Obstetrics 2

1.Warfarin is contraindicated during pregnancy. Which of the

following complications develop if warfarin is used in second
trimester of pregnancy?
A. Fetal chondrodysplasia punctata.
B. Hypercalcemia.
C. Facial anomalies.
D. Maternal cerebral bleeding.
E. Fetal optic atrophy.
Warfarin
• Class X drug in T1, Class B drug in T2/T3
• Teratogenicity: These birth defects may include skeletal abnormalities,
central nervous system defects, and other malformations.
• Risk of Fetal HemorrhageWas arfarin can cross the placenta
• LMWH does not cross the placenta to the same extent as warfarin and is
considered safer for the fetus.
• "Fetal warfarin syndrome" refers to a set of birth defects and
developmental abnormalities that can occur in babies born to mothers
who took the anticoagulant medication warfarin
• Skeletal Abnormalities
• Central Nervous System (CNS) Abnormalities.
• Cardiovascular Abnormalities:
• Ocular Abnormalities
• Growth Restriction.
Chondrodysplasia Punctata Optic atrophy
2. A 20-year-old Asian woman with background history of primary
pulmonary hypertension attends your clinic. She is planning to become
pregnant in the next few months. She enjoys good health at the
moment. Which one of the following would be the most appropriate
advice?
A. Pulmonary hypertension becomes better during pregnancy.
B. If she becomes pregnant, termination of pregnancy is not required.
C. Pregnancy is contraindicated for her.
D. Maternal mortality in this setting is low.
E. Sudden death is a rare complication.
• Primary pulmonary hypertension is a condition characterized by
increased blood pressure in the pulmonary arteries, which can lead to
right heart failure. Pregnancy places additional strain on the
cardiovascular system, and for women with PPH, it significantly
increases the risk of maternal morbidity and mortality.
• Pregnancy is associated with a high risk of worsening of pulmonary
hypertension, heart failure, and maternal mortality. Therefore, it is
strongly advised that women with PPH avoid pregnancy and use
effective contraception to prevent unintended pregnancies
3. Which one of the following is incorrect regarding hypothyroidism in
pregnancy?
A. Thyroxin requirement increases by 25- 30% during pregnancy.
B. Children born to women whose hypothyroidism was inadequately
treated in pregnancy are at increased risk of neuropsychological
impairment.
C. Thyroxine dose should be increased by 30% at the beginning of
pregnancy.
D. TSH should be monitored every 4 to 6 weeks in the first half of the
pregnancy, and thyroxin dose adjusted if necessary.
E. Thyroxin requirement does not increase in pregnancy and
maintenance dose must be continued.
Parameter Physiological Changes During Pregnancy
- Increased production of thyroid hormones (T3 and T4) due to the influence of hCG
Thyroid
and estrogen. - Increased iodine requirements for hormone synthesis. - Changes in
Function
thyroid hormone-binding proteins.

- Suppressed TSH levels in the first trimester due to the stimulatory effect of hCG. -
TSH Levels
Gradual normalization postpartum.
- Elevated T3 levels, especially in the first trimester. - T3 remains relatively stable
T3 Levels
throughout pregnancy.
- Elevated T4 levels, particularly in the first trimester. - T4 levels remain higher
T4 Levels
during pregnancy. - Gradual normalization postpartum.

Thyroxine- - Increased levels of thyroxine-binding globulin (TBG) due to estrogen. - Elevated

binding Globulin TBG levels can lead to higher total T4 and T3 levels but free T3

- Often an increase in the thyroxine dose is required during pregnancy for women
Thyroxine (T4) with pre-existing hypothyroidism. - Dose adjustments are made to maintain TSH
Dose levels within the target range. - Frequent monitoring is essential to ensure
adequate thyroid hormone replacement.
4. You are working at a busy GP clinic. Your next patient is 24-year-old
woman with irregular menstrual and a positive pregnancy test. She is
keen to know the age of her baby. Which one of the following methods
would be the most accurate one for estimation of gestational age?
A. Bimanual examinations at 12 weeks.
B. Transvaginal Ultrasound at 12 weeks.
C. Transvaginal ultrasound at 8 weeks.
D. Transabdminal ultrasound at 08 weeks.
E. Transabdominal ultrasound at 16 weeks.
• Transvaginal ultrasound provides a
clear image of the developing fetus
and allows for accurate measurement
of crown-rump length (CRL) at this
stage of pregnancy. CRL measurement
is highly reliable for estimating
gestational age because fetal growth is
fairly consistent during the first
trimester. An ultrasound at 8 weeks
can provide an accurate estimate of
the baby's age and due date.
• Transvaginal ultrasound at 12 weeks
can still provide a reasonably accurate
estimate but may not be as precise as
an ultrasound at 8 weeks
5. A 20-year-old female presents to your practice at 18 weeks
pregnancy with right iliac fossa pain that is particularly brought on by
getting up from a chair, sneezing and coughing. On examination she has
normal vital signs and is otherwise healthy. Abdominal examination
reveals no tenderness, rebound tenderness or guarding. Which one of
the following is the most likely diagnosis?

A. Round ligament pain

B. Acute appendicitis.
C. Ovarian torsion
D. Ruptured ectopic pregnancy.
E. Uncomplicated ectopic pregnancy
Round ligament pain
6. A 21-year-old nulliparous woman presents with lower abdominal
pain at 15 weeks of gestation. Her temperature is 37.8°C. She is
otherwise well and eating normally. At the time of her previous
antenatal visit at 11 weeks of gestation, her uterus had been found to
be retroverted but of the expected size. Which one of the following is
the most likely diagnosis?
A. Impaction of a retroverted gravid uterus.
B. Urinary tract infection.
C. Complication of a corpus luteum cyst.
D. Tubal ectopic pregnancy.
E. Acute appendicitis.
7. A 30-year-old pregnant woman presents to the Emergency
Department with severe right-sided throbbing head ache, nausea,
and vomiting. She is 24 weeks pregnant. Her medical history is
remarkable except for migraine. Which one of the following is the
most appropriate management of this patient?
A. Paracetamol.
B. Paracetamol and codeine
C. PCM, Codeine and metoclopramide.
D. Codeine and promethazine.
E. Sumatriptan.
8. A 35-year-old woman pregnant woman presents to the Emergency
Department with left-sided retro- orbital and occipital severe
headache associated with nausea and vomiting. She has been
suffering from migraine for the past 10 years, and has been on
treatment with sumatriptan. Which one of the following drugs if used
for treatment of migraine would lead to premature closure of fetal
ductus arteriosus?
A. Codeine.
B. Paracetamol.
C. Metoclopramide.
D. Non-steroidal anti-inflammatory drugs (NSAIDS).
E. Sumatriptan
• Intake of NSAIDs limits the
production of prostaglandin and
may lead to constriction or
closure of the ductus arteriosus,
causing pulmonary hypertension
and, eventually, fetal death.
• NSAIDsshould used with causion
and only when other options are
not available
9. A 27 year old primi woman presents with vaginal bleeding at 14
weeks of gestation. What is the main indication for TVS in this
patient?
A. Screen for Down syndrome
B. Exclude ectopic pregnancy
C. Establish the cause of bleeding
D. Determine the viability of fetus
E. Screen for birth defects
10. A 32-year-old woman presents with placenta previa. You offer
cesarean section as the most appropriate mode of delivery. She wants
to know about the risks of cesarean delivery. Which one of the
following is correct regarding cesarean section?
• Decreased risk of maternal mortality.
• Decreased need for repeated cesarean sections.
• No damage to adjacent viscera.
• Increased risk of adhesions.
• Decreased risk of infections.
11. A 32-year-old pregnant woman, gravida 3, para 2, at 32 weeks gestation presents
to the emergency department with sudden-onset abdominal pain and vaginal
bleeding. She has no significant past medical history, and her prenatal care has been
unremarkable until now. On examination, she appears anxious and is in moderate
distress. Her blood pressure is 150/90 mm Hg, pulse rate is 110/min, and respiratory
rate is 20/min. Abdominal examination reveals tenderness and rigidity in the upper
abdomen, and the uterine fundus feels firm and board-like on palpation. Vaginal
examination reveals dark red vaginal bleeding. Fetal heart rate monitoring shows
bradycardia. Which of the following is the most likely diagnosis based on this
presentation?
A. Placenta previa
B. Placenta accreta
C. Uterine rupture
D. Abruption of the placenta
E. Cervical insufficiency
Causes of APH
• marginal placental bleeds
• local vaginal causes: cervical ectropion, polyp, cervical dysplasia/carcinoma,
trauma
• blood stained show
• placenta praevia
• placental abruption
• abnormal placentation
• abnormal placental shape
• vasa praevia
• uterine rupture
• non-gynaecological causes: urinary tract infection, urethral caruncle,
haemorrhoids, inflammatory bowel disease
Risk factors for Placental Abruption
• Previous abruption
• Pre-eclampsia
• Fetal growth restriction
• Non-vertex presentations
• Polyhydramnios
• Advanced maternal age
• Multiparty
• Low BMI
• Pregnancy following assisted reproduction
• Intrauterine infection
• Premature rupture of membranes
• Abdominal trauma
• Smoking & drug use
• Maternal thrombophilias
12. A 27-year-old nulliparous woman is admitted to hospital at 37 weeks of
gestation having lost about 200mL of blood per vaginum after having had
sexual intercourse. The bleeding has now ceased. On clinical examination
the pulse rate is 64/min, BP 120/80mmHg and temperature 36.8°C. The
uterus is enlarged to a level 37cm above the pubic symphysis, is lax and
non-tender, the presentation is cephalic with the head still freely mobile
above the pelvic brim. The fetal heart rate assessed by auscultation is
155/min. Which one of the following is the most likely cause for the
bleeding?

A. Vasa praevia.
B. Placental abruption.
C. Placenta praevia.
D. A cervical polyp.
E. A heavy showe.
• The clinical examination mentions a lax, non-tender uterus with the
presentation as cephalic, and the fetal head still freely mobile above
the pelvic brim. These findings suggest that labor has not yet started,
and there is no evidence of placental abruption.
• The fetal heart rate is 155/min, indicating that the baby's well-being is
not compromised at this time.
• This is a characteristic presentation of placenta praevia, where
bleeding often occurs after mechanical stimulation of the cervix, such
as sexual activity.
• Vasa praevia involves fetal blood vessels overlying the cervix, but it
typically presents with severe bleeding and is less likely at this
gestational age.
13. A 31-year-old primi-gravida at 28 weeks of gestation presents to
the obstetric clinic with a complaint of vaginal bleeding after
intercourse. An ultrasound scan reveals marginal placenta previa. She
is currently asymptomatic and not experiencing any active bleeding.
What is the most appropriate management for this patient?
A. Immediate hospitalization and bed rest until delivery
B. Scheduled elective cesarean section at 34 weeks of gestation
C. Serial ultrasounds to monitor placental position
D. Vaginal delivery with continuous fetal monitoring
E. Administration of tocolytics to prevent preterm labor
• In cases of marginal placenta previa without active bleeding or significant
symptoms, serial ultrasounds are used to monitor the placental position
and assess whether it migrates away from the cervix as the pregnancy
progresses. This approach helps to determine whether the condition
resolves on its own, reducing the risk of complications.
• Immediate hospitalization and bed rest until delivery (Option A) are
generally not recommended for asymptomatic patients with marginal
placenta previa, as it may lead to unnecessary hospitalization and has not
been shown to be beneficial.
• Scheduled elective cesarean section at 34 weeks of gestation (Option B)
may be considered if the placenta remains over the cervix at term, but this
decision should be based on the results of serial ultrasounds and a
thorough assessment by the healthcare provider.
• Vaginal delivery with continuous fetal monitoring (Option D) and
administration of tocolytics to prevent preterm labor (Option E) are not
appropriate initial management strategies for marginal placenta previa
without active bleeding or other complications.
14. A 29-year-old woman presents with two episodes of bleeding, one
hour apart at 39 weeks gestation. She has no abdominal pain or any
other complaints. Physical exam is inconclusive. An ultrasound scan
reveals placenta previa. Which one of the following is the most
appropriate next step in management?
A. Admit her for supervision.
B. Discharge her home.
C. Induction of labor.
D. Cesarean section.
E . Vaginal examination
15. A 28-year-old woman presents for antenatal visit at 39 weeks
gestation. On examination, the fetus is found to be in transverse lie.
Which one of the following would be the most appropriate next step
in management?
A. Immediate ultrasonography.
B. Vaginal examination.
C. External cephalic version.
D. Lower segment cesarean section.
E. Ask her to come back in two weeks.
• Transverse lie is not a favorable fetal position for a vaginal delivery, and it
increases the risk of complications during labor and delivery. Before
determining the final management approach, it's crucial to confirm the
fetal position accurately through ultrasound. Ultrasonography will confirm
the fetal lie and allow for a more detailed assessment of the fetal
presentation, as well as the presence of any other factors that might be
influencing the position (e.g., multiple pregnancies, placental
abnormalities, or cord issues).
• The management of a transverse lie will depend on the findings from the
ultrasound:
• If the fetus is confirmed to be in a transverse lie, immediate steps should
be taken to consider options for repositioning the fetus, such as ECV if
appropriate and if no contraindications are present.
• If the ultrasound shows other complicating factors or if ECV is unsuccessful,
a LSCS may be indicated to safely deliver the baby.
Contributing factors for unstable lie
• High parity
• Pendulous abdomen
• Placenta previa
• Polyhydramnios
• Pelvic inlet contracture and/or fetal macrosomia
• Uterine abnormalities (e.g. bicornuate uterus or uterine fibroids)
• Fetal anomaly (e.g. tumors of the neck or sacrum, hydrocephaly, abdominal
distension)
• Distended maternal urinary bladder
• Poorly formed lower segment
• Wrong dates i.e. more premature than appears
• Undiagnosed twins
• If transverse lie is identified antenatally, a scan should be undertaken
to exclude placenta praevia, polyhydramnios, lower uterine fibroids or
an enlarged fetal head.
• ECV is usually possible
• She should be advised to come to hospital if there is any suspicion of
early labour, as it may still be possible to carry out an external
cephalic version at that stage, providing the membranes are still
intact
• She should also be advised to present to the hospital immediately if
there is any suspicion of membrane rupture, as there is a risk of cord
prolapse or prolapse of a limb
16. A 37-year-old woman presented to your clinic for an
antenatal check-up. She has past obstetric history of breech
presentation, premature rupture of amniotic membrane and
twin pregnancy. She also had post- natal depression during
her last 2 pregnancies, anaemia and gestational diabetes in
her last Pregnancy. Which ONE of the following would not
increase the risk for cord prolapse during delivery?
A. Multiple gestation
B. Anemia
C. Breech presentation
D. Gestational diabetes
E. Premature rupture of membrane
• Multiple gestation: Having a multiple gestation can increase the risk of
cord prolapse because there is a greater likelihood of abnormal fetal
presentations, including breech presentation, which can allow the cord to
descend before the baby.
• Breech presentation: Breech presentation is a known risk factor for cord
prolapse because the baby's bottom or legs may not effectively block the
cervix, allowing the cord to descend.
• Gestational diabetes: While gestational diabetes itself is not directly
associated with an increased risk of cord prolapse, it can lead to other
complications during pregnancy and delivery that may increase the
likelihood Premature rupture of membranes: PROM can increase the risk
of cord prolapse because there is a lack of cushioning amniotic fluid to
protect the cord from prolapsing through the cervix.
• Anemia: Anemia itself, is not a risk factor for cord prolapse
Risk factors for cord prolapse
17. A 35-year-old woman presented with breech presentation
confirmed on ultrasound at 37 weeks of gestation. External cephalic
version has failed. What is the most appropriate next step in her
management?
A. Steroids
B. Elective cesarian delivery at 38 weeks of gestation
C. Consider vitamin K
D. Emergency cesarean delivery
E. Induce labour now
• Timing of Delivery: Elective cesarean delivery is typically planned at or
after 39 weeks of gestation, which allows for full fetal lung development
and minimizes the risk of preterm birth-related complications. However, in
some cases, delivery might be considered slightly earlier based on
individual circumstances, such as medical conditions or concerns about
fetal well-being.
• Emergency Cesarean Delivery: An emergency cesarean delivery might be
indicated if there is a sudden change in the baby's condition or if there are
signs of fetal distress during labor. However, planning for an elective
cesarean section allows for a more controlled and less urgent delivery.
• Steroids and Vitamin K: Steroids are typically administered when a
preterm birth is anticipated to help with fetal lung maturation. Considering
vitamin K is not directly related to the management of breech
presentation.
Absolute contraindications for ECV
• Where caesarean delivery is required
regardless of presentation (e.g.
placenta praevia)
• Antepartum haemorrhage within the
last 7 days
• Abnormal cardiotocography
• Major uterine anomaly
• Ruptured membranes
• Multiple pregnancy (except delivery
of second twin)
• Absence of maternal consent
Relative contraindications for ECV
• Scarred uterus
• Nuchal cord
• Fetal growth restriction
• Proteinuric pre-eclampsia
• Oligohydramnios
• Major fetal anomalies
• Hyperextended fetal head
• Morbid maternal obesity
18. You are a resident medical officer In a high-risk pregnancy clinic.
One of your patients with past obstetrical history of placenta previa
and cesarean section is found to have breech presentation at 36
weeks gestation. Which one of the following is a risk factor for
increased chance of term breech presentation?

A. Prior cesarean section

B. Nulliparity
C. Fetal anomalies
D. Polyhydramnios
E. All of the above
Contraindications to vaginal breech delivery
• Cord presentation
• Fetal growth restriction (estimated fetal weight< 10th%) or
macrosomia (estimated fetal weight > 3.8kg
• Any presentation other than frank (extended) or complete (flexed)
breech
• Hyperextension of fetal neck on ultrasound
• Evidence of antenatal fetal compromise (e.g. abnormal CTG)
• Fetal anomaly incompatible with vaginal delivery
19. A 20-year-old primigravida at 41 weeks of gestation has had
irregular painful contractions for the last nine hours. Pelvic
examination shows the cervix is fully effaced but only 2-3cm dilated.
The fetal head is at the level of the ischial spines in a left occipito-
posterior (LOP) position. The membranes ruptured one hour ago.
Which one of the following would be the most appropriate next step
in management?
A. Oxytocic (Syntocinon®) infusion.
B. Hydration drip of 5% dextrose.
C. Cross-match blood.
D. Caesarean section.
E. Lumbar epidural block.
• The fetal head is at the level of the ischial spines in a LOP position. An
epidural block can provide effective pain relief while allowing the
labor to progress naturally. It can help the patient cope with the pain
and discomfort of labor, especially in cases where the cervix is not yet
fully dilated.
• Hydration and cross-matching blood may be important in some
situations but are not the primary interventions in this case.
Caesarean section would typically be considered if there were
significant concerns about fetal well-being or if labor was not
progressing safely
20. 19-year-old woman, at 39 weeks of gestation in her second pregnancy,
is admitted hospital because of severe abdominal pain, vaginal bleeding
(900mL) and uterine Contractions. Her previous baby was delivered
vaginally, without difficulty. after a 6hour labour. At the time of her
admission her BP is 95/50mmHg, and pulse rate 120/min. The uterus is
palpable at the level of the xiphisternum, is firm and acutely fender to
palpation, and fetal heart beats cannot be heard on auscultation or
Doppler assessment. The cervix is 3cm dilated and fully effaced. Which one
of the following, in addition to immediate resuscitation, is the most
appropriate next step in management?

A. Caesarean section.
B. Oxytocin (Syntocinon) infusion.
C. Amniotomy.
D. Ultrasound examination of the uterus.
E. Vaginal prostaglandin.
21. A 34-year-old woman from country-side of Victoria presents to
the hospital at 37 weeks gestation after she noticed a sudden gush of
clear fluid per vagina. Uterine contractions are absent. Speculum
examination shows pooling of liquor in the posterior fornix. After 12
hours, she develops fever, tachycardia and chills. Apart from giving
antibiotics, which one of the following would be the next best step in
management?
A. Discharge from hospital after 14 days of antibiotics
B. Induce labour now
C. Perform vaginal examination
D. Continue the pregnancy until natural delivery
E. Give corticosteroids
 RNZCOG-PROM Mx
• Initial assessment of women presenting with term PROM should include
confirmation of the diagnosis, confirmation of gestation, confirmation of
presentation and assessment of maternal and fetal wellbeing.
• In women with ruptured membranes at term, induction of labour within 24
hours is recommended
• Where there is diagnostic uncertainty, a sterile speculum examination should
be performed.
• If uncertainty remains regarding the diagnosis, tests for the presence of
amniotic fluid proteins in vaginal fluid (e.g. Amnisure) may be used.
• In women known to have vaginal Group B streptococcus (GBS) colonisation, or
who are being treated as positive for GBS, prophylactic antibiotics and early
planned birth is recommended.
• In women with ruptured membranes at term, who are negative for GBS, and
where timely induction of labour is planned, antibiotics should not be
prescribed as part of routine care.
• Induction of labour with oxytocin is the usual method of induction, but in
women with an unfavourable cervix, prostaglandins may be used.
22. A 25-year-old woman, who lives 50km from the nearest tertiary referral
obstetric hospital, presents because of premature rupture of her membranes
(PROM) at 26 weeks of gestation, two days ago. This is her first pregnancy and it
had been progressing normally until the time the membranes ruptured. No
contractions have occurred in the last 48 hours, she has been transferred to the
tertiary referral obstetric hospital, glucocorticoid therapy has been given, cervical
swabs collected, prophylactic antibiotics commenced and ultrasound and
cardiotocograph (CTG) assessments made. The cervical swabs showed growth of
normal vaginal flora only, the ultrasound showed almost no liquor was present,
and the CTG was normal and reactive. Which one of the following options is most
appropriate regarding her subsequent care?

A. Prophylactic antibiotic therapy should be continued until delivery occurs.

B. Contraction-inhibiting drugs should be administered from now until established
labour occurs.
C. CTG assessments of the fetal heart rate should be repeated weekly.
D. The white cell count (WCC) and C-reactive protein (CRP) levels should be
assessed every 2-3 days.
E. Labour should be induced now.
23. A 27-year-old woman is in labor at 39 weeks gestation when
passage of meconium is noted. A cardiotocography (CTG) is arranged
that shows a fetal heart rate (FHR) of 149 bpm, a beat-to-beat
variability of 15, no acceleration, and no deceleration. Which one of
the following should be the next best step in management?
A. Fetal scalp blood sampling as there is a 10% chance of hypoxia.
B. Fetal scalp blood sampling as there is a 50% chance of hypoxia.
C. Fetal scalp blood sampling as there is 75% chance of hypoxia.
D. Emergency cesarean section
E. Close monitoring until delivery as there is no abnormality
24. Mary, 27 years old, is admitted to the Maternity Ward after her labor
pain started. After amniotomy, she is placed in the left lateral position and
on supplemental oxygen by nasal canula, and intravenous fluids and
Syntocinon® (oxytocin) infusion is started. A while later and during fetal
heart auscultation, fetal heart rate (FHR) of 70 bpm is noted. CTG is applied
which reveals a baseline fetal heart rate of 140 bpm dropping to 70 bpm
periodically with each episode of bradycardia lasting approximately three
minutes. Which one of the following is the most appropriate next step in
management?
A. Fetal scalp blood sampling.
B. Stop Syntocinon.
C. Immediate cesarean delivery.
D. Continuous CTG monitoring
E. Reposition to supine.
• The significant drop in fetal heart rate (FHR) to 70 bpm with each
episode of bradycardia is concerning and may be indicative of fetal
distress.
• is known to stimulate uterine contractions, and it can sometimes
lead to uterine hyperstimulation, which in turn can reduce blood flow
to the fetus and result in bradycardia. Therefore, discontinuing the
oxytocin infusion is a critical step to see if it resolves the FHR
abnormalities and improves fetal well-being.
• Continuous CTG monitoring should continue to assess the fetal heart
rate response after stopping Syntocinon. If the FHR does not improve
or if there are signs of ongoing fetal distress, further interventions,
such as fetal scalp blood sampling or considering immediate cesarean
delivery, may be necessary. The decision to proceed with a cesarean
section would depend on the ongoing assessment of fetal well-being
and clinical judgment
25. A 28-year-old pregnant woman is involved in a car accident at 26
weeks gestation,while wearing seatbelt. On examination, there are
visible bruises on the abdomen. She is otherwise normal. Fetal heart
sounds are audible and within normal parameters and CTG is
reassuring. Which one of the following the next best step in
management?
A. Observe for six hours and discharge home
B. Admit her and observe for 24 hour
C. Perform a continuous 30-minute CTG and discharge home if
reassuring
D. Perform 24-hour cardiotocography (CTG) monitoring
E. Reassure and discharge home
26. A 35-year-old 'grand multiparous' woman, with seven children
previously born by vaginal delivery, had a normal delivery of a live
baby weighing 4750gm one hour ago after a three-hour labour. She is
now suddenly found to be profoundly shocked (pulse 140/min, BP
80/50mmHg) after an apparently normal and spontaneous third stage
of labour. Total blood loss at the time of delivery of the placenta was
500ml, and the vaginal blood loss since then has not been excessive.
Which one of the following is the most likely diagnosis?
A. Acute inversion of the uterus.
B. Overwhelming infection.
C. Uterine atony.
D. Amniotic fluid embolism.
E. Uterine rupture.
27. A31-year-old G2P1 woman presented to the maternity unit at 38 weeks
gestation and in labour. Her previous pregnancy led to caesarean section
and delivery of a healthy baby. The current pregnancy had been uneventful
without any remarkable problems in antenatal visits except first trimster
nausea and vomiting. On arrival, she had a cervical dilation of 4 cm and the
fetal head was at -1 station. After 5 hours, the cervical length and fetal
head station are still the same despite regular uterine contractions.
Suddenly, there is sudden gush of blood of approximately 1000 mL and the
fetal heart rate drops to 80 bpm on CTG. Which one of the following could
be the most likely cause?
A. Lower genital tract lacerations.
B. Placenta previa.
C. Placenta accreta.
D. Uterine atony.
E. Ruptured uterus.
 Uterine Rupture
• Abdominal Pain: Sudden and severe abdominal
pain is a common symptom of uterine rupture.
This pain can be localized or may spread
throughout the abdomen.
• Fetal Distress: The baby's heart rate may show
signs of distress on fetal monitoring. This can
include a sudden bradycardia, variable
decelerations, or other abnormal patterns.
• Vaginal Bleeding: Vaginal bleeding may occur, but
it is not always present, and the amount can vary.
• Hypovolemic Shock: If there is significant internal
bleeding due to uterine rupture, the mother may
go into hypovolemic shock, characterized by
symptoms such as rapid heart rate, low blood
pressure, confusion, pallor, and cold, clammy skin.
• Abnormal Uterine Contractions: Contractions may
become erratic or stop altogether if the uterus
ruptures. This can lead to a lack of progress in
labor.
Risk factors
• Previous caesarean section – this is the
greatest risk factor for uterine rupture.
• Classical (vertical) incisions carry the
highest risk.
• Previous uterine surgery – such as
myomectomy.
• Induction – (particularly with
prostaglandins) or augmentation of
labour.
• Obstruction of labour – this is an
important risk factor to consider in
developing countries.
• Multiple pregnancy.
• Multiparity.
28. A 30-year-old woman at 37 weeks of gestation presented with a history
of sudden onset of severe abdominal pain, vaginal bleeding, and cessation
of contractions after 18 hours of active pushing at home. She has been fine
otherwise antenatally . On examination, she is conscious and pale .Vital
signs include blood pressure 70/45 mmHg, and pulse 115 beats per minute
and weak. The abdomen is irregularly distended. Shifting dullness and fluid
thrill, both are present. Fetal heart sounds are not audible. What is the
most likely diagnosis?

A. Disseminated intravascular coagulation

B. Shoulder dystocia
C. Placenta previa
D. Uterine rupture
E. Placental abruption
29. A 25-year-old woman, in her first pregnancy, has been in spontaneous labour at term for 6
hours. The membranes ruptured two hours ago and the liquor was meconium stained.
Cardiotocography (CTG) was therefore commenced and showed some intermittent late
decelerations, from 140 down to 110/min. Vaginal examination showed the cervix was 5cm
dilated, the presentation was cephalic, position left occipitotransverse (LOT), and the bony head
was at the level of the ischial spines (IS). Because of the deceleration pattern a fetal scalp pH
estimation was performed and the pH was shown to be 7.32. One hour later the CTG showed the
following pattern over the preceding period of 30 minutes.
Baseline- 140/min
Baseline variability - 1/min
Accelerations- none
Decelerations - Two decelerations were evident, with the heart rate falling to 80/min, and with
each lasting 4 minutes.
Vaginal examination at that time showed the cervix was 8cm dilated but was otherwise
unchanged from one hour previously. Which one of the following would be the most appropriate
next step in management?
A. Immediate delivery by Caesarean section.
B. Further fetal scalp pH assessment.
C. Allow labour to proceed with continuous CTG evaluation.
D. Augment labour with Syntocinon /oxytocin.
E. Perform a ventouse delivery
• Abnormal FHR patterns, especially with reduced baseline variability,
prolonged decelerations and lack of accelerations, are significant
concerns. Late decelerations and prolonged decelerations, which
suggest reduced oxygen supply to the fetus and are concerning signs
of fetal distress.
• Emergency LSCS is the best option
30. In the event of chord prolapse during labor, which one of the
following findings is more likely on CTG monitoring?
A. Sinusoidal pattern.
B. Early decelerations.
C. Variable decelerations.
D. Late decelerations.
E. Fetal tachycardia.
• Umbilical cord prolapse can lead to compression or occlusion of the
umbilical cord, which can result in variable decelerations in FHR. .
• Sinusoidal pattern pattern can also be associated with fetal distress, it
is a distinct pattern characterized by a smooth, sine-like waveform,
not typically seen in cord prolapse.
• Early decelerations are typically caused by head compression during
contractions and are not directly related to cord prolapse.
• Late decelerations are associated with uteroplacental insufficiency
and can occur for various reasons but are not specific to cord
prolapse.
• Fetal tachycardi can be a sign of fetal distress, but it is not a direct
indicator of cord prolapse.
31. A 31-year-old woman gave birth to a baby of normal weight
through vaginal delivery. The delivery was complicated by a small
perianal tear that was taken care of without stitching. Today on the
fifth day postpartum, she presents with heavy bright red vaginal
bleeding. She mentions that the lochia was in scant amounts after
delivery compared to her previous pregnancy. On examination, she
has a temperature of 38.8°C. The uterus is mildly tender to palpation.
Which one of the following could be the most likely diagnosis?
A. Endometritis.
B. Infection of the perianal tear.
C. Retained products of conception
D. Cervical tear
E. Uterine rupture
Primary PPH Secondary PPH
Excessive bleeding that occurs after the first 24
Excessive bleeding (>500 mL) within 24 hours
hours but within the first 12 weeks postpartum
- Uterine atony - Retained placental tissue
- Trauma to the birth canal or uterus - Uterine infection or endometritis
- Coagulation disorders - Subinvolution of the uterus
- Retained placental tissue - Uterine fibroids
- Uterine inversion - Endometrial polyps
- Uterine rupture - Bleeding disorders or coagulopathies
- Coagulation disorders - Arteriovenous malformations
- Abnormal placentation (e.g., placenta previa) - Cervical or vaginal lacerations
- Pelvic inflammatory disease (PID)
- Maternal systemic infections
- Medication-related (e.g., anticoagulants)
 PPH due to Endometritis
Typically occurs within a few
Timing of Presentation
days to weeks postpartum.
Heavy vaginal bleeding may be
Vaginal Bleeding
present, often with a foul odor.
Fever and Infection Fever, chills, malaise, and
Signs other signs of infection are common.
Uterine tenderness is often
Uterine Tenderness present and can be a sign of
infection.
Lochia may have a foul odor
Lochia Characteristics
and may be persistently heavy.
PPH due to Retained Products
Can occur within the immediate
postpartum period or weeks after
childbirth.
Heavy vaginal bleeding may
be present, but the bleeding
may not always have an odor.
May or may not be associated
with fever or infection signs.
Uterine tenderness may or may
not be present, depending on
the extent of retained tissue.
Lochia may be heavier and have
a foul odor if infection is
present.
the presence of complications.
• Lochia Rubra: This is the initial stage of postpartum bleeding and
usually lasts for the first 3 to 5 days after childbirth. Lochia rubra is
characterized by bright red blood and contains small blood clots. It is
similar in appearance to a heavy menstrual period.
• Lochia Serosa: Following the lochia rubra stage, lochia serosa typically
begins around day 4 or 5 and can last up to around day 10
postpartum. Lochia serosa is pink or brownish in color and consists of
a mixture of blood, mucus, and white blood cells. It is less heavy than
lochia rubra.
• Lochia Alba: After the serosa stage, lochia alba takes over and can last
from about day 10 postpartum to several weeks after childbirth.
Lochia alba is lighter in color, typically pale yellow or white, and
contains mainly mucus, white blood cells, and uterine tissue. It
resembles the discharge seen in the later stages of a menstrual
period.
32. A 28-year-old woman attends the mental health antenatal clinic
at 12 weeks for a booking assessment. This is her first baby. Which
condition gives her the highest risk of puerperal psychosis?
A. Anorexia nervosa
B. Bipolar affective disorder
C. Moderate depression
D. Obsessive compulsive disorder
E. Recurrent anxiety
33. A 28-year-old woman visits her general practitioner for a routine check-up 6
weeks after giving birth to her first child. She reports feeling persistently sad,
fatigued, and overwhelmed since the birth of her baby. She also mentions
difficulty sleeping and changes in appetite. Physical examination shows no
abnormalities. She denies any thoughts of harming herself or the baby. The
patient has a history of major depressive disorder but was in remission before
pregnancy. What is the most appropriate next step in management?
A. Prescribe a TCA antidepressant medication immediately.
B. Refer to a psychiatrist for electroconvulsive therapy (ECT).
C. Recommend starting individual psychotherapy.
D. Reassure the patient that her symptoms are a normal part of the postpartum
period.
E. Initiate a trial of SSRIs after discussing risks and benefits
• Women with a history of bipolar affective disorder are at a significantly higher
risk of experiencing puerperal psychosis compared to other mental health
conditions. Bipolar disorder involves periods of mania and depression. The
hormonal and emotional changes that occur during pregnancy and the
postpartum period can potentially trigger episodes of mania or psychosis in
individuals with a history of bipolar disorder.
• The other conditions listed (anorexia nervosa, moderate depression, obsessive-
compulsive disorder, recurrent anxiety) are not typically associated with as high a
risk of puerperal psychosis as bipolar disorder. However, any history of mental
health conditions should be discussed with healthcare providers during
pregnancy to ensure appropriate support and management.
34. A 24-year-old woman presents to local emergency department
three days after caesarean section at 37 weeks of gestation, with lower
abdominal pain, fever, a headache and lethargy. On examination, her
temperature is 39.6c, heart rate is 120 beats per minute, blood
pressure is 102/70 mmHg. There is purulent lochia discharge noticed
on vaginal examination. She is breastfeeding her baby and is known to
have an anaphylactic allergy to penicillin. What is the most appropriate
treatment?
A. Clindamycin
B. Cefuroxime
C. Gentamicin
D. Metronidazole
E. Gentamicin and clindamycin
• Penicillin Allergy: The patient has a documented anaphylactic allergy to
penicillin, which rules out the use of penicillin-based antibiotics.
• Broad-Spectrum Coverage: Gentamicin and clindamycin together provide
broad-spectrum coverage against a range of potential pathogens that can
cause postoperative infections.
• Clindamycin is effective against anaerobic bacteria, and gentamicin covers
many aerobic gram-negative bacteria.
• Combination Therapy: Combining antibiotics with different mechanisms of
action can be more effective in treating serious infections and preventing
the development of antibiotic resistance.
• Cefuroxime is a cephalosporin antibiotic and is generally not considered
the first-line choice for treating postpartum infections like endometritis
when there are other suitable alternatives available.
35. A 24-year-old lady delivered a male baby at 35 weeks of
gestation.She wasdiagnosed with gestational hypertension at 22 weeks
of the same pregnancy.Her blood pressure is 170/100 post-partum. She
is motivated to breastfeed her baby Which of the following medication
to treat her blood pressure is safe for both mother and the baby?

A. Frusemide
B. Atenolol
C. Lisinopril
D. Metoprolol
E. Prazosin
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