Obs Handbook Cases

Contents
Condition 013 Pre-pregnancy advise for DVT ................................................................................. 1

Condition 014 Pre-pregnancy advise to a 24-year-old woman with Type 1 Diabetes Mellitus ..... 3
Condition 015 Anencephaly ............................................................................................................ 7
Condition 071 Anemia in a 28 year old pregnant woman .............................................................. 9
Condition 078 Breech in labor ...................................................................................................... 13
Condition 079 Vaginal bleeding in a 23 year old woman ............................................................. 15
Condition 081 Positive culture for GBS......................................................................................... 19
Condition 082 Vaginal bleeding .................................................................................................... 21
Condition 096 Eclampsia in a 22 year old primigravida ............................................................... 23
Condition 097 Abnormal GTT ....................................................................................................... 26
Condition 105 Abdominal pain and vaginal bleeding ................................................................... 29
Condition 110 Fundus greater than dates .................................................................................... 33
Condition 117 Severe postpartum hemorrhage ........................................................................... 36
Condition 125 Meconium staining................................................................................................ 39
Condition 133 Fundus less than dates .......................................................................................... 41
Condition 144 Nausea and vomiting in the first trimester ........................................................... 43
Condition 013 Pre-pregnancy advise for DVT

You are working in a general practice. Your next patient is a 28-year-old woman, who had one
pregnancy 18 months ago, which was complicated by deep vein thrombosis and a postpartum
pulmonary embolus. She has come to see you for pre-pregnancy counselling as she wishes to
conceive again. At the time of a previous assessment twelve months ago, she had ceased
warfarin. When assessed six months ago, there were no sequelae or symptoms and she had no
signs of chronic venous insufficiency in the legs. There are no abnormalities on physical
examination and she is not overweight.
TASKS
Take any further relevant history you require from the patient.
Advise the patient on the management she will require before and during the next pregnancy.
APPROACH
History
Hi Jane, I'm Dr. _____, your GP today. I read from the notes that you are planning another
pregnancy. That's wonderful. However, I understand that you have some questions about it as
you had some problems in your previous pregnancy, is that right?
Is it alright if I just ask you a few questions about your condition so we can appropriately plan for
your next pregnancy?
Questions about previous pregnancy:
Can you tell me more about what happened in your previous pregnancy?
What was the mode of delivery? Was your baby born at term? Any problems during delivery?
Was your baby alright after birth?
Did you take folic acid during your last pregnancy?
Did you do a rubella serology during your last pregnancy? What was the result?
Questions about previous DVT:
When did the DVT and the pulmonary embolus happen? How was it treated? Are you still on any
medications for that right now? Have you had any clotting episodes other than that?
Risk factors for DVT: (ADD COST VMPF)
Do you take any over the counter or prescription medications?
What is your occupation?
Do you take any contraceptive pills?
Have you had any surgeries in the past 3 months, or any trauma especially on the legs or pelvis?
Do you smoke, drink alcohol or take recreational drugs?
Any recent travel, especially greater than 12 hours? Did you walk around during the flight?
Have you noticed any prominent veins in your legs? Any calf pain? Any edema?
Have you noticed any lumps and bumps around your body? Have you experienced any weight
loss, or loss of appetite?
Are you sexually active? Do you have a stable partner? Are you on any contraception? Any chance
that you might be pregnant right now?
Any family history of DVT or any coagulation disorders?
Any recent fractures?
Do you experience any shortness of breath?
Management
Look Jane, since you had a previous history of clotting during your first pregnancy, there is an
increased risk of about 20 % of developing another one in your next pregnancy. During pregnancy
itself, there is increased tendency for clotting because of the hormonal and physiological changes
happening in the body.
If you would decide to carry on with a pregnancy, you would be referred to the high risk
pregnancy clinic and be managed in consultation with a hematologist and an obstetrician. But
before you become pregnant, we would need to screen for your clotting propensity by doing
some investigations such as anticardiolipin antibody, lupus anticoagulant, protein S, protein C,
anti-thrombin 2, and factor V Leidin, all of which are markers to screen for both inherited and
acquired clotting diseases.
At about 14 weeks of your pregnancy, we will start you on a low molecular weight heparin such
as enoxaparin, which is a medication to prevent your blood from clotting. You will take this 12
hourly as subcutaneous injections throughout your whole pregnancy and about 4-6 weeks after
you deliver. It is also advised that you use compression stockings by day throughout the
pregnancy, and avoid prolonged immobilization. You should also start taking folic acid 0.5 mg
orally, once a day, 3 months before pregnancy and up to the first 12 weeks of pregnancy.
Labor will be induced and delivery will be done in a controlled manner at 38-39 weeks of
gestation. During the planned date, we will withhold your morning dose of heparin. After
delivery, warfarin would be given for 6 weeks and we will monitor INR everyday and dose will be
adjusted accordingly.
I will give you reading materials about DVT for further insight.
KEY ISSUES
Ability to recognise that she is at increased risk of a recurrent thrombosis in her next pregnancy
and requires at least low dose heparin during the puerperium if not for most of the antenatal
period as well.
Recognition of relative risks and indications for heparin and warfarin therapy.
Recognition of significant risks of warfarin during pregnancy.
CRITICAL ERROR
Failure to screen for an inherited or acquired coagulation disorder.
Failure to advise anticoagulant therapy at least for 4-6 weeks postpartum in the next pregnancy.
Advising warfarin therapy throughout pregnancy.
IMPORTANT POINTS FROM THE COMMENTARY

This young woman has survived a life-threatening pulmonary embolus in a previous pregnancy,
so she must receive treatment to prevent a similar episode occurring in her next pregnancy.
It is essential to exclude any acquired or inherited coagulation disorder.
In any event, she will need anticoagulant therapy for the majority of her next pregnancy.
The benefits of heparin must be carefully explained, as opposed to the risks of warfarin in
pregnancy. It is also important that the anticoagulant therapy be continued beyond the birth of
her infant for at least 4-6 weeks.
Common problems likely with candidate performance are:
Failure to enquire about the particulars of the previous thrombosis/pulmonary embolism.
Suggesting that warfarin therapy should be given throughout the pregnancy, which can be
teratogenic if given in the first trimester, and is impossible to reverse quickly in the late third
trimester when labour is likely to occur
Condition 014 Pre-pregnancy advise to a 24-year-old woman with Type

1 Diabetes Mellitus
You are working in the primary care facility of a teaching hospital. Your patient is a woman aged
24 years (para 0, gravida 0), a known diabetic for 15 years and well controlled on insulin. She has
come to see you for counselling and advice about possible future pregnancies.
TASKS
Take any further relevant history you require
Advise the patient of the information she needs to be given for pre-pregnancy counseling
APPROACH
I understand that you are here to seek advice regarding future pregnancies. Are you planning to
be pregnant anytime soon? Let me ask you some questions to identify some factors in your life
And I can see from your notes that you have been diabetic for 15 years, could you tell me more
about it?
ASSESS DM SEVERITY & CONTROL (must be symptom free, with good control for at least 3
months)
When was your last check-up for your diabetes? Do you regularly have check-ups?
How is your blood sugar control? DO you regularly monitor your sugar levels? What are your
recent blood test results?
Have you ever had any hypoglycemic episodes or low blood sugar level episodes?
If yes--were you admitted in the hospital? Any complications (hypoglycemic coma)
Do you feel thirsty all the time, go to the toilet to urinate more often?
Any concerns about your water works? Have you seen a kidney specialist?
Any blurring of vision? Have you been referred to an eye specialist?
Any infections from down below?
5P's: I will be asking you some sensitive and personal questions to identify some factors which
can affect your pregnancy, and rest assured everything will be kept confidential. Will that be ok?
Is this your first time to go for a prenatal check-up?
Any concerns with your periods? Do you get it every month? How many days do you usually
bleed? How heavy is your bleeding? Any pain during your periods?
Are you in a stable relationship? Any history of STIs? Do you practice safe sex?
Are you on the pill or other forms of contraception?
When were you last on the pill?
Have you ever been pregnant before?
If yes, ask for details (when, how many times, complications, etc)
When was your last pap smear?
PATIENT ADVISE
It's good that you are planning to become pregnant and that you came here for advice regarding
your pregnancy. However, you should be aware that having diabetes in pregnancy proves to have
a high risk for complications both for you and for your baby. The state of being pregnant itself
has anti-insulin effects which tend to further worsen your diabetic state. But don't worry too
much, as you did the right thing to have a consult here first before becoming pregnant. We can
do our best to minimize the possibilities of all of these complications from happening as long as
proper blood sugar control prior and during pregnancy is achieved.
From your history, it can be seen that you seem to have a fair control over your blood sugar
levels. An initial test that I can do for you to confirm this is the HBA1c blood test together with
your regular blood sugar level checks in your diary to give an assessment of your blood sugar
control. We need to keep your sugar levels within 5-7mmol/L to reduce the risk of complications
for you and your baby
But to give you further assessment, I will refer you to a diabetic specialist who will check your
general state and check for complications of diabetes. He might do investigations such as renal
function tests, 24 hour urinary protein checks. I will also refer you to an eye specialist to assess
for your vision, as diabetes can often affect your vision as part of the complications of the disease.
So with this, it is very important that you do not get pregnant until you have reached optimal
control of your blood sugar levels.
Providing all of your tests are normal, then we can now plan for your pregnancy. I will then start
you with folic acid which you will take from the time pregnancy is attempted until at least 12
weeks of your pregnancy.
We can already do your basic tests for pregnancy now as part of your general assessment. We
can do blood group testing, indirect coombs test, full blood examination, urine microscopy and
culture, and also an STI screening tests which include hepatitis screening, VDRL, rubella serology
and HIV testing with your consent. We can also arrange for your pap smear now as your last pap
was done 3 years ago.
Once you become pregnant, You will be referred to the high risk pregnancy clinic where you will
be managed by a multidisciplinary team consisting of a diabetic specialist and an obstetrician.
Your insulin requirement will increase to keep your sugar levels controlled and keep the fetal
malformation rate to a minimum, and to keep the size of your baby (avoid macrosomia) to an
acceptable level.
Your iron and folic acid tablets will be continued during your pregnancy
You will have a planned delivery at around 38-40 weeks, either by induction or by c-section.
Earlier delivery might be necessary if problems might occur during your pregnancy
Despite all of the adequate care during pregnancy, you must still be aware of the complications
related to diabetes in pregnancy. Sorry for the medical terms I have to say to you but you need
to be aware of these. Your pregnancy can be complicated by preeclampsia or a sharp rise in BP
during pregnancy, polyhydramnios or an excessive water inside your womb which can predispose
to early labor or early rupture of these bag of water, and a big baby necessitating early labor or
c-sections. There is also an increased risk of unexplained fetal death in late pregnancy, and
possible breathing difficulties in the baby after delivery.
I can imagine that this must be very distressing for you, but I am here to give you all the
information you need before you proceed with your pregnancy. I am here to support whatever
decision you make, and if you do decide to proceed with pregnancy, we will look after you and
do the best we can to minimize these complications.
Here are reading materials for you to give you more insight about your condition.
I will arrange a review again with you once I receive your results.
KEY ISSUES
Ability of the candidate to counsel a diabetic woman, prior to a pregnancy, about the care she
will require and the methods of keeping the complication rate to herself and her fetus to a
minimum
CRITICAL ERRORS
Failure to ensure the patient is aware that her diabetic control prior to pregnancy should be good,
to ensure the risk of fetal abnormality is kept as low as possible
Failure to do pre-pregnancy blood tests (hemoglobin estimation, blood group, rubella antibodies
and tests as above) and failure to recommend pre-pregnancy and early pregnancy folic acid
therapy (routine pre-pregnancy counselling)

MOST IMPORTANT THING: pregnancy must be managed in consultation with a physician
specializing in diabetes and a specialist obstetrician.
MOST IMPORTANT ADVICE: control of blood sugar levels
Complications: unexplained fetal deth in utero, fetal macrosomia
Insulin requirements fall back to pre-pregnancy requirements within 24 hours of delivery
Condition 015 Anencephaly
You are an HMO working in a primary care clinic attached to a teaching hospital. Your next patient
is a 25 year old primigravida who has just had an ultrasound performed at 18 weeks of gestation,
which has revealed an anencephalic fetus. A maternal serum screening (MSS) was done at 16
weeks and this had shown elevated levels of alpha fetoprotein.
TASKS
Take any further relevant history
Advise the patient, in lay terms, of the relevance of the diagnosis and the subsequent
management you would propose in this pregnancy
Advise the patient of the care you would recommend in a subsequent pregnancy
You will not be expected to request examination findings, nor to arrange any further
investigations.
APPROACH
History
I understand that you are here because of the results of the ultrasound done to you and the
results of your blood tests. Do not worry, I will try to help you understand what your results
mean. But before that, I would like to ask you a few questions, is that alright with you?
Obstetric history
How is your pregnancy so far?
Any issues in your pregnancy? Any tummy pain? Any bleeding or discharge from down below?
Did you take your folic acid for this pregnancy?
Were you able to do your blood tests, blood group and indirect Coomb's test? Do you remember
the results?
Were you diagnosed with any medical and surgical illness especially asthma?
Do you smoke, drink alcohol or take any recreational drugs?
Are you taking any medications? Do you have any allergies?
Do you have a family history of neural tube defects or brain and spinal disorders in pregnancy?
Diagnosis and Management
Jane, before I discuss with you the results of your ultrasound and serum screening test, do you
want me to call someone to be with you? I am afraid that I have a not so good news for you.
The results of your tests show that your baby has a condition we call anencephaly. I'm sorry for
using medical terms. Do you know anything about this?
In the womb during the development of the baby, a structure called the neural tube goes on to
develop into the baby's brain and spinal cord. When the neural tube does not fuse together
properly, a problem with the development of the spine or brain occurs.
Fetal anencephaly is a developmental defect of the brain which occurs somewhere between five
and eight weeks of gestation.
When the neural tube does not close at the head, a condition called anencephaly results, such as
the case in your baby. This is when the top part of the brain, skull and scalp are partially or totally
missing. I am very sorry to say, that in this condition, the baby usually die at, or soon after birth.
At this point, I would like to inquire on your preference regarding your pregnancy. Do you wish
to terminate the pregnancy forthwith, or continue with the pregnancy until labor occurs?
Because you wish to terminate your pregnancy now, I would like to discuss your options for you.
Termination of the pregnancy could be performed using medications called prostaglandins or by
the surgical procedure of dilatation and evacuation.
Dilatation and evacuation has the advantage of being performed under general anesthesia or you
will be asleep, with the procedure being over when you wake up. However it also carries the risk
of weakening of your cervix (cervical incompetence) in your subsequent pregnancies, when the
procedure is done after 16 weeks of pregnancy.
Prostaglandin termination on the other hand may take several hours, or even days, and results
in uterine contractions similar to those experienced in labor, followed by vaginal delivery of the
fetus. But there will also be a possible need for curettage to remove any retained placental
fragments.
After termination of the pregnancy, the fetus will be examined to see if there is any other
abnormality present.
The risk of recurrence of a neural tube defect such as anencephaly in the subsequent pregnancy
is somewhere between 2% to 5%. But to reduce this risk, you must take a higher dose of folic
acid, 5mg per day, a month before you are planning to get pregnant and continue until about 12
weeks of your pregnancy. Also, a serum alpha fetoprotein assessment could be done at 16 weeks
of gestation along with an ultrasound examination to detect such problems in your subsequent
pregnancy.
KEY ISSUES
Ability to advise the mother:
empathically of the fact that her baby has a lethal abnormality
of the appropriate options regarding her further care in this pregnancy
of the methods available to reduce the recurrence risk of this abnormality
CRITICAL ERRORS
Failure to:
recognise and advise the patient that this is a lethal abnormality to the baby
determine the preferences of the mother in respect to termination of pregnancy
counsel the patient appropriately concerning management in a subsequent pregnancy

The most important aspect of managing this case is to understand the anxiety and
disappointment of the mother. She will need considerable support and understanding when
discussing the abnormality with her and the management of the termination of the pregnancy
that she has requested.
While helping her to deal with the extreme disappointment of the outcome of this pregnancy,
the candidate should be positive in terms of prevention (folic acid) and screening tests in a
subsequent pregnancy.
Common problems with candidate performance are:
Not focusing enough on the actual problem when taking the history, but asking for information
such as the date of the last menstrual period, irrelevant past history, social history etc. This just
takes time to do and reduces the time available for the remaining tasks.
Advising the patient that a suction curette would be the preferred method of termination. This
is not the case at 18 weeks of gestation, although it would be appropriate for a pregnancy
termination being performed at less than 15 weeks of gestation.
Advising that maternal serum screening at 11-12 weeks gestation in the next pregnancy would
be appropriate to exclude another NTD. This test would be appropriate to assess the likelihood
of a chromosome abnormality but an alpha-fetoprotein assessment at 15-16 weeks gestation is
also necessary for recognition of a likely NTD. Earlier ultrasound examination, at 11-12 weeks of
gestation, may allow a diagnosis of anencephaly to be made, but would not exclude spina bifida.
Condition 071 Anemia in a 28 year old pregnant woman

This 28 year old pregnant woman, who is attending a general practice in which you work, has just
been found to have a hemoglobin level of 80 g/L when tested at 26 weeks of gestation.
TASKS
Ask the examiner about relevant findings likely to be evident on general and obstetric
examination
Advise the patient of the tests required to define the most likely diagnosis and the subsequent
management you would advise
APPROACH
I have read from your notes that you have a hemoglobin level of 80g/L. But if it's okay, I would
like to ask you some questions first to identify some risks which may have caused this. Is that
alright with you?
QUICK HISTORY
SEVERITY of ANEMIA: Do you feel tired more than the usual? Any dizziness, racing of the heart,
or shortness of breath or chest pain? Are you on any iron supplements?
DIET: Can you tell me about your diet? What do you usually eat? Are you on a special diet (Celiac
disease can predispose to IDA)
PREGNANCY: How is your pregnancy so far? Have you had regular antenatal check-ups? How are
your blood tests and ultrasound? Have undergone down screening test? Do you have any
bleeding episodes? Is the baby kicking well? Are you taking folic acids or iron supplements during
this pregnancy?
When was your last pregnancy? How many pregnancies have you had? Have you had any
complications during your pregnancy? Bleeding episodes before, during, and after your delivery?
Are you aware if you have low hemoglobin during your previous pregnancy? Did you take any
medications (iron supplements) during your previous pregnancy?
PERIODS
How are your periods before this pregnancy? Are they heavy?
R/O Other causes of anemia
Do you have bleeding or bruising from other parts of your body?
Have you traveled recently? (R/O malaria)
Any lumps or bumps anywhere in your body? Weight loss?
Are you aware of your blood group?
Any history of medical or surgical conditions?
Do you have any family history of blood or bleeding disorders? Do you have any Mediterranean
heritage in your family?
Do you have support for this pregnancy?
PHYSICAL EXAMINATION
GA: pallor? Lymphadenopathy? Dehydration?
VS: BP with postural drop? O2 sats? HR with rhythm?
CVS, RESPI, CNS
Focused abdominal exam:
Fundic height?
Fetal heart sounds?
Fetal lie
Fetal presentation
Uterine tenderness?
PELVIC:
Inspection: any bleeding or discharge from the vulva or vagina? Any rashes or vesicles present?
Speculum: is the cervical os open/closed? Any discharge or bleeding coming from the cervical os
and the vagina?
Per vaginal:
What is the size and position of the uterus? Is it mobile? Any palpable masses or tenderness?
Any tenderness and palpable masses over the adnexa?
OFFICE TESTS: UDS, BSL
PHYSICAL EXAM: Apart from looking pale, general examination is normal. The uterus is enlarged
to about 4cm above the umbilicus, and measures 26cm above the pubic symphysis.
DIAGNOSIS AND MANAGEMENT
As you can see from your blood test results, your hemoglobin levels in your blood is decreased,
and we define this condition as anemia. Hemoglobin is the pigment in your red blood cells which
is responsible in distributing oxygen to the rest of your body to optimize bodily functions. Because
of this decrease, your body tends to lack oxygen needed to fully function that's why you're feeling
tired, dizzy, and look pale. And based on your history and examination, it seems that the most
likely cause of this anemia is an iron deficiency anemia. It is a common condition in pregnancy. It
is often asymptomatic and only detected on screening tests
Iron is a substance that is needed in the development of red blood cells, which carry hemoglobin
and oxygen in the body. There is a higher demand of iron in pregnancy, and most of the time we
get the iron through our diet. And from your history it seems that you may have not been taking
iron-rich foods nor supplements, which may have caused the gap between your pregnancy's
demands with your iron supply, thereby causing you to have this condition.
There are some risks because of this anemia, as this can predispose you to develop infections, to
have excessive blood loss during pregnancy, and can also affect your heart. Your baby might have
reduced oxygen supply which can lead to growth restriction inside the womb, distress, and in
severe cases, stillbirth (death).
But don't stress yourself too much about this. It is good that we caught it early on so that we can
avoid these complications so that you'll have a normal course of pregnancy.
Again, iron deficiency anemia is a probable diagnosis, and in order to confirm it, we need to do
certain investigations, which include FBE, iron studies (serum iron and ferritin). And if these show
abnormal results which lead to findings suggestive of other causes of anemia, I will refer you to
a hematologist who might suggest further investigations to determine the cause of your anemia
(hemoglobin electrophoresis to r/o thalassemia)
I will now start you with iron tablets (ferro-gradumet/Fefol), one tablet twice a day. Possible side
effects of this drug include constipation, tummy pain, nausea, and dark stools. There is no need
for a blood transfusion (or IV iron therapy) at this time as you don't have severe symptoms or
severely decreased hemoglobin levels.
I also advise you to eat more iron rich foods such as iron-fortified cereals, legumes, nuts, and nut
butters, seeds, whole grain breads, green leafy vegetables. Also eat a lot of vitamin C rich foods
like citrus fruits to increase the absorption of iron.
If ever you'll have bleeding, dizziness, weakness, chest pain, or difficulty of breathing, please
report to the hospital immediately.
I will arrange a review with you after two weeks to check your hemoglobin levels again along with
a reticulocyte count. If it does not improve, I will refer you to a specialist for advise concerning
your diagnosis and appropriate treatment.
Providing that your anemia can be treated satisfactorily, there should be little effect on your
pregnancy and your baby.
I can give reading materials for you to give you more insight to your problem.
Side notes:
Parenteral iron indications: if close to delivery and if cannot tolerate oral iron and Hgb<7g/L
Anemia: Hgb<110g/L in 1st trimester and <100g/L in late second or third trimester. Iron
requirements increased to 1300mg/day.
KEY ISSUES
Ability to evaluate appropriately a patient who has become anemic during pregnancy
Ability to commence treatment and arrange appropriate follow-up in such a patient
CRITICAL ERRORS
Failure to make a provisional diagnosis of probable iron-deficiency anemia due to the demands
of successive pregnancies
Failure to administer oral iron therapy
Recommending blood transfusion at this time

Most common form of anemia in pregnancy is Iron Deficiency Anemia, but other forms of anemia
should also be considered
Important to commence treatment for simple IDA while awaiting results of investigations
Blood transfusion is NOT INDICATED under these circumstances in mid-pregnancy
Common problems
Failing to focus on other causes of anemia--failing to ask about menstrual loss, loss from other
sites, and possibility of thalassemia minor
Failing to arrange appropriate blood tests which would include hemoglobin electrophoresis if
anemia is hypochromic and microcytic without evidence of iron deficiency, and assessment of
serum iron or ferritin levels
Condition 078 Breech in labor
You are working in the Emergency Department of a general hospital. This patient is a 25-year-old
woman in her second pregnancy, at 38 weeks of gestation and is in early labour. Vaginal
examination unexpectedly reveals a breech presentation: the legs of the fetus are apparently
both extended. The cervical dilatation is 4 cm. The previous pregnancy resulted in a normal
cephalic vaginal delivery of a 4 kg baby at 41 weeks of gestation. The current pregnancy has been
uneventful to date and the fundal height is 38 cm above the pubic symphysis at the time of
admission in labour at 38 weeks.
TASKS
Advise the patient of the possibilities in regard to subsequent management and the pros and
cons of these
You may take any further relevant history you require, but do this briefly as the essential features
have been provided above.
APPROACH
History
Hi Jane, I am Dr. ___. From my examination, your baby is now in breech presentation, with both
legs extended or what we call a frank breech. Have you known this from your previous antenatal
tests?
Let's discuss your options for your delivery, but before that, is it alright if I confirm with you some
details from the notes and a few questions? I read from the notes that your current pregnancy
have so far been uneventful. That's great. Did you do all your antenatal tests? Were all your tests
normal?
I understand also that your previous pregnancy was a 4kg baby delivered at 41 weeks, via normal
cephalic vaginal delivery, is that correct? Did you have any problems with your delivery? Was
forceps used to deliver the baby? Did you have any problems during your pregnancy?
Do you have any past history or family history of diabetes?
Management
So as I said, your baby’s position is breech. Normally, the baby’s head is down and the bottom is
up. In your case, the baby’s butt/bottom is presenting down. Since it is a frank breech, it would
be possible for us to try a vaginal delivery or a caesarean delivery. What would be your
preference?
Your baby's type of breech presentation is actually a favorable one, and since you're keen to
avoid a Caesarean delivery, we could attempt to do a vaginal delivery. However, there are certain
risks to this such as fetal distress because of cord prolapse, hip or shoulder dislocation, fracture
of humerus, femur or clavicle, and asphyxia. If breech presentation were diagnosed prior to labor,
ultrasound would have been of value to check your baby's size, type of breech presentation, and
to check whether the fetal neck is extended. However, as you are already in labor, ultrasound
examination will probably be difficult to arrange urgently. What we would do is, as soon as your
membranes rupture, we would do a vaginal examination to exclude cord prolapse and confirm
the type of breech presentation. We would also do a continuous cardiotocograph monitoring so
that we could pick up any abnormalities during labor and delivery. However if there will be slow
progress or inadequate progress of labor, or there is fetal distress or any significant CTG
abnormality occurs, we would need to do an immediate caesarean section. But do not be
stressed, a successful outcome of labor can be anticipated with your condition.
KEY ISSUES
Ability of the candidate to advise and counsel a patient of the current options in regard to breech
delivery by vaginal or Caesarean delivery.
CRITICAL ERROR
Failure to advise of the appropriate risks of vaginal breech delivery
Recommending that external cephalic version should be attempted despite the fact she is in
labour.
Indicating to the patient that vaginal breech delivery is absolutely contraindicated despite her
desires.

Approximately 4% of all babies present by the breech, and vaginal delivery is safe in selected
patients. This particularly applies where the baby is:
Normal size (between 2.5 and 4.0 kg)
Breech presentation is a complete breech or a breech with extended legs
Fetal neck is not extended
Labour occurs spontaneously and progresses at the appropriate rate
Pelvic dimensions are normal
Condition 079 Vaginal bleeding in a 23 year old woman
You are working in a hospital emergency department. Your next patient is a 23-year old
nulliparous woman who has been trying to conceive, and she believes she is pregnant. She has
developed vaginal bleeding after eight weeks of amenorrhea.
TASKS
Ask the examiner about the findings you would look for on general and gynecological
examination and the results of any leads you would expect to be available at the time you are
seeing the patient
Advise the patient of the probable diagnosis and subsequent management you would institute,
including any further investigations you would arrange.
APPROACH
I'm sorry to hear that you currently have bleeding. But before we proceed further with this
consultation, may I ask if you have any pain right now? Can you point to me where exactly is the
pain? From a scale of 1-10, 10 being the most painful, how bad is your pain right now? Do you
have any allergies? I will talk to my examiner first, and get back to you, is that alright?
I would like to offer some pain killers for my patient. And I would like to know what is her BP and
is there a postural drop, pulse and its rhythm, respiratory rate and oxygen saturation, and
temperature?
If not stable, transfer to resuscitation room, insert IV lines and draw blood
Before we proceed further, I am going to ask you some sensitive and personal questions to help
me assess your condition. Rest assured everything will remain confidential between us, unless it
poses harm to you or to others. Is that alright with you?
I understand from your notes that you have vaginal bleeding and had been trying to get pregnant.
Can you tell me more about it?
ASK ABOUT VAGINAL BLEEDING (PERIOD HISTORY)
When did it start? What were you doing before this started? Is it continuous (always there) or is
it on and off? Is it getting worse (has it increased in amount since it started)? What is its color? Is
it smelly or not? How many pads did you use up until now? Did you pass any clots? Did you feel
any dizziness? Has this happened before? Any tiredness or dizziness? Any fever or discharge from
down below? Any rash or skin lesions noted?
Do you know your blood group?
Do you have any pain associated with this bleeding? If yes, ask details about the pain, especially
if the pain preceded the bleeding.
Do you have any bleeding or bruising from anywhere else in your body?
PERIOD DETAILS
When was your last period? Do you get it every month? How long do you usually bleed? Do you
usually have a light, moderate, or heavy flow? Do you have any pain or dizziness with your
menses?
How does this bleeding episode compare with your usual period/menstrual bleeding?
ASK ABOUT PREGNANCY DETAILS (PREGNANCY & PARTNER & CONTRACEPTIVE HISTORY)
I understand that you are sexually active and has been trying to get pregnant, is that correct? Are
you on a stable relationship?
Prior to this occurrence, were you on any forms of contraception?
When were you last on the pill?
Is there any chance that you are pregnant now?
Have you had a pregnancy test done? When was it done and what was the result?
Have you ever been pregnant before? (If yes, ask for details)
Do you have any nausea, vomiting, or breast tenderness? (early pregnancy symptoms)
In case you're pregnant now, will you have support for this pregnancy?
Any history of sexually transmitted infections?
PAP SMEAR
When did you have your last pap smear, and what was the result? (must be within 2 yrs)
If not within 2 yrs, I will arrange another review with you to arrange for your pap smear.
R/O DDX (triggers for the bleeding) -- **FOR COMPLETION, BUT THE CASE SUGGESTS THAT THIS
WILL ONLY TAKE YOUR TIME. JUST FOCUS ON THE 5Ps
How is your waterworks? Any burning or stinging sensation?
Are there any changes in your bowel movement?
Do you have any cough or colds, or headache?
Any recent falls or injuries?
SADMA**FOR COMPLETION, BUT THE CASE SUGGESTS THAT THIS WILL ONLY TAKE YOUR TIME.
JUST FOCUS ON THE 5Ps
Do you smoke? Drink alcohol? Engage in recreational drugs?
If positive: "It's best to stop smoking/drinking alcohol/engage in recreational drugs now, as this
will be harmful to you, and especially to the baby in case you're pregnant.:
Any intake of prescription or over the counter medications?
Any allergies?
Do you have previous illnesses or surgeries?
Do you have any family history of bleeding disorders, thyroid disorders, or womb conditions such
as myoma, polyps, etc?
General appearance: what is the BMI? Any pallor, cyanosis, lymphadenopathies, edema,
dehydration?
VS - already asked in the beginning
Run through ENT, CVS, RESPI, CNS exam
ABDOMEN: any distention or visible masses? Any palpable masses or tenderness?
PELVIC:
Speculum: is the cervical os open/closed? Any discharge or bleeding coming from the cervical os
and the vagina?
Per vaginal: is there cervical motion tenderness? Is the cervix firm/soft?
I would like to end my examination by performing a urine pregnancy test, Urine dipstick, blood
sugar level.
PE EXAMINATION FINDINGS:
PULSE: 80/min, regular
BP 120/80, not distressed
Pelvic exam: cervix closed, firm, no blood in the vagina
Uterus retroverted, enlarged to the size of an 8th week pregnancy
Adnexa: no mass or tenderness
Pregnancy test positive previously, confirmed on spot urine testing now
RH negative patient
MANAGEMENT
Hello Mary, based on my history and examination findings, it seems that most likely you are
having a threatened miscarriage. Do you have any idea what it is? Let me explain this to you. Your
pregnancy test result came out positive.
(ILLUSTRATE) Normally, the baby inside your womb is attached to you through a cord, which we
call as the placenta. Sometimes, because of the attachment of the placenta to your womb, some
bleeding can happen. It is quite common, especially during the early period of pregnancy. In
majority of cases, this bleeding is quite harmless. It will stop on its own within a few days, and
your pregnancy may continue without any problems.
However, because of your bleeding, we may have to admit you in the hospital to monitor you
and your baby, and do investigations to further confirm your pregnancy and to check for other
reasons why you are having this bleeding. I will refer you to an obstetrician as well. The tests
include basic blood tests such as an FBE, UEC, Blood group, (urine mcs if positive urine findings).
We need to do an ultrasound to fully confirm your pregnancy, to check the sac surrounding the
baby, the liquor volume or the amount of water that the baby needs to thrive, and to check for
the presence of the baby's heart sounds. We need all of these to be done, and if everything
comes out normal--meaning that you have no infections, and that the baby is thriving well inside
your womb, the OB might advise you to just take some rest, and we confirm the condition of you
having a threatened miscarriage with a good prospect of continuing your pregnancy. If this is
truly a threatened miscarriage, you will only be subjected to bed rest and to avoid stressors in
your life. Unfortunately, there is no specific medication effective in improving the pregnancy
outcome. Again, providing the ultrasound examination is normal, the chance of a successful
pregnancy is between 90-95%. If this bleeding continues, we will do serial ultrasound checks to
see the condition of the baby.
As you have an O- blood test result, we will also check your blood for an indirect coombs test. It
checks some factors in the blood that if present, might affect the development of your baby
during your next pregnancies. We will arrange medications for you (anti-D) in case you turn out
positive for it.
Do you have any questions?
Rest assured, we will do our best to manage your condition the best way we can. Here are some
reading materials for you to give you more insight to your condition.
KEY ISSUES
Ability to define the diagnoses needing to be considered in the presence of eight weeks of
amenorrhea
Ability to appropriately investigate a woman with these symptoms
CRITICAL ERRORS
Failure to confirm pregnancy by pregnancy testing
Failure to arrange ultrasound to check site and visibility of pregnancy
Failure to consider the use of anti-D in view of Rhesus negative state

In all cases of bleeding in EARLY pregnancy, the MOST CRITICAL EXAMINATION FINDINGS are:
UTERINE SIZE, THE STATE OF THE CERVIX (OPEN OR NOT), and the PRESENCE OR ABSENCE OF
PELVIC TENDERNESS.
Reliance on ultrasound exam alone is inappropriate
Ultrasound in this case will enable the viability of the pregnancy to be assessed, to reassure the
patient with confidence
If pregnancy test NEGATIVE: : Most likely, this is a delayed period. Sometimes, due to stress and
with the use of the pill, your periods can become irregular. If it continues for the next 2 or 3
cycles, you will need to see the specialist gynecologist. She might decide to start you on regular
OCPs to regulate the cycle.
Condition 081 Positive culture for GBS
Your next patient is a 26 year old woman who is now at 37 weeks of gestation in
her first pregnancy. You have been looking after her pregnancy in a shared care
arrangement in a general practice setting. All has been normal, and at 36 weeks
you ordered a vaginal and rectal swab for Group B streptococcal (GBS) testing. This
test has shown GBS organisms were detected in the lower vagina. She has returned
to receive the results and any implications if the test is positive.
TASKS
Advise the patient of the results of the GBS test
Advise her about the subsequent management you would advise
There is no need for you to take further history or to request any examination
findings or investigation results from the examiner.
APPROACH
I understand that you are here to discuss the results of your Group B streptococcal
test.
Before I proceed further, let me explain to you why we usually do this test.
(ILLUSTRATE) Group B streptococcus, or GBS, is a bug that is part of the normal
vaginal flora in healthy women, and is found in 10-15% of pregnant women at your
stage of the pregnancy. It doesn't cause any harm to the mother, however, if
present in the mother, it can possibly harm the baby when the baby is delivered
vaginally. Around 40-50% of babies are colonized by this bug, but only 1% of these
babies develop a severe life threatening infection. And worse, by the time baby
presents with these signs of infection, it may be too late to treat it effectively.
In essence, the important principle of doing this test is to prevent your baby from
developing an overwhelming infection. Do you understand so far?
As for your results, your vaginal swab shows the presence of GBS. But do not stress
yourself about this. It is good that we have picked it up at this stage and we will do
our best to prevent your baby from developing an infection.
Do you have any allergies to any medications?
Having found that you are GBS positive, we will give you IV antibiotics during your
labor (penicillin 3g initially as loading dose, then 1.5, or erythromycin if allergic to
penicillin) which is started at least 4 hours before your delivery or when your bag
of water ruptures even before the onset of labor. The antibiotics we'll give to you
will cross the placenta and protect your baby before passing through your vagina--
where the GBS is present--during delivery. This is the best means that we can
prevent your baby from developing an infection
However, you have to be aware that there are some risk factors which can increase
the risk of the baby developing the infection. That is when the mother develops
preterm labor, when the bag of water ruptures even prior to onset of the labor,
and if the mother develops fever. Antibiotics are given immediately to the mother
in these cases, but it puts 0.5% of babies at significant risk to develop the infection.
After the delivery, your baby will be assessed by the paediatrician. If he is seen to
be completely healthy, no further antibiotics will be given to him.
If you develop any fever, abdominal pain, difficulty and pain in urination, please
come back to me so that I can review you again.
I will arrange another review for you next week, as your labor can start anytime
soon.
I can give you reading materials to give you more insight to your condition.
Do you have any questions?
Thank you and see you again during your next review.
KEY POINTS
Defining the management plan
Counselling the patient as to why antibiotic treatment in labor is recommended
CRITICAL ERRORS
Failure to advise patient of the significance of GBS organisms to mother and her baby.
Failure to advise antibiotic treatment of the pregnant woman if the membranes rupture, or when
labor commences, to protect the fetus from the risk of severe infection

CRITICAL ASPECT OF MANAGEMENT is giving antibiotics only when she presents in labor.
Counsel that colonisation with the organism poses little, if any, risk to the mother, but may affect
the baby
Condition 082 Vaginal bleeding
Your patient is a 25-year-old married nulliparous woman who presents to you in a general
practice with vaginal bleeding after eight weeks of amenorrhoea. Her cycles are often irregular
with the periods occurring at intervals of 4-8 weeks.
TASKS:
Take a further focused history.
Ask the examiner about the findings you wish to elicit on general and gynaecological/obstetric
examination.
Advise the patient of the probable diagnosis and subsequent management, including any
investigations you would arrange.
APPROACH
History
I understand from the notes that you are because of vaginal bleeding. Is it alright if I ask you a
few questions?
When did the bleeding start? Is this the first episode of the bleed? What is the colour of the
bleed? Does it have any offensive smell? Is there clots? How heavy is the bleed? How many pads
do you soak in a day? Is it fully soaked? Is it a continuous bleed? Is it associated with pain? Is it
associated with sexual activity?
Period history: when was your last menstrual period? Are your cycles regular? What is the usual
length of your cycles? What is the usual duration of your periods? Any pain or clots during your
periods?
Sexual history: are you sexually active? Do you have a stable partner? Do you use any
contraception? Any chance that you might be pregnant right now? When was your last pap smear
and what was the result?
Symptoms of pregnancy: Do you experience any nausea, vomiting, breast enlargement or nipple
discomfort?
Any previous medical or surgical illness especially bleeding disorders?
Any family history of any gynecological disorders?
Do you smoke, drink alcohol, take recreational drugs?
Do you take any prescription or over the counter medications? Any allergies?
Physical Exam
General appearance: pallor, edema, lymph node enlargement, BMI
Vital signs
Systemic examination
CNS/CVS/Respiratory
Abdomen: any visible distention? Any palpable mass or tenderness?
Pelvic examination
Inspection of the vulva and vagina
Speculum: is the cervix closed or open? Is there discharge or bleeding?
Per vaginal exam: what is the size and position of the uterus? Any tenderness? Any mass or
tenderness in the adnexa?
Office tests: Pregnancy test
Diagnosis, Investigations and Management

From the history and examination, the cause of your vaginal bleeding is still unclear. However,
the most important thing that I want to confirm if whether you are pregnant or not. To confirm
this, I would first like to do a beta Hcg to see if you are pregnant. If beta Hcg is negative, your
bleeding might just be a late period, and we will just wait and observe the pattern of your periods.
If your periods remain irregular, then we can order some hormonal tests such as FSH, LH,
prolactin and thyroid function tests to look for other causes of your irregular periods, and plan
subsequent treatment accordingly. However, if beta Hcg is positive, we will do an estimation of
the beta Hcg level. If it is greater than 1000 U/L, then we will do an ultrasound to check the site
and normality of the pregnancy, and the gestation and due date. We will also investigate the
cause of the vaginal bleeding in relation to the pregnancy, and manage accordingly.
I will review you once the results of the tests are available.
KEY ISSUES
Ability to evaluate a patient with bleeding after amenorrhoea.
Ability to confirm or exclude pregnancy as a cause.
CRITICAL ERRORS
Failure to consider non-pregnancy as well as pregnancy causes.
Failure to arrange ultrasound if pregnant and β -hCG is greater than 1000 U/L.

It is important to differentiate whether this woman could be pregnant, or whether she simply is
having one of her longer, irregular menstrual cycles. Therefore, symptoms suggesting pregnancy,
and tests for pregnancy, must be discussed in the management of this case.
It is also important to remember that where pregnancy is proven not to exist, further
investigations for the irregular menstrual cycles should be considered.
Condition 096 Eclampsia in a 22 year old primigravida
This 22-year-old primigravida has been seeing you in general practice clinic for her shared
antenatal care since early in her pregnancy. She is now at 38 weeks of gestation.
The pregnancy has been progressing normally until now. Whilst in the waiting room along with
her mother waiting to see you for her routine antenatal visit, she has had a grand mal fit. She had
brought a urine specimen with her to the appointment
TASKS
Take any further relevant history from the mother of the patient who is in the waiting room
Ask the examiner about the specific findings you would look for on general and obstetric
examination and any office test results which should be available to you
Advise the mother of the patient, in lay terms, of the diagnosis and the subsequent management
you would advise for her daughter.
APPROACH
I understand that your daughter had a fit while waiting here, but before I proceed further, I would
like to talk to my examiner first if it's okay with you.
To examiner: I would like to know what is her BP and is there a postural drop, pulse and rhythm,
respiratory rate, oxygen saturation, and temperature of my patient? Can I ask for the fetal heart
sound rate and rhythm?
If not stable: I would like to transfer my patient to the treatment room, insert large bore iv lines,
and draw some blood for investigations: FBE, UEC, LFTs, RFTs. I would like to check her urine for
a urine dipstick to check for proteinuria.
If stable, go with the history
HISTORY
I understand that you are very distressed about your daughter's condition as she had a fit a while
ago. Could you tell me more about how this happened?
How long did the fit last?
Can you describe how she looked like when she had the fit?
What happened after the episode?
Further history related to preeclampsia/eclampsia:
Did she complain about recent headaches, visual disturbances, swelling lately?
If positive, ask further
Headaches: Pain Qs
Visual disturbance: Describe what is the visual disturbance, always there or on and off?
Swelling: where is the swelling? one leg or both legs? Swelling up to where? Any pain? When is
it most severe (worsens as the day goes by)?
Rule out other causes of seizures:
Did she have any recent cough, colds, problems with her water works, loose bowel motions? Any
nausea or vomiting? Any fever or rashes?
Does she have any history of hypertension, kidney disease, or other medical problems in the
past?
Thank you. I would like to talk to my examiner
GA: is she alert, drowsy, rousable? Any signs of pallor, icterus, cyanosis, lymphadenopathy
present?
Edema: is there generalized edema? If not, where is it localized?
VS: BP, HR with rhythm, RR with saturation, Temperature
CNS: level of consciousness, motor power, tone, reflexes, sensory examination? Any unilateral
localizing signs?
Abdominal exam:
Inspection: distention, visible masses? Tenderness?
Fundic height?
Fetal heart sounds?
Fetal lie and presentation?
Head engaged?
PELVIC EXAM
Inspection: any bleeding discharge, rashes vesicles
Speculum: bleeding, discharge, cervical os open or not
Per vaginal: uterine size, cervix soft/firm, cervix dilated?
I would like to end my examination by doing a urine dipstick to check for proteinuria, blood sugar
level
From history and physical examination, it seems that most likely your daughter developed
ECLAMPSIA. Have you heard about it? It is a condition which occurs late in pregnancy and
generally in women having their first baby. It is a condition where there is a sharp rise in your
daughter's blood pressure with massive swelling and leakage of proteins through urine, which
prompt the body to respond by having a fit or in medical terms, a seizure. This leakage of proteins
were manifested by the swelling she had for the past few days, and as well as her headaches.
Unfortunately, the exact cause is unknown but anything that decreases the blood supply to the
placenta can cause the placenta to secrete certain chemicals which could damage the lining of
the blood vessels of all major organs. Providing it is well controlled, no long-term harm usually
occurs to either the mother or the baby, although it is potentially very dangerous to both of them.
Because of this, I will refer her to the obstetrician and she needs to be transferred via an
ambulance and be admitted to the hospital immediately, and the delivery of the baby arranged
as soon as her blood pressure and any further fits are controlled. She needs an urgent admission
as these seizure episodes compromise the blood supply of the baby.
As we are waiting for the ambulance, I will start an anticonvulsant for her which we will give
through her veins (IV diazepam) to prevent another seizure episode. We will also arrange basic
blood investigations such as a renal function test, liver function test, FBE, coagulation profile,
blood group and crossmatching.
In the hospital, she will be seen by the obstetrician and she will receive IV medications to prevent
further fits and to control her blood pressure (4 grams of MgSO4 initially, over 10-15minutes,
and then 1g per hour as continuous infusion, IV hydralazine 5mg or diazoxide). We will continue
to monitor her vital signs and her urine output and urine proteins, also check the condition of the
baby through a monitor called cardiotocogram (CTG). She will be placed in a dark, quiet room fit
to manage another seizure episode in case it happens again.
The method of the delivery of her baby will depend on her over-all assessment by the
obstetrician. This will depend on her BP control, the condition of the baby, and the findings on
cervical examination. If favorable for a vaginal delivery, her labor will be induced, and she will be
given an epidural anesthetic for pain relief and to also aid in her blood pressure control with
continued monitoring. However, if anything would show abnormalities, especially with the
condition of the baby, the OB might decide to perform a cesarean section.
I can imagine how this can be very distressing for you. Do you want me to call someone who can
assist you now?
We will do what we can to give the best care for your daughter and her baby. Thank you.
KEY ISSUES
Knowledge of the causes of fitting in pregnancy
Ability to manage a patient who has had an eclamptic fit in late pregnancy and is not in the
hospital
CRITICAL ERRORS
Failure to diagnose eclampsia and recognise risk of this to mother and baby
Failure to sedate, and failure to transfer her immediately to the hospital
Failure to outline the three principles of management in the hospital -- sedation, lower blood
pressure, and delivery of the baby

History of fits should be sought
THREE BASIC PRINCIPLES OF ECLAMPSIA MANAGEMENT
Prevention of further fits
Lowering of blood pressure
Arrangement for immediate delivery by the most appropriate route
Important PE:
Level of consciousness
Hyperreflexia
VERY IMPORTANT to ask if there is proteinuria
Any prolongation of pregnancy is IRRELEVANT as patient is already 38 weeks
Administer INTRAVENOUS BP LOWERING DRUGS
REMEMBER: Preeclampsia - can still give oral labetalol. IV HYDRALAZINE NEEDS HOSPITAL
MONITORING BEFORE IT IS GIVEN!
Condition 097 Abnormal GTT
This patient is a 34-year-old obese primigravida whom you are managing in a country general
practice. She has had a screening glucose tolerance test performed at 28 weeks of gestation. This
revealed a fasting blood glucose of 7.5 mmol/L and a two hour level of 9.5 mmol/L (Normal levels
— fasting < 5.5 mmol/L; two hour < 8.0 mmol/L). Progress of her pregnancy has until now been
normal. No other investigations have been done apart from routine screening tests at the first
antenatal visit which were all normal.
TASKS:
Take any further relevant history you require. This should be limited to 1-2 minutes only.
Ask the examiner for the findings you would expect on general and obstetric examination.
Advise the patient of the diagnosis you have made.
Advise the patient of the management you would give in the remainder of the pregnancy.
APPROACH
History
I understand from the notes that you have the results of your sweet drink test with you. I am
happy to discuss your results with you, but is it alright if I ask you a few questions before we get
to that?
How many weeks are you pregnant right now? How is your pregnancy going so far? Any issues
in your pregnancy? Any tummy pain? Any bleeding or discharge from down below? Is the baby
kicking well? Is this your first pregnancy?
Diabetes questions: Any symptoms of frequent urination? Do you feel more thirsty nowadays?
Any recurrent skin or vaginal infections? Any numbness or tingling sensation in your extremities?
Have you been tested for diabetes previously?
Pre-eclampsia questions: any headaches, blurring of vision, edema or swelling?
Routine antenatal history: Any blood test and blood group done? Down syndrome screening?
Folic acid? Ultrasound at 18 weeks? Any complications in the position of the placenta?
How is your diet? Activity and exercise?
Any smoking, alcohol?
Do you have good support?
Any other medical and surgical illness? Any medications?
Any family history of diabetes?
Physical Exam
General appearance: BMI
Vital signs: BP
CNS: signs of peripheral neuropathy
Eyes: fundoscopy for cotton wool spots
CVS/Respiratory
Abdomen: fundic height, FHR, lie, presentation
Pelvic exam: inspection, speculum

The results of your sweet drink test show that that the value is a bit high, which means that you
have a condition called gestational diabetes.
During pregnancy, the placenta secretes certain hormones like human placental lactogen, beta
HCG, and cortisol, all of which has got anti-insulin properties. And insulin is the hormone that
keeps your blood sugar level under control. Usually during pregnancy, your production of insulin
is heightened up, however in your case, it isn't the case.
If your blood sugar doesn’t get controlled, complications can happen in your or the baby.
Complications for you include polyhydramnios. This is a condition where the fluid in the bag
surrounding the baby becomes high. Due to this, you could also go into preterm labor or
premature rupture of membranes, or membranes rupture before labor pains sets in. There is also
increased chance of induction or C-section. Another complication is pre-eclampsia, which is a
condition where there is a sharp rise in blood pressure with leakage of proteins in the urine. Next
is placental abruption, which is a condition where the placenta separates from the womb
resulting in bleeding.
In your baby, complications include macrosomia or big baby. To detect this, we will do an
ultrasound at 32-34 weeks. He can also have birth defects like neural tube or nervous system
defects, heart defects, and vertebral defects. And if the blood sugar level gets uncontrolled for
a long time, the baby can even go for intrauterine growth retardation. Therefore, weekly CTGs
will be performed until delivery or twice weekly if you will be on insulin or if macrosomia or
polyhydramnios is detected. There can be complications after birth as well, such as low blood
sugar levels in the baby. He can also develop respiratory distress syndrome or difficulty in
breathing, and a high incidence of jaundice or yellowing of the skin.
It is still possible to avoid these complications as long as we keep your blood sugar level under
control. I will refer you to the high pregnancy clinic where you will be seen by the obstetrician,
the diabetic physician, the dietician and the diabetic educator.
The first thing to do is a strict diet control for 2 weeks. You will be given a diet chart by the
dietician and you need to monitor your blood sugar level 3-4 times a day, especially about two
hours after a meal and record that in a diary.
Your aim is to maintain the blood sugar level between 4-6 mmol/litre before meals. If the diet
control is not working, the diabetic physician will decide to start you on insulin. Again, you have
to monitor your blood sugar level 3-4 times/day. You will monitor you blood sugar using a
glucometer. This and the proper administration of insulin will be taught to you by the diabetic
educator. You will be monitored for diabetic control by doing an HbA1c.
You may also be seen by the ophthalmologist and the nephrologist if necessary. You need to have
weekly antenatal checks from 30 weeks, ultrasound at 32 weeks and then 4 weekly, CTG weekly
from 32 weeks.
You can go in for a normal vaginal delivery if everything goes on well with her antenatal checks,
but it should be at term at the latest. During delivery, your blood sugars will be checked
intermittently and insulin injections will be given as needed. The baby will be monitored by
continuous CTG.
After delivery, there is a high chance that your blood sugar level will come back to normal because
the hormones present during pregnancy will now be gone. You can already stop insulin injections
when that happens. Your baby however will be checked by the pediatrician and monitored for
low blood sugar levels.
Once you have gestational diabetes, there is a 30-60% chance, that you could develop diabetes
later in life. We will repeat an OGTT, 6 weeks after delivery, and then a blood sugar level 3 yearly.
You must also control any weight gain in the future.
KEY ISSUES
Ability to recognise that the blood sugar results are diagnostic of gestational diabetes.
Ability to appropriately assess the control of the diabetes during the remainder of the pregnancy,
and to appropriately manage the patient, in consultation with a physician and obstetrician.
Ability to recognise the need for insulin if the blood glucose levels are not reduced satisfactorily
with diet alone.
Ability to recognise the increased risks to the fetus, and the need for close monitoring.
CRITICAL ERRORS
Failure to diagnose gestational diabetes.
Failure to advise diabetic diet and testing of blood sugar levels 3-4 times daily.
Failure to arrange for consultation with a diabetic physician and obstetrician.

The most important aspects of the management of the case are:
To recognise the need for assessment of the blood sugars three or four times a day
The need to consider insulin if the blood glucose levels do not respond
The need to include in the management of this patient a diabetic physician and an obstetrician.
Failing to recognise a need for special fetal monitoring because of the increased risks to the fetus.
Condition 105 Abdominal pain and vaginal bleeding
Your patient is a 39 year old woman who has been married for 12 months and suffered a
spontaneous abortion at eight weeks of gestation six months ago. This was her only previous
pregnancy.
An ambulance has brought her to the hospital today because of severe lower abdominal pain and
heavy vaginal bleeding for the last 12 hours. Her last period was nine weeks ago. You are seeing
her in the Emergency Department at the local hospital.
TASKS
Take any further relevant history you require (it should not take you more than 3-4 minutes to
do this)
Ask the examiner for the appropriate findings you would look for on general and gynecological
examination, and then ask for any investigation results you feel are necessary to enable you to
make a diagnosis
Advise the patient, in lay terms, of the diagnosis and the subsequent management required.
APPROACH
I'm sorry to hear that you have been suffering from tummy pain and vaginal bleeding. Are you
comfortable enough to go through this consultation or do you want me to do something about
the pain first? From the scale of 1-10, 10 being the most painful, how bad is your pain? Do you
have any allergies?
To examiner: I would like to offer painkillers to my patient (morphine) and I would like to know
what is her BP and is there a postural drop, pulse and rhythm, respiratory rate, oxygen saturation,
and temperature of my patient?
If not stable: I would like to transfer my patient to the resuscitation room, insert large bore iv
lines, and draw some blood for investigations: FBE, UEC, blood group with cross-matching,
indirect coombs test.
If stable, go with the history
HISTORY
Which came first? Abdominal pain or the bleeding?
ABDOMINAL PAIN Q
Can you point to me where exactly is the pain? When did it start, what were you doing before it
started? was it sudden or gradual? Is it always there or does it come and go? Is it cramping,
stabbing? Does the pain go anywhere else? Is there anything that makes the pain better or
worse?
Any recent injuries before the pain started?
Do you feel any stinging or burning sensation when you pass urine?
Any fever, cough, or colds?
VAGINAL BLEEDING
When did it start? What were you doing before this started? Is it continuous (always there) or is
it on and off? Is it getting worse (has it increased in amount since it started)? What is its color? Is
it smelly or not? How many pads did you use up until now? Did you pass any clots or tissues? Did
you feel any dizziness? Has this happened before? Any tiredness or dizziness? Any fever or
discharge from down below? Any rash or skin lesions noted?
Do you have any bleeding or bruising from anywhere else in your body?
PERIOD DETAILS
When was your last period? Do you get it every month? How long do you usually bleed? Do you
usually have a light, moderate, or heavy flow? Do you have any pain or dizziness with your
menses?
How does this bleeding episode compare with your usual menses?
ASK ABOUT PREGNANCY DETAILS (PREGNANCY & PARTNER & CONTRACEPTIVE HISTORY)
I understand that you are sexually active and has been trying to get pregnant, is that correct?
I'm sorry to hear that you just had a miscarriage six months ago. I would just like to ask if there
were any procedures done to you or any medications given to you during that time? (ask if she
underwent D&C or just took meds, etc)
And have you been actively trying to get pregnant since then?
Do you have any nausea, vomiting, or breast tenderness? (early pregnancy symptoms)
In case you're pregnant now, will you have support for this pregnancy?
Any history of sexually transmitted infections?
PAP SMEAR
When did you have your last pap smear, and what was the result? (must be within 2 yrs)
If not within 2 yrs, I will arrange another review with you to arrange for your pap smear.
SADMA**FOR COMPLETION, BUT THE CASE SUGGESTS THAT THIS WILL ONLY TAKE YOUR TIME.
JUST FOCUS ON THE 5Ps
Do you smoke? Drink alcohol? Engage in recreational drugs?
If positive: "It's best to stop smoking/drinking alcohol/engage in recreational drugs now, as this
will be harmful to you, and especially to the baby in case you're pregnant."
Any intake of prescription or over the counter medications?
Any allergies?
Do you have previous illnesses or surgeries?
Do you have any family history of bleeding disorders, thyroid disorders, or womb conditions such
as myoma, polyps, etc?
GA: is she alert, drowsy, rousable? Any signs of pallor, icterus, cyanosis, lymphadenopathy,
edema present?
Dehydration: what is the CRT? Is there oral mucosa dry or moist? How is the skin turgor?
VS: BP, HR with rhythm, RR with saturation, Temperature
CVS, RESPI, CNS: level of consciousness?
ABDOMEN:
Any distention or visible masses? Any guarding or rigidity? Any palpable masses or tenderness?
PELVIC:
Speculum: is the cervical os open/closed? Any discharge or bleeding or products of conception
coming from the cervical os and the vagina?
Per vaginal: is there cervical motion tenderness? Is the cervix firm/soft?
Is the cervix dilated? By how much is it dilated?
I would like to end my examination by performing a blood sugar level test.
DO NOT REQUEST FOR A URINE PREGNANCY TEST OR AN ULTRASOUND IF THERE ARE
PRODUCTS OF CONCEPTION PRESENT ON THE PELVIC EXAM. YOU WILL BE MARKED DOWN!
PE FINDINGS FROM THE CASE
GA: clammy, pale, obviously distressed and in pain
CVS: pulse 90/min, BP 80/50 mmhg
Abdomen: Lax, non-tender, no mass or viscus palpable
Speculum: cervix open, products of conception in cervical os (if candidate does not ask if the cervix
is open or closed, do not give this information but comment on the uterine size alone)
Pelvic: uterus enlarged to size of an eighth week of pregnancy, anteverted, and mobile. Cervical
os is open and easily admits tip of one finger. No adnexal masses or tenderness
Investigations:
Blood group: O Rh negative, indirect coombs test negative
Hb 112 g/L

From my history and examination, I am sorry to say that you are having a miscarriage. Most
miscarriages occur without any obvious reasons, and this loss was probably because of a genetic
abnormality of the fetus itself especially during miscarriages occurring in the first 14 weeks.
Unfortunately these cases become more common as women get older. But let me reassure you
that this is not your fault. You did not do anything wrong so please do not feel guilty about this.
Since you are actively bleeding and your vitals still unstable as of now, I will have to admit you. I
have informed the OB registrar and sent all the bloods for investigations. Your bleeding is caused
by retained tissues of the fetus inside your womb, causing you to bleed more as long as it stays
there. Thus, they will probably do a procedure called curettage as soon as possible to control
your bleeding. This essentially involves inserting a small instrument we call curette (ILLUSTRATE)
inside your womb to scrape out the remaining tissues that causes you to bleed. This will be done
under anesthesia and is basically a pain free procedure.
As we are waiting, fluids have been started in your IV line, and we will also give you medicines
for your womb to contract to control your bleeding (IV ergometrine or a similar oxytocic agent).
We will also give you an injection called anti-D immunoglobulin as we have seen your blood to
be O negative to prevent future bleeding to you and to your child during your next pregnancy.
If your blood pressure remains low despite these interventions, it is possible that we give you
more IV fluids or a possible blood transfusion, depending on specialist advice.
You will still get pregnant, but it is advisable to wait for at least one normal period to occur before
trying to get pregnant again.
The likelihood of having a miscarriage in your next pregnancy is probably about 25-30%. But do
not stress too much about this, there is still a good chance that you will become pregnant. Thus,
in your next pregnancy, we will do a regular review for you as your advanced age also increases
the risk of having fetal abnormalities for your baby. We will do an ultrasound as early as seven
weeks as well as blood tests for screening and confirmation of congenital disorders to provide
reassurance that all is normal.
I can imagine how this must be very hard for you. But let me reassure you that we will do what
we can to provide you the best care possible. Do you want me to call anyone for you? Do you
have enough support?
KEY POINTS
Ability to define the likely cause of the symptoms and the low blood pressure found
Ability to recognize that no investigations are required in this patient other than urgent
determination of blood group, as the diagnosis can clearly be made on clinical grounds
Ability to define the subsequent management plan
CRITICAL ERRORS
Inappropriate investigation requested such as pregnancy test after results of physical
examination are known, ultrasound examination, or coagulation screen
Failure to recognize the need to remove POC from cervix
Failure to check blood group to see if anti-D antibody was indicated

Importance of speculum and vaginal examination
Recognize the products of conception trapped in the cervical os opening, causing 'cervical' shock
Importance of removing products of conception and administering ergometrine to contract the
uterus and prevent/reduce further bleeding
Avoid irrelevant history: irrelevant past hx, social hx
Adequate diagnosis and resuscitation havefirst priority
IF CERVIX IS CLOSED, ULTRASOUND IS REQUIRED TO DEFINE WHETHER THE PREGNANCY IS
PRESENT IN THE UTERUS, AND WHETHER IT IS VIABLE
Don't forget to advise the cause of the miscarriage and the likely outcome of future pregnancies
Condition 110 Fundus greater than dates
Your patient is a 26-year-old primigravida. She has been attending the general practice where
you are working and seeing the doctors there in a shared care arrangement with a specialist in a
major city 30 km away. She is not due to see the specialist again for a further six weeks. All
appeared to be normal up to and including her last visit at 26 weeks of gestation, when the
symphysis-fundal height was 28 cm. Today, four weeks later at 30 weeks of gestation, the
symphysis fundal height is 40 cm, and a weight gain of 6 kg has occurred during the four week
time interval.
TASKS:
Take any further relevant history you require.
Ask the examiner about the relevant findings on examination and the results of specific previous
investigations which you believe would have been performed.
Advise the patient of the diagnosis and subsequent management.
APPROACH
History
I read from the notes that you are now at your 30th week of pregnancy. How is your pregnancy
so far?
Is the baby kicking well? Did you do your antenatal checks, blood tests and blood group and Rh
typing? Have you done your pap smear? What was the result? Have you done your down
syndrome screening? Did you take your folic acid? How was your ultrasound at 18 weeks? Was it
a single pregnancy? Was there any uterine fibroids seen? Was correct dating confirmed on
ultrasound? What was the result of your sweet drink test at 28 weeks?
I also read from the notes that you gained a substantial amount of weight since 4 weeks back,
and your fundal height seems to be much larger than your age of gestation. What was your initial
weight prior to pregnancy? Do you know your weight right now?
Diabetes questions: Any symptoms of frequent urination? Do you feel more thirsty nowadays?
Any recurrent skin or vaginal infections? Any numbness or tingling sensation in your extremities?
Have you been tested for diabetes previously?
Pre-eclampsia questions: any headaches, blurring of vision, edema or swelling, proteins or
glucose in the urine?
Any past history of medical or surgical illness?
Do you have any family history of diabetes?
Any smoking, alcohol or recreational drugs? Any medications taken?
Do you have a good support?
Physical Exam
Vital signs
CNS/CVS/Respiratory
Abdomen: fundic height, FHR, lie, presentation, uterine tenderness, fluid thrill
Pelvic examination
Investigations
Blood group and Rh typing? Indirect Coombs test
Urine test: protein and glucose
Sweet drink test at 28 weeks
FBE: hemoglobin
Ultrasound at 18 weeks: single baby?

From the history and examination, most likely the cause why your uterus is larger than it should
be is polyhydramnios or an excessive amount of amniotic fluid. There are other causes as to why
your uterus may be larger than it should be such as wrong dating, multiple pregnancy,
macrosomic or big baby, or uterine fibroids. However, these are unlikely because your ultrasound
at 18 weeks have confirmed your dates, a singleton pregnancy, there is no evidence of diabetes,
and there were no fibroids detected on your ultrasound. However, I will need to refer you back
to the specialist now or within the next few days, and we need to confirm the diagnosis by doing
an ultrasound which would also look for the possible cause of the excessive amount of amniotic
fluid, such as fetal malformation of the central nervous system, gastrointestinal system,
abdominal wall, or a benign tumor (chorioangioma) of the placenta. Other causes are diabetes
and fetal infection with cytomegalovirus and toxoplasmosis. That is why we would also need to
do a glucose tolerance test, a confirmatory test, to exclude diabetes since the glucose challenge
test that you did before is only a screening test.
Polyhydramnios can cause problems in late pregnancy and labour including malpresentation,
premature rupture of the membranes, premature labour, and placental abruption following
membrane rupture. As you are already at 30 weeks of gestation, it would probably beneficial for
you to take an extra bed rest to prevent premature delivery. However, if at any time you feel that
you might be in premature labor, you should immediately go to the ED. Depending also on the
assessment of the specialist, she may decide to give you prophylactic steroid therapy to reduce
the likelihood of respiratory distress in the baby in the event that delivery will occur before 34
weeks of gestation.
I will give you reading materials about polyhydramnios for further insight.
KEY ISSUES
Knowledge of the causes of excessive uterine enlargement in pregnancy.
Diagnosis of polyhydramnios.
Determining the cause of polyhydramnios in this patient.
CRITICAL ERRORS
Failure to consider and confirm that the problem is most likely due to polyhydramnios.
Failure to consider the possible causes of polyhydramnios and failure to arrange the appropriate
investigations, or failure to refer to a specialist for these within the next few days.
This case tests the candidate's ability to understand and be able to diagnose the causes of a
fundus being larger than dates at any specific gestation.
It also is important to understand the risks associated with conditions such as polyhydramnios
and to be able to counsel the patient accordingly. The complications of polyhydramnios (such as
premature labour and premature rupture of the membranes) require the cooperation of the
patient to enable the correct management and therefore the information given to the patient
about such complications is critical.
Failing to enquire about the possibility of diabetes in this pregnancy.
Failing to enquire about the results of the 18-20 week ultrasound examination.
Condition 117 Severe postpartum hemorrhage
This 25 year old primigravida had a normal vaginal delivery by the midwife 20 minutes ago in a
country District Hospital which you are a Hospital Medical Officer (HMO), and currently on call
for the Obstetric Unit. The pregnancy had been perfectly normal. The labor was of 14 hours
duration. Only one dose of analgesia had been required. The estimated blood loss at delivery was
only about 250ml. However a further 1500ml of bright blood has been passed in the last 15
minutes. The midwife has just phoned you to advise you of these facts, and to ask you to come
and help with the patient's care.
TASKS
Ask the midwife the appropriate questions to define the probable cause of the haemorrhage and
to assist you to define what care is now required. You should not take more than four minutes to
do this task.
Advise the midwife of what she should do between now and when you will arrive in the delivery
suite. You are currently at your flat which is ten minutes from the hospital
Advise the examiner of the most probably cause of the haemorrhage, and what you will do when
you arrive in the delivery suite.
APPROACH
DDx of post partum hemorrhage
Uterine Atony - most common
Genital tract lacerations: vagina/cervix/uterine rupture
Retained placental fragments
Coagulation disorders
QUESTIONS TO MIDWIFE
HEMODYNAMIC STABILITY--VITAL SIGNS: What is her current BP and is there a postural drop,
pulse and rhythm, respiratory rate, oxygen saturation, and temperature?
If UNSTABLE: please transfer the patient to the resuscitation room, secure IV lines, and take blood
for blood grouping and cross-matching and coagulation studies. Please start IV fluids: normal
saline, hartmann solution or Haemaccel whichever is available.
Please give her an oxygen mask and start high flow oxygen at 10/L
Is there any shortness of breath? How is her level of consciousness?
What mode of delivery was done? Was instrumental delivery performed?
Was it a single or a multiple pregnancy? How much did the baby weigh? And how is the baby?
Can you describe the bleeding for me? What is the color (bright or dark red)? Is it continuously
pouring out? Are there clots? How much blood was lost so far?
Was episiotomy done? Any visible genital/perineal tears from outside?
Is the uterus lax or contracted? What is its position (central or not)? Is there abdominal
tenderness?
Have you checked the placenta? Is it complete? When was it delivered? Any possibilities that
there are retained products inside the uterus?
Is the patient bleeding from anywhere else?
What has been done so far? Was ergometrine or oxytocin given to the patient?
Does she have any history of bleeding disorders or previous uterine surgeries?
Do you know her latest hemoglobin count?
Is she on a urinary catheter? If not, please insert a catheter to drain her bladder.
ADVISE TO MIDWIFE
I will be on my way there but as of now please do the following interventions
Please put a firm force over the uterine fundus and massage it
Continue the IV fluids that we started. Transfuse it on a fast drip rate.
Give IV or Intramuscular ergometrine at 0.25mg, or intramuscular oxytocin immediately.
Alternative: prostaglandin per rectum
Follow-up blood test results as soon as possible
Observe any clotting on the blood that is passed
COMMENTARY TO THE EXAMINER
The cause of the bleeding can be uterine atony, retained placental fragments, genital lacerations
from the vagina, cervix, or uterus, or a coagulation disorder. But most likely, the cause is uterine
atony because of the prolonged labor of 14 hours, lack of administration of oxytocics and the
abdominal findings of having a lax uterus. Although the other causes cannot be fully excluded
now, the initial treatment should be targeted to address uterine atony.
As soon as I arrive, I will do the following unless the bleeding has substantially decresed:
I will insert an intravenous drip if it has not been completed by the midwife, and
commence/continue crystalloid fluids until blood is available
Inspect the placenta to ensure that it is complete and normal
Do a speculum examination to check for any vaginal or cervical lacerations that may require
suturing
Regularly monitor the vital signs
Give oxygen by mask
Give blood as soon as available and cross-matched
If the bleeding continues:
I will add 20-50units/liter of Oxytocin (Syntocinon) to the intravenous fluids being given.
I will refer the patient to the OB specialist, as it is likely that the patient requires an examination
under anesthesia (EUA) to ensure no retained products of conception are present, and that the
uterus is intact, and that there is no uterine inversion. This examination should not be performed
until a blood transfusion is running and she is hemodynamically stable.
It is only after an EUA has been perfoermed that the use of intramyometrial prostaglandins such
as PGF2a and major surgery such as an internal iliac ligation, or even a hysterectomy should be
considered.
KEY ISSUES
Knowledge of the causes of primary postpartum haemorrhage
Ability to recognize the most likely cause of a primary postpartum haemorrhage
Ability to advise the midwife of the initial management required
Ability to understand the steps required if the initial management is not successful in controlling
the haemorrhage
CRITICAL ERRORS
Failure to define that uterine atony is likely to be present on the information obtained from the
midwife
Failure to ask for information regarding the vital signs
Failure to advise the midwife to initiate initial actions in detail. The performance of coagulation
studies is not mandatory but other actions are.

Severe PPH causes
Genital tract trauma, Retained tissues, Blood clotting abnormalities, Uterine atony
Various treatments for each of these conditions must be discussed
Various drugs used to manage uterine atony MUST BE KNOWN
Common problems encountered
Failure to recognize cervical/vaginal lacerations because perineum is intact
Failure to do a speculum examination
Failure to consider about retained products of conception as a cause
Failure to consider that examination under anesthesia would be required if bleeding continued
Condition 125 Meconium staining
Your patient is a 25-year-old primigravida who is in early labour at 41 weeks of gestation. She is
in the local district hospital where you are attending as a general practitioner. The hospital has
good facilities but a consultant obstetrician is not available. Pelvic examination 30 minutes ago
showed the cervix was 3 cm dilated, well effaced, and well applied to the presenting part. The
cephalic presentation was position left occipitotransverse (LOT), at zero station, with no caput or
moulding evident. The membranes were still intact and allowed to remain so. Spontaneous
rupture of the membranes then occurred and revealed profuse, thick meconium-stained liquor.
The pregnancy had been uneventful to date, and blood pressure and urine testing have been
normal in labour. The fetal heart rate, as defined using auscultation, has been between 130 and
140/min.
TASKS:
examination.
Advise the patient of the diagnosis and subsequent management during and after delivery.
APPROACH
History
I understand from the notes that you are already in your 41 weeks of pregnancy. When is your
due date?
How was your pregnancy course? Any problems during your pregnancy? Did you have a CTG
done? What was the result? Do you know your blood group?
Do you feel your baby kicking? Are the kicks consistent? No decrease in the fetal movements?
Are your contractions coming regularly? How often do they come? How long does one
contraction last?
Have you noticed any discharge or bleeding from down below?
When did your water break? Was it green in color?
Physical Exam
Vital signs: BP, temp
CNS/CVS/Respiratory
Abdomen: fundic height, FHR, lie, presentation, station, uterine tenderness, contractions
Pelvic examination
Speculum: discharge? Meconium present?
Per vaginal exam: cm dilation of the cervix? Percent effacement? Evidence of caput? Evidence of
cord prolapse?
It seems that the greenish material that we see is what we call meconium. Meconium is the
baby's first stool. Meconium staining of the liquor is common in post-term labour. Sometimes it
means the baby is having problems, such as fetal distress due to lack of oxygen, but in most
instances the baby is perfectly healthy. We will also do a cardiotocography to assess the fetal
condition. A cardiotocograph is a safe, non-invasive method commonly used during pregnancy
and labor. We will place 2 sensors in your abdomen to record your baby's movements, heart rate
and your uterine contractions. If we find something abnormal in the CTG, then further
investigations will be done such as fetal scalp pH or lactate level to find out the significance of
this abnormality in the CTG, and if necessary, a caesarean section or vaginal manipulative delivery
will be done.
We would also do a pelvic examination to assess the progress of labour and to make sure that
the cord has not prolapsed, which can be another cause of meconium staining of the liquor. If we
don’t find any abnormality in the CTG or abnormality in the pelvic examination, then we would
just let you progress with labor and monitor you accordingly until vaginal delivery is ultimately
possible.
At the time of vaginal delivery, adequate aspiration of the mouth, pharynx, and nasal cavity will
be done to prevent any inhalation of meconium into the respiratory tract of the baby.
Visualisation of the vocal cords, immediately after birth, with aspiration of meconium in any
adjacent region will also be done.
During delivery, a pediatrician will also be there to ensure that resuscitation will be adequate and
to commence any further therapy which may be required in the event that your baby inhales any
meconium.
KEY ISSUES
Understanding the relevance of the meconium staining of the liquor.
Understanding the management required.
CRITICAL ERRORS
Failure to do vaginal examination to check cervical dilatation and exclude cord prolapse.
Failure to adequately monitor the baby throughout the rest of the labour using continuous CTG
assessment.
Failure to aspirate the mouth and pharynx adequately, at delivery, to reduce the risk of
meconium aspiration.

This case assesses the understanding of the significance of the presence of meconium staining of
the liquor in full term (or slightly past-term) pregnancies. It is important to understand that,
although the presence of meconium may be a normal accompaniment of term (or slightly post-
term) pregnancies, the sudden appearance of meconium when the membranes rupture
mandates the subsequent necessity of monitoring of the baby throughout the remainder of the
labour.
It should also be remembered that that baby's pharynx and mouth must be adequately aspirated
at birth to prevent meconium aspiration syndrome.
An apparent lack of understanding that meconium staining of the liquor is common in post-term
labour and does not imply the baby is in extreme difficulty.
Pelvic examination to exclude cord prolapse and continuous CTG monitoring are required to
determine whether the baby is at risk of hypoxia. Only occasionally is Caesarean section
required.
Condition 133 Fundus less than dates

Your next patient is a 28-year-old primigravida who works as a nurse in a renal transplant unit.
You have been looking after her pregnancy since the first trimester. You are seeing her in a
general practice setting in a shared care arrangement with the local obstetric hospital. All
appeared to be normal up to and including her last visit at 30 weeks of gestation, when the
symphysis-fundal height was 28 cm. Today, four weeks later, the symphysis-fundal height is 29cm
and there appears to be a reduced amount of liquor present.
TASKS:
examination and available investigation results.
Advise the patient of the diagnosis and subsequent management including any further
investigations you would arrange.
APPROACH
History
I read from the notes that you are currently in your 31st week of pregnancy now, and your fundal
height seems to be smaller than expected and there is reduced amount of liquor in your tummy.
How is the baby? Is the baby kicking well? Are the fetal movement same as it was before?
Possible causes of small fundus:
Are your dates certain? Did you do your ultrasound at 18 weeks? What was the result?
Were you ever diagnosed with hypertension or renal disease? Ever been diagnosed with lupus or
arthritis or any thrombotic disorder in the past?
Pre-eclampsia questions: any headaches, blurring of vision, edema or swelling, proteins or
glucose in the urine?
Do you have pets at home? Did you have any contact with dogs or cats?
Routine antenatal history: Any blood test and blood group done? Down syndrome screening?
Folic acid? Any complications in the position of the placenta? Sweet drink test at 28 weeks?
Do you smoke, drink alcohol or take recreational drugs?
Do you have enough support at home? Who do you live with?
Physical Exam
Vital signs
CNS/CVS/Respiratory
Abdomen: fundic height, FHR, lie, presentation, is the head engaged, uterine tenderness
Pelvic examination
Office test: UDT for proteins
Investigations
CMV antibody testing
Toxoplasma antibody testing
Management
From history and physical examination, most likely your baby is having an intrauterine growth
restriction. This is when the baby is not able to grow properly inside the womb. This is why your
fundal height is less than expected and you have reduced amount of liquor. The reason for this,
and its severity need to be assessed by some investigations such as ultrasound examination to
confirm the size of the baby, to look for the amniotic fluid volume, and to see whether there is
any obvious congenital abnormality which might explain the IUGR. Ultrasound will probably need
to be repeated each 2-3 weeks. A Doppler study could also be done to assess the blood flow in
the umbilical cord which supplies the needs of the baby. A cardiotocographic evaluation will be
done as well twice a week from now until the time of delivery to assess and monitor the condition
of the baby.
There are many causes why IUGR could happen. It could be due to karyotypic abnormalities or
problems in the genetic makeup of the baby, kidney disease, pre-eclampsia or abnormal, abrupt
elevation of the patient's blood pressure with leakage of proteins into the urine,
or congenital infections due to CMV or toxoplasmosis or placental dysfunction. That is why, in
addition to the ultrasound, Doppler and CTG, we would also do a serum urea, uric acid, and
creatinine to look for evidence of renal compromise, lupus anticoagulant and anticardiolipin
antibodies, antibodies for toxoplasmosis, and amniocentesis to assess the karyotype of the baby
and to rule out toxoplasmosis in the specimen as well.
Your baby will most probably be delivered via caesarean section and will be done prior to your
due date. The timing of this will depend on the ultrasound evaluation, the CTG record and the
amount of growth which occurs subsequently.
But do not be too stressed, as long as the baby does not become deprived of oxygen and becomes
acidotic, and does not have a congenital malformation or a congenital infection, the long-term
prognosis for the baby is satisfactory.
KEY ISSUES
Understanding the causes of oligohydramnios.
Management of a growth-restricted fetus in late pregnancy.
CRITICAL ERRORS
Failure to recognise that the clinical picture is of intrauterine growth restriction.
Failure to arrange appropriate assessment (or referral to specialist). At the least ultrasound and
serial CTG must be done.

This case assesses the candidate's ability to understand the causes of a fundus measuring less
than that expected for the gestational age. The most common of these is that the fetus is
suffering from intrauterine growth restriction (IUGR) with usually a degree of oligohydramnios.
The important aspect of this case is to have an understanding of the management of a fetus
which is growth restricted in late pregnancy. The means of monitoring the fetus for the remainder
of the pregnancy must be known, and also the options for safe delivery. Referral to a specialist
may be advised, but the candidate will be expected to have an understanding of what the
specialist will advise the patient.
Failure to consider the various causes of apparent oligohydramnios.
Failure to advise that delivery prior to the estimated date of confinement will probably be
required and the chance of this needing to be by Caesarean section is certainly increased.
Condition 144 Nausea and vomiting in the first trimester

Your next patient is a 38 year old woman who has come to the general practice because of severe
nausea and vomiting for the last two weeks in this, her first pregnancy. She claims that she has
been unable to keep foods or fluids down. Her last menstrual period was eight weeks previously,
and pelvic examination by your colleague in the general practice two weeks ago showed the
uterine size was appropriate for gestation and a pregnancy test was positive. She has had no
previous operations or illnesses
TASKS
Ask the examiner about relevant findings evident on general and obstetric examination which
would assist you in making a diagnosis
Advise the patient of the likely diagnosis
Advise the patient of the care you would advise for her, including any investigations you would
arrange
APPROACH
HEMODYNAMIC STABILITY--VITAL SIGNS: What is her current BP and is there a postural drop,
pulse and rhythm, respiratory rate, oxygen saturation, and temperature?
If UNSTABLE: please transfer the patient to the treatment room, secure IV lines, and take blood
for FBE, UEC, ESR, CRP, blood grouping and cross-matching. I would also like to do urine dipstick
to check for ketones. Please start IV fluids: normal saline, hartmann solution or Haemaccel
whichever is available.
Please give her an oxygen mask and start high flow oxygen at 10/L (if rr / o2 sat unstable)
HISTORY
Congratulations on your pregnancy. I have read from your notes that you are currently at 8 weeks
of pregnancy, and you have been suffering from vomiting for about two weeks now. I know this
can be very distressing for you, but we'll do our best to manage you. Could you tell me more
about your vomiting?
Is it getting worse? Does it usually come in the morning or a particular time during the day? Could
you describe to me the manner in how you vomit--is it projectile, do you retch, etc? What does
your vomit usually consist of? What's its color? Does it have any blood? Did you eat anything out
of the usual before you had these symptoms?
Any changes in your bowel motion? Do you still pass gas? (r/o bowel obstruction or
gastroenteritis)
Assess dehydration
How is your appetite? Are you still eating or drinking? Did you have any fever, diarrhea, or
dizziness? How is your waterworks? Any burning or stinging sensation? Do you go to the toilet
more/less than the usual? Any change in the color of the urine? Any loin pain?
QUESTIONS ABOUT CURRENT PREGNANCY
Is this a planned pregnancy? How were you able to confirm your pregnancy?
Are you in a stable relationship? Do you have support for this?
R/O causes of vomiting
Do you have any family history of twins?
Is this a natural or an assisted pregnancy?
Any bleeding or tummy cramps?
Did you have your initial blood tests requested during your previous visits to your GP? Were you
advised regarding screening and confirmatory tests for diseases in the baby?
Any history of STIs?
When was your last pap smear?
Do you smoke, drink alcohol, engage in recreational drugs?
Do you take other medications? Any allergies?
Do you have any history of any medical or surgical conditions?
GA: dehydration--skin turgor, CRT, tongue & oral mucosa moist? Lymphadenopathies, pallor?
VS: BP with postural drop? Temperature? HR?
CVS, CNS, Respi
Abdomen: distended or any masses? Tenderness? Rigidity/guarding? Any bowel sounds?
Pelvic exam not needed
Office tests: Urine dipstick and BSL
Check for ketones
PE findings from the case:
She looks unwell and drawn. Her tongue dry and firm. Tissue turgor of the skin is diminished.
Pulse: 110/min
BP: 120/80
Temperatue 36.8C
Abdominal examination, uterus not palpable
No loin tenderness
Pelvic examination not repeated
From history and examination, it seems that most likely you have a condition we call as
Hyperemesis gravidarum. Have you heard about it? It is a condition common in early pregnancy
manifested by excessive nausea and vomiting. Its cause is multifactorial, however it is usually
implicated that the excessive vomiting and nausea is due to increasing hormone levels especially
the b-hcg hormone which supports your pregnancy.
This condition usually goes away on its own, especially by 14 weeks of gestation as your body
becomes used to these new hormones, and the level of b-hcg goes down.
However, it was seen from your examination that you are severely dehydrated, supported by
findings of ketones in your urine. Because of this, I will have to refer you to a hospital so that you
can be admitted for intravenous rehydration and monitoring. I will call an ambulance to transfer
you to the hospital.
I will also refer you to a specialist who will see you and might do further investigations. Although
hyperemesis gravidarum can be a complication of a normal pregnancy, it also occurs with
increased frequency in association with other conditions such as a multiple pregnancy, a urinary
tract infection, or even a condition we call as a hydatidiform mole--where there is an abnormal
growth of placenta mimicking pregnancy. To rule out these conditions, you will undergo blood
tests such as an FBE, UEC, serum b hcg, liver function tests, and also urine microscopy and culture,
and a transvaginal ultrasound. You will be given fluids through IV, and anti-vomiting/nausea meds
(metoclopramide - maloxon/stemetil), vitamin B supplementation (pyridoxine) to address your
symptoms. You and your baby will continually be monitored throughout your admission.
Another thing that I would like to address is that you are currently 38 years old now, and this puts
you at a very high risk of having a baby with Down syndrome or other genetic abnormalities.
SHORTCUT: Because of this, I will arrange genetic counselling for you to undergo screening tests
for down syndrome which consists of a blood test done as early as 9-13 weeks looking for factors
in blood which denote possible presence of a baby with down syndrome, combined with an
ultrasound examination done at 11-13 weeks. We can also do a screening test in your second
trimester which will also involve a blood test looking for 4 factors in the blood (AFP, BHCG,
ESTRIOL, INHIBIN) which will screen for the condition. We can also do confirmatory tests: the
chorionic villous sampling test done during 11-14 weeks, which involves getting samples from
your placenta and to send it for genetic testing. We can also do amniocentesis, which can be
done at 15-18 weeks, which involves getting a sample of your bag of water and we send it for
genetic analysis for down syndrome. All of these confirmatory tests have certain risks for
miscarriage with 1:100 for CVS, and 1:200 for Amniocentesis.
FULL EXPLANATION: We have two screening tests, we usually do blood tests looking for factors
namely the bhcg and pappa as early as 9-13 weeks, together with an ultrasound of the baby's
back of the neck at about 11--13 weeks of your pregnancy. The bhcg is inc, and pappa is decreased
in a baby suspected of having downs. The detection rate of this combined test is 87%
Another test that we do is the Noninvasive Prenatal Test (NIPT) which is done at 10 weeks. We
get a blood sample from you and we send it for genetic testing. The detection rate is 99% but it is
not covered by medicare and usually costs around 600-700aud.
For the second trimester, 15-17wks. we can also do what we call a quadruple and a triple screen.
We test factors in your blood, namely the bhcg, inhibin, esriol and afp. Both bhcg and inhibin are
increased while the other two are decreased in a quad screen.we test the bchg, estriol, and afp in
the triple screen. Detection rates are 81% and 71% respectively.
Once we get positive for downs in the screening tests, we do confirmatory testing for downs
Chorionic Villous sampling that we do during 11-14 wks of pregnancy where we insert a needle
guided by ultrasound from down there and get a sample from the placenta which we send for
genetic testing. However miscarriage rates are 1:100.
We can also do an amniocentesis, which is done at around 15-18 weeks. We pass a needle guided
by an ultrasound to your womb, to get a sample of your bag of water and we send it for genetic
analysis. Risk of miscarriage for this is 1:200.
KEY ISSUES
Ability to investigate and treat a woman with hyperemesis gravidarum
Recognition of the need for genetic counselling in the view of advanced maternal age
CRITICAL ERRORS
Failure to recognise the need for hospitalization
Failure to do ultrasound and urine examination to check pregnancy, diagnose twins, molar
pregnancy, urinary infection, and the presence of urinary ketones

Management depends upon the degree of vomiting and therefore the potential diagnosis.
Common problems
Failure to advise that the vomiting will usually cease or be markedly reduced by around 14 weeks
of gestation

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Contents

Condition 013 Pre-pregnancy advise for DVT ................................................................................. 1

Condition 013 Pre-pregnancy advise for DVT

IMPORTANT POINTS FROM THE COMMENTARY

Condition 014 Pre-pregnancy advise to a 24-year-old woman with Type

IMPORTANT POINTS FROM THE COMMENTARY

IMPORTANT POINTS FROM THE COMMENTARY

Condition 071 Anemia in a 28 year old pregnant woman

IMPORTANT POINTS FROM THE COMMENTARY

IMPORTANT POINTS FROM THE COMMENTARY

IMPORTANT POINTS FROM THE COMMENTARY

IMPORTANT POINTS FROM THE COMMENTARY

Diagnosis, Investigations and Management

IMPORTANT POINTS FROM THE COMMENTARY

IMPORTANT POINTS FROM THE COMMENTARY

Diagnosis and Management

IMPORTANT POINTS FROM THE COMMENTARY

DIAGNOSIS AND MANAGEMENT

IMPORTANT POINTS FROM THE COMMENTARY

Diagnosis and Management

IMPORTANT POINTS FROM THE COMMENTARY

IMPORTANT POINTS FROM THE COMMENTARY

Condition 133 Fundus less than dates

IMPORTANT POINTS FROM THE COMMENTARY

Condition 144 Nausea and vomiting in the first trimester

IMPORTANT POINTS FROM THE COMMENTARY

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