39. A 24-year-old woman with gestational diabetes has been progressing normally through an uncomplicated labour. The midwife delivers the head but it retracts and does not descend any further. What should the midwife do next?

40. A 29-year-old multiparous woman is in established labour contracting strongly. She is 4 cm dilated and had been having regular painful contractions fr 6 hours befre they stopped abruptly, heralded by a sudden onset of severe, continuous lower abdominal pain. The fetal heart trace is difcult to identify, and the tocometer does not register a signal. What is the most appropriate management?

41. A 23-year-old woman is in her frst labour. Her cervix is 6 cm dilated and she is in distress. She is asking for an epidural. Befre you call the anaesthetist you check her history. Which of the following would be an absolute contraindication to an epidural?

42. The obstetric team is alerted to a blue-light trauma call expected in accident and emergency. A 28-year-old woman who is 37 weeks pregnant has been involved in a high-speed road trafc collision. On arrival, where the obstetric team is on standby, her Glasgow Coma Scale score is 5 and she has a tachycardic hypotension. What is the most appropriate management sequence?

43. A 31-year-old undergoes a planned caesarean section for a breech presentation. After delivery of her healthy baby there is difculty in delivering the placenta, as it is adhered to the uterus. She has lost 5 L of blood as a result of the placenta accrete. The placenta has been removed but she is still bleeding and is cardiovascularly unstable despite blood product replacement. What would be the most management to defnitively arrest haemorrhage?

44. An 18-year-old woman has been successfully delivered of a healthy female infant by elective caesarean section for maternal request. Estimated blood loss was 1120 mL. Forty minutes after return to the recovery area, she has a brisk vaginal bleed of around a litre. Her pulse rate is 120 bpm and blood pressure is 95/55 mmHg. What should the immediate management process be?

45. An 89-year-old woman attends the gynaecology clinic with a long history of a dragging sensation in the vagina. Apart from severe aortic stenosis, she has no signifcant medical history. She leaks fluid when she sneezes or coughs. On examination with a Sims' speculum in the lef lateral position, a grade 1 uterine prolapse is seen, with an additional cystocoele. What is the most appropriate management?

46. A 46-year-old woman presents to your clinic with a 6-year history of Incontinence. She has had four children by vaginal deliveries, has a body mass index (BMI) of 35 kg/m2 and suffers from hayfver. Initial examination reveals a very small cystocele. A mid-stream urine culture is negative and urodynamic studies show a weakened urethral sphincter. What is the most appropriate first line management?

47. A 25-year-old woman attends accident and emergency with an exquisitely sore, large swelling of her vagina which she noticed only a couple of days before. It has steadily got much bigger. On examination there is a soft fluctuant mass on the right labia minora which is very tender. What is the most appropriate management?

48. A 49-year-old woman presents to a private clinic expressing her desire to become pregnant. She has no past medical history. Initial investigations show that she still has ovarian function, is ovulating and is having regular periods. An ultrasound of her pelvis shows no structural abnormality and an hysterosalpingography demonstrates patent fllopian tubes. Analysis of her partner's semen is normal. Which would not be an appropriate frst line management option?

49. A 42-year-old woman presents to the urogynaecology clinic with a 3-year history of urge incontinence. She has features of an overactive bladder and is desperate to start treatment for her problem as it is affecting her quality of life. She opts fr medical treatment. What is the most appropriate frst line pharmacological therapeutic?

50. A 16-year-old girl presents to your surgery with a history of unprotected sexual intercourse (UPSI) 70 hours ago. Her last menstrual period was 8 days ago. Her only past medical history of note is that of epilepsy which is well controlled by carbamazepine. She is worried about becoming pregnant, does not want her mother to fnd out and is in a hurry to get home befre suspicions are raise Which of the following options are available to her?

51. A 28-year-old woman attends her GP clinic fr routine cervical screening. Liquid based cytology (LBC) shows mild dyskaryosis. A repeat sample again shows mild dyskaryosis. What is the most appropriate management?

52. A 26-year-old undergoes potassium-titanyl-phosphate (KTP) laser laparoscopic excision of endometriosis. Her postoperative haemoglobin is 8.1 g/dL. Six hours postoperatively she complains of increased umbilical swelling, abdominal pain and shortness of breath and she appears pal A repeat full blood count now shows a haemoglobin count of 6.5 g/dL. What are the most appropriate steps you should take next?

53. A 54-year-old woman presents to her GP with a 1-year history of bloating, early satiety and occasional crampy pelvic pain. She was diagnosed a year ago with irritable bowel syndrome (IBS). A serum CA 125 is 62 IU/mL (normal range <36 IU/mL). What is the most appropriate management?

54. A 61-year-old woman has recently been diagnosed with a stage la endometrial carcinoma. She has had fur children, she has mild utero-vaginal prolapse and she has never been operated on. She needs to have surgery. You see her in clinic and talk about the different operations available to her. Which is the most appropriate operation?

55. A 65-year-old woman is referred by her GP to the gynaecology clinic with increasing bloating and a raised CA 125 level. A CT scan shows an irregular, enlarged left ovary and several wel circumscribed nodular lesions in the liver and on the omentum which are highly suspicious for metastatic ovarian cancer. What is the most appropriate treatment regimen?

56. A 28-year-old woman attends accident and emergency unable to walk because she is so fint. She has had heavy vaginal bleeding fr 4 hours since she engaged in sexual intercourse with a new partner, which she described as 'rough and very painful'. She is still bleeding and cannot tolerate vaginal examination due to the pain. A point-of-care haemoglobin estimation is 6.4 g/dL and she is haemodynamically unstable. What is the most appropriate management?

57. A 64-year-old woman with asthma is admitted to the ward prior to an elective vaginal hysterectomy fr symptomatic uterine prolapse. Her medications include Seretide (fluticasone/salmeterol 500/50) four times daily and oral prednisolone 20 mg twice daily. What is the most important peri-operative consideration?

58. A 46-year-old woman is returned to the ward from the recovery room following a routine vaginal hysterectomy for heavy periods and prolapse. The estimated blood loss at operation was 200 mL. Two hours later the ward sister becomes concerned that her urine output is low and calls the doctor. Her observations show: pulse 115 bpm, BP 90/62 mmHg, temperature 37.1° What are the most appropriate next steps in her management?

59. A 20-year-old female attends clinic requesting advice on appropriate contraception. She has a steady relationship and has no desire to start a fmily. There are no risk fctors for venous thrombosis in her family history and she drinks approximately 12 units of alcohol each week. Apart from acne, she is otherwise ft and well. She has a body mass index of 35.5 kg/m2 and a blood pressure of 122/70 mmHg. Which of the fllowing contraceptives would be most appropriate fr this patient?

60. A 14-year-old girl presents to her health care provider infrming him that she has missed two periods and that she has a pregnancy test confirming that she is pregnant. She has a boyfiend who is 15 and has been having protected sex with condoms fr six months. She wants a termination but does not want to involve her parents at all. She is counselled regarding abortion and what it entails and is also asked to involve her parents, but she flatly refuses, indicating that she will otherwise get an abortion elsewhere. She understands the risks of having an abortion. What is the most appropriate action fr this patient?

61. A 27-year-old female presents with a three hour history of vaginal bleeding, abdominal pain and right shoulder tip pain. Her past history includes pelvic inflammatory disease (PID), a miscarriage and two terminations. A urine pregnancy test is positive. From the following, which is the most appropriate next step of management?

63. A 22-year-old nulliparous female, who is not sexually active, seeks treatment fr menorrhagia and primary dysmenorrhoea, but she does not want a contraceptive treatment. Which of the following is the most appropriate choice, initially?

64. A 36-year-old overweight woman presents with irregular heavy bleeding. Her endometrial biopsy reveals cystic hyperplasia but no atypia. Which of the following would be the most appropriate treatment for this woman?

65. A 25-year-old woman who has three children and has recently undergone a second termination of pregnancy presents with menorrhagia and seeks appropriate contraceptive advice. Which of the fllowing would be the most appropriate agent fr this patient?

66. A 35-year-old female presents with menorrhagia that has not responded to treatment with nonsteroidal anti-inflammatory drugs. One year ago she underwent sterilisation. Which of the following would be the most appropriate treatment fr her?

67. A 25-year-old woman is admitted on the medical intak She is 10 weeks post-partum and has been generally unwell fr two weeks with malaise sweats and anxiety. On examination she is haemodynamically stable, and clinically euthyroid. TFTs show the fllowing: Free T4: 33pmol/L (9-23); Free T3: 8 nmol/L (3.5-6); TSH <0.02mU/L (0.5-5). What is the appropriate management?