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Question 1
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A patient is seen in the gynaecology outpatient clinic and is noted to have large volume genital warts perianally and near the urethral meatus. You discuss treatment options and the patient opts for LASER therapy. Which of the following is the most appropriate type of LASER to use?
Your Answer: CO2
Explanation:Vulval intraepithelial neoplasia is a premalignant condition which is associated with HPV or lichen sclerosis. Biopsy is essential for diagnosis. Treatment depends of the patients choice and include surgical excision of the area or laser therapy with CO2. Other treatment modalities include immunomodulating creams.
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This question is part of the following fields:
- Biophysics
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Question 2
Correct
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A patient undergoes oophorectomy and the ovarian veins are ligated. Which vein does the right ovary drain into?
Your Answer: Inferior vena cava
Explanation:The right ovarian vein travels through the suspensory ligament of the ovary and generally joins the inferior vena cava whereas the left ovarian vein drains into the left renal vein.
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This question is part of the following fields:
- Anatomy
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Question 3
Incorrect
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Which of the following causes of polyhydramnios is more common?
Your Answer: Anencephaly
Correct Answer: Idiopathic
Explanation:Maternal disorders, such as diabetes, in-utero infections, drug usage, placental abnormalities and fetal conditions as congenital and chromosomal abnormalities, Rh iso-immunization, and multiple gestations, are generally associated with polyhydramnios. Congenital abnormalities such as duodenal, oesophageal, or intestinal atresia of the foetus are the most common malformations that typically cause gastro-intestinal obstruction and interfere with fetal swallowing and/or absorption resulting with polyhydramnios. However, in about 70% of cases, none of the aforementioned aetiologies are causes of polyhydramnios, and it is referred to as idiopathic or isolated.
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This question is part of the following fields:
- Physiology
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Question 4
Correct
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A 23-year-old woman, G1PO comes to your clinic at 12 week of pregnancy. She is complaining of mild vaginal bleeding for the past 12 hours, along with bouts of mild cramping lower abdominal pain. On vaginal examination, the cervical os is closed with mild discharge containing blood clots and an ultrasonography confirms the presence of a live fetus with normal heart rate. Which among of the following is the most likely diagnosis?
Your Answer: Threatened abortion
Explanation:Uterine bleeding in the presence of a closed cervix along with sonographic visualization of an intrauterine pregnancy with detectable fetal cardiac activity are diagnostic of threatened abortion.
Abortion does not always follow a uterine bleeding in early pregnancy, sometimes not even after repeated episodes or large amounts of bleeding, that is why the term “threatened” is used in this case. In about 90 to 96% cases, the pregnancy continues after vaginal bleeding if occured in the presence of a closed os and a detectable fetal heart rate. Also as the gestational age advances its less likely the condition will end in miscarriage.
In cases of inevitable abortion, there will be dilatation of cervix along with progressive uterine bleeding and painful uterine contractions. The gestational tissue can be either felt or seen through the cervical os and the passage of this tissue occurs within a short time.
In case were the membranes have ruptured, partly expelling the products of conception with a significant amounts of placental tissue left in the uterus is called as incomplete abortion. During the late first and early second trimesters this will be the most common presentation of an abortion. Examination findings of this includes an open cervical os with gestational tissues observed in the cervix and a uterine size smaller than expected for gestational age and a partially contracted uterus. The amount of bleeding will vary but can be severe enough to cause hypovolemic shock, with painful contractions and an ultrasound revealing tissues in the uterus.
An in utero death of the embryo or fetus prior to 20 weeks of gestation is called as a missed abortion. In this case the women may notice that the symptoms associated with early pregnancy like nausea, breast tenderness, etc have disappeared and they don’t ‘feel pregnant’ anymore. Vaginal bleeding may occur but the cervix remains closed and the ultrasound done reveals an intrauterine gestational sac with or without an embryonic/fetal pole, but no embryonic/fetal cardiac activity will be noticed.
In case of complete abortion, miscarriage occurs before the 12th week and the entire contents of conception will be expelled out of uterus. If this case, the physical examination will show a small and well contracted uterus with an open or closed cervix. There is scant vaginal bleeding with only mild cramping and ultrasound will reveal an empty uterus without any extra-uterine pregnancy.
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This question is part of the following fields:
- Obstetrics
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Question 5
Correct
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Management of a patient with threatened abortion includes all of the following, EXCEPT:
Your Answer: Dilatation and curettage
Explanation:Patients with a threatened abortion should be managed expectantly until their symptoms resolve. Patients should be monitored for progression to an inevitable, incomplete, or complete abortion. Analgesia will help relieve pain from cramping. Bed rest has not been shown to improve outcomes but commonly is recommended. Physical activity precautions and abstinence from sexual intercourse are also commonly advised. Repeat pelvic ultrasound weekly until a viable pregnancy is confirmed or excluded. A miscarriage cannot be avoided or prevented, and the patients should be educated as such. Intercourse and tampons should be avoided to decrease the chance of infection. A warning should be given to the patient to return to the emergency department if there is heavy bleeding or if the patient is experiencing light-headedness or dizziness. Heavy bleeding is defined as more than one pad per hour for six hours. The patient should also be given instructions to return if they experience increased pain or fever. All patients with vaginal bleeding who are Rh-negative should be treated with Rhogam. Because the total fetal blood volume in less than 4.2 mL at 12 weeks, the likelihood of fetal blood mixture is small in the first trimester. A smaller RhoGAM dose can be considered in the first trimester. A dose of 50 micrograms to 150 micrograms has been recommended. A full dose can also be used. Rhogam should ideally be administered before discharge. However, it can also be administered by the patient’s obstetrician within 72 hours if the vaginal bleeding has been present for several days or weeks.
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This question is part of the following fields:
- Obstetrics
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Question 6
Correct
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A 24 year old who is 32 weeks pregnant presents with a rash to the abdomen. Looking at the picture below what is the diagnosis?
Your Answer: Polymorphic Eruption of Pregnancy
Explanation:This is Polymorphic Eruption of Pregnancy (PEP) also known as Pruritic Urticarial Papules and Plaques of Pregnancy (PUPPP). Papules and plaques form on the abdomen (commonly within striae). It is most common in women during their first pregnancy and typically occurs in the 3rd trimester.
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This question is part of the following fields:
- Clinical Management
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Question 7
Correct
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A 51-year-old woman comes to your doctor's office for a breast cancer screening. For the past year, she has been on combination hormone replacement treatment (HRT). Mammography is the sole accessible form of breast cancer screening, and she is predicted to have dense breast tissue due to HRT. Which of the following is the best HRT and breast cancer screening suggestion for this patient?
Your Answer: Continue HRT and perform mammography as recommended for other women
Explanation:Among a variety of imaging modalities developed for breast cancer screening, mammography is the best-studied and the only imaging technique that has been shown to decrease mortality as demonstrated in multiple randomized trials. However, it is important to know that, even in the best circumstances, mammography may miss up to 20 percent of underlying breast cancers.
Women on HRT are likely to have dense breast. Dense breasts are associated with an increased risk of breast cancer and can decrease the sensitivity of mammography for small lesions. Nevertheless, we do not alter our general approach to age- and risk-based screening based on breast density. However, for women with dense breasts, we do prefer digital mammography over film mammography, due to greater sensitivity; digital mammography is the modality typically used for mammography in most locations in the United States.
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This question is part of the following fields:
- Gynaecology
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Question 8
Correct
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Which of the following is the most accurate estimate of mature breast milk composition?
Your Answer: Fat 4%, Protein 1%, Sugar 7%
Explanation:Breast milk contains around 4% fat, 7% sugar and 1% proteins. The rest is water and minerals.
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This question is part of the following fields:
- Clinical Management
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Question 9
Correct
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Question 10
Incorrect
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48 hours after having unprotected intercourse, a 16-year-old female requested a pregnancy test from her GP. What advice can you give her regarding the reliability of pregnancy testing at this time?
Your Answer: Even if conception has already occurred, beta hCG is likely to be normal
Correct Answer:
Explanation:Even if conception has already occurred, beta hCG is likely to be normal. Beta hCG is made by syncytiotrophoblast cells following conception. It then activates the corpus luteum to continuously produce progesterone for implantation to happen. In week 10/40, levels of HCG peak and the placenta can produce adequate progesterone by itself. As a general rule, a beta HCG concentration >25 U/I or a doubling of levels of HCG within two days is required to diagnose pregnancy. A urine pregnancy test would only likely prove positive around 8 days to 2 weeks following conception.
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This question is part of the following fields:
- Gynaecology
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Question 11
Correct
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If your patient is 8 weeks pregnant which one of the following USS measurements is most useful?
Your Answer: Crown rump length
Explanation:Fetal crown-rump length (CRL) is recommended over last menstrual period for estimating GA when measured in early pregnancy i.e. before 9 to 13+6 weeks.
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This question is part of the following fields:
- Anatomy
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Question 12
Incorrect
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A 50-year-old third-generation Australian woman presents with intermittent lower abdominal pain. An abdominal ultrasound was performed and showed a probable malignancy involving the left ovary. The report suggests that the ovarian lesion may represent a metastatic disease. Which one of the following is the most appropriate investigation that will likely show the site of the primary tumour?
Your Answer: Computed tomography (CT) of the abdomen.
Correct Answer: Colonoscopy.
Explanation:This woman presents with a metastatic tumour of the ovary. Being from Australia is a hint in this question as the likely site of the primary tumour can vary depending on the country the patient is in and the availability of screening mammography. In underdeveloped countries, breast cancer is usually diagnosed later in life as screening mammography is generally not available, making the most likely site of the primary tumour in the breast. In Japan, where the incidence of stomach cancer is much higher than in western countries, the most likely primary site would be the stomach with a Krukenberg tumour in both ovaries. In Australia, mammographic screening is recommended every other year for all women over the age of 50, and so the most likely primary site would be the colon.
The most appropriate work-up to find the primary tumour in this patient would be performing a colonoscopy. A computed tomography (CT) of the abdomen may miss a small tumour, and an ultrasound examination would not be able to diagnosis a colon cancer. Mammography would be the correct response in under-developed countries. A lung malignancy would be detectable by chest X-ray, but would rarely cause a metastasis in the ovary.
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This question is part of the following fields:
- Gynaecology
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Question 13
Correct
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During vertex presentation, the position is determined by relationship of which part of the fetal vertex to the mother's pelvis?
Your Answer: Occiput
Explanation:A cephalic presentation is the one where head of the foetus enters the pelvic cavity at the time of delivery. The commonest form of cephalic presentation is the vertex presentation in which the occiput of the foetus enters the birth canal.
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This question is part of the following fields:
- Anatomy
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Question 14
Correct
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Regarding the pubic symphysis, what type of joint is it
Your Answer: Secondary Cartilaginous
Explanation:The pubic symphysis is a cartilaginous joint. The cartilaginous joints are divided further into primary and secondary joints. The primary joint is called the synchondrosis. It articulates with the pubis of the other side.
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This question is part of the following fields:
- Anatomy
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Question 15
Correct
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Which one of the following features indicates complete placental separation after delivery?
Your Answer: All of the options given
Explanation:At the time of delivery, the most important signs of complete placental separation are lengthening of the umbilical cord, per vaginal bleeding and change in shape of uterus from discoid to globular shape. The uterus contracts in size and rises upward.
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This question is part of the following fields:
- Obstetrics
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Question 16
Correct
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Which one of the following combination hormonal contraceptives is most effective in obese women?
Your Answer: The etonogestrel/ethinyl oestradiol vaginal ring (NuvaRing)
Explanation:Depot medroxyprogesterone acetate and the combination contraceptive vaginal ring are the most effective hormonal contraceptives for obese women because they do not appear to be affected by body weight. Women using the combination contraceptive patch who weight 90 kg may experience decreased contraceptive efficacy. Obese women using oral contraceptives may also have an increased risk of pregnancy.
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This question is part of the following fields:
- Gynaecology
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Question 17
Incorrect
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During normal pregnancy, the renal glomerular filtrate rate (GFR) can increase as much as:
Your Answer: 75%
Correct Answer: 50%
Explanation:Pregnancy involves remarkable orchestration of physiologic changes. The kidneys are central players in the evolving hormonal milieu of pregnancy, responding and contributing to the changes in the environment for the pregnant woman and foetus. The functional impact of pregnancy on kidney physiology is widespread, involving practically all aspects of kidney function. The glomerular filtration rate increases 50% with subsequent decrease in serum creatinine, urea, and uric acid values.
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This question is part of the following fields:
- Physiology
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Question 18
Correct
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Which of the following structures does the broad ligament contain?
Your Answer: Uterine artery
Explanation:The broad ligament is one of the secondary supporting structures of the uterus which attaches the lateral portion of the uterus to the pelvic sidewall. The broad ligament primarily serves a protective layer for important structures including the fallopian tubes, the ovaries, the ovarian arteries, and the uterine arteries, the round and ovarian ligaments, and the infundibulopelvic ligaments.
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This question is part of the following fields:
- Anatomy
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Question 19
Correct
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A 24-year-old nulliparous lady has lately started having sexual encounters. She seeks your advice since she is experiencing painful coitus at the vaginal introitus. It's accompanied by painful involuntary pelvic muscular contractions. The pelvic examination is normal except for confirmation of these findings. The most prevalent cause of this ailment is one of the following?
Your Answer: Psychogenic causes
Explanation:Vaginismus is an uncontrollable painful spasm of the pelvic muscles and vaginal exit that this patient has. It’s mainly caused by psychological factors. It’s important to distinguish it from frigidity, which indicates a lack of sexual desire, and dyspareunia, which is characterized as pelvic and/or back pain or other discomfort linked with sexual activity. Endometriosis, pelvic adhesions, and ovarian neoplasms are all common causes of dyspareunia. Vaginismus pain can be psychogenic, or it might be caused by pelvic diseases like adhesions, endometriosis, or leiomyomas. Organic vulvar or pelvic reasons (such as atrophy, Bartholin gland cyst, or abscess) are extremely rare, hence vaginismus is mostly treated with psychotherapy.
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This question is part of the following fields:
- Gynaecology
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Question 20
Correct
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Sertoli cells contain receptors to which hormone?
Your Answer: FSH
Explanation:Sertoli cells contain receptors for FSH. In response to this Sertoli cells synthesize inhibin, androgen binding proteins and anti Mullerian hormone all which are connected to the reproduction cycle.
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This question is part of the following fields:
- Anatomy
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Question 21
Correct
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A 21 year old patient presents to the clinic with a 48 hour history of unprotected sexual intercourse. She is not on any form of contraception. After discussion you prescribe a dose of Ulipristal 30 mg stat. Which of the following would be the appropriate advice regarding vomiting?
Your Answer: If vomiting occurs within 3 hours a repeat dose should be taken
Explanation:Ulipristal acetate is a selective progesterone receptor modulator which regulates the luteinizing hormone (LH) surge, preventing ovulation. This emergency contraceptive can be used up to five days after unprotected sexual intercourse and is given as a 30mg oral dose. If vomiting occurs within three hours, then a second tablet is needed to ensure its effects.
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This question is part of the following fields:
- Clinical Management
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Question 22
Correct
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Which species of candida is the most common cause of genital candida infection in pregnancy?
Your Answer: Candida albicans
Explanation:Vulvovaginal candidiasis is the most common genital infection and it is caused by candida albicans in 80-92% of the cases. Other non albicans species include C.tropicalis, C.glabrata, C.krusei and C.parapsilosis. 20% of women of childbearing age are asymptotic colonisers of Candida species as part of their normal vaginal flora. This increases to 40% in pregnancy.
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This question is part of the following fields:
- Clinical Management
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Question 23
Incorrect
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Regarding electronic fetal monitoring, which one of the following statements is true?
Your Answer: Has high specificity but low sensitivity
Correct Answer: Has low specificity but high sensitivity
Explanation:There are different ways of monitoring fetal heart rate during pregnancy. It can be done by just auscultation or by electronic fetal heart rate monitoring which is done with the help of an ultrasound machine and has a low specificity but high sensitivity.
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This question is part of the following fields:
- Physiology
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Question 24
Correct
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A 26 year old patient with a past medical history of 2 terminations of pregnancies over the past 2 years, presents to the emergency centre complaining of severe abdominal pain and some vaginal bleeding. She has a regular 28 day cycle, and is on an oral contraceptive pill, but missed last month's period. Her last termination was over 6 months ago. She smokes almost a pack of cigarettes a day. Which of the following is the most likely diagnosis?
Your Answer: Ectopic pregnancy
Explanation:The clinical picture demonstrated is most likely that of a ruptured ectopic pregnancy. The period of amenorrhea may point to pregnancy, while the past medical history of 2 recent terminations of pregnancy may indicate a failure of her current contraceptive method. Smoking cigarettes have been shown to not only decrease the efficacy of OCPs, but also serve as a known risk factor for ectopic pregnancy. The lady is unlikely to have endometritis as her last termination was over 6 months ago. The lack of fever helps to make appendicitis, PID and pyelonephritis less likely, though they are still possible.
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This question is part of the following fields:
- Clinical Management
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Question 25
Incorrect
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Fetal urine production starts at what gestation?
Your Answer: 5-7 weeks
Correct Answer: 8-11 weeks
Explanation:Fetal urine contributes significantly to amniotic fluid production in the second trimester of pregnancy. As early as 8-11 weeks, urine production begins and can be observed in the fetal bladder on ultrasound scans. The urine creates a hypotonic fluid which contains increasing concentrations of urea and creatinine. By term, a foetus produces about 800 ml of urine a day, of which 250ml is eliminated through fetal swallowing.
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This question is part of the following fields:
- Clinical Management
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Question 26
Correct
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You see a patient who gave birth earlier in the day. She was taken off warfarin during pregnancy and is currently on LMWH. She intends to breastfeed for the first 6-8 weeks and wants advice regarding restarting warfarin. Which of the following is appropriate?
Your Answer: Recommence warfarin in 5-7 days
Explanation:The use of anticoagulants during pregnancy is a complicated issue because warfarin is teratogenic if used in the first trimester, and is linked with fetal intracranial haemorrhage in the third trimester (mainly at doses 5 mg daily). Low molecular weight heparin may be insufficient at preventing thrombosis in women with mechanical prosthetic heart valves, where the risk of valve thrombus is 10 per cent. Anticoagulation is essential in patients with congenital heart disease who have pulmonary hypertension, or artificial valve replacements, and in those in or at risk of atrial fibrillation. The options are either to continue warfarin for the pregnancy, or replace it with heparin between 6 and 12 weeks gestation to avoid the teratogenic risk. Warfarin should be started a week after delivery.
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This question is part of the following fields:
- Pharmacology
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Question 27
Correct
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Regarding lymph drainage of the lower vagina where does the majority of lymph drain to?
Your Answer: Inguinal nodes
Explanation:Lymphatic vessels from the vagina drain from the parts of the vagina as follows:
• Superior part: to the internal and external iliac lymph nodes.
• Middle part: to the internal iliac lymph nodes.
• Inferior part: to the sacral and common iliac nodes. -
This question is part of the following fields:
- Anatomy
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Question 28
Correct
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The resting pulse in pregnancy is:
Your Answer: Increased by 10 to 15 bpm
Explanation:During pregnancy cardiac output increases by 30 to 50%. As a result, the resting pulse speeds up from a normal of about 70 bpm to 80 or 90 bpm.
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This question is part of the following fields:
- Physiology
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Question 29
Correct
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A 32-year-old woman visited your clinic at her 30th week of gestation, complaining of left lower limb pain. The doppler ultrasound findings had confirmed proximal deep vein thrombosis and she was treated with low molecular weight heparin. Now she is at her 34 weeks of gestation, and is expecting delivery in next four weeks. What would be your advice for her today?
Your Answer: Low molecular weight heparin should be switched to unfractionated heparin
Explanation:This patient has developed deep vein thrombosis during pregnancy and required anti-coagulation as part of treatment for up to 3-6 months. Enoxaparin, which is a low molecular weight heparin, is preferred over heparin due to the once or twice a day therapeutic dosing. Also monitoring of aPTT is not required in this case.
There is an association between Enoxaparin and an increased risk for epidural hematoma in women receiving epidural anaesthesia during labour. Considering that the patient mentioned is expected to go for delivery in 4 weeks and the possibility of her needing an epidural anaesthesia or general anaesthesia in case of undergoing a cesarean section, enoxaparin should be switched to unfractionated heparin, four weeks prior to the anticipated delivery. This is because of the fact that heparin can be antidoted with protamine sulphate.
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This question is part of the following fields:
- Obstetrics
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Question 30
Correct
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A 45 year old women is seen in clinic following hysteroscopy and biopsy due to irregular menstrual bleeding. Her BMI is 34 kg/m2. This shows atypical hyperplasia. Which of the following is the most appropriate 1st line management?
Your Answer: Laparoscopic hysterectomy
Explanation:Endometrial hyperplasia with atypia is at high risk of progression to cancer and hysterectomy is indicated There is high risk of progression to cancer with endometrial hyperplasia with atypia and hysterectomy is indicated. Although weight loss would be beneficial this shouldn’t delay surgical management.
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This question is part of the following fields:
- Clinical Management
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