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MRCOG PART 2 SBAs and EMQs

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SBA 8

SBA 8 Posted by PAUL A.

Question 1

A healthy 37 year old woman with known placenta previa presents with vaginal bleeding at 34 weeks gestation. Pulse = 80/min, BP = 132/87 mmHg and fetal heart rate is normal. Bleeding has stopped and she is admitted to the antenatal ward. The most appropriate thromboprophylaxis is

A. Low molecular weight heparin

B. Low molecular weight heparin if no bleeding for 48 hours

C. Anti-embolic stockings

D. Unfractionated heparin

E. Mobilization & avoid dehydration

 

 

 

Question 2

A 23 year old woman with type 1 diabetes attends the antenatal clinic at 8 weeks gestation in her second pregnancy. She had deep vein thrombosis at the age of 18 related to use of the combined oral contraceptive pill.

a) Low molecular weight heparin from 8 weeks

b) Low molecular weight heparin after 11-14 weeks scan

c) Low molecular weight heparin from 28 weeks

d) Low molecular weight heparin for at least 10 days post-partum if vaginal birth

e) Low molevular weight heparin for at least 6 weeks post-partum if caesarean section

 

 

Question 3

A healthy 32 year old woman attends the antenatal clinic at 12 weeks gestation in her first pregnancy. At the age of 20 years, she suffered a ruptured appendix requiring laparotomy. Three weeks post-operatively, she suffered pulmonary embolism. Her BMI is 25 kg/m2 and she has a singleton pregnancy.

a) Reassure and manage as low-risk

b) Refer to haematologist

c) Prophylactic low molecular weight heparin from 28 weeks

d) Prophylactic low molecular weight heparin from 12 weeks

e) Low molecular weight heparin for 3-5 days post-partum if vaginal birth

 

Question 4

A 33 year old woman attends the antenatal clinic at 8 weeks gestation. She has a 20 years history of type I diabetes with retinopathy and nephropathy. Her blood glucose is well controlled with a multi-dose insulin regimen. Her BMI = 23 kg/m2, pulse = 78/min, BP = 120/88 mmHg and urine analysis shows 3+ protein. Urinary protein creatinine ratio = 98 mg/mmol. With specific reference to thromboprophylaxis during pregnancy

a) Low molecular weight heparin from 28 weeks

b) Consider low molecular weight heparin from 8 weeks

c) Consider low molecular weight heparin from 12 weeks

d) Unfractionated heparin from 28 weeks

e) Low molecular weight heparin if 24 hour urine shows > 5g protein

 

 

Question 5

A 23 year old woman attends the antenatal clinic at 10 weeks gestation in her first pregnancy. She has a 10 year history of type 1 diabetes but no secondary diabetic complications. Her blood glucose levels are within the target range with a multi-dose insulin regimen. BMI – 22 kg/m2, BP = 122/83 mmHg and urine analysis is normal. She has no other risk factors.

a) Aspirin from 12 weeks

b) Low molecular weight heparin from 10 weeks

c) Aspirin from 12 weeks plus low molecular weight heparin from 28 weeks

d) Consider low molecular weight heparin from 10 weeks + aspirin from 12 weeks

e) Consider low molecular weight heparin from 28 weeks

 

Question 6

A 33 year old woman attends the antenatal clinic at 12 weeks gestation in her first pregnancy. She has a 10 year history of systemic lupus erythematosus that has been in remission for 2 years. She was taking NSAIDs but discontinued these before pregnancy. Her BMI = 28 kg/m2, BP = 133/67 mmHg and urine analysis is normal.

a) Aspirin from 12 weeks

b) Aspirin + low molecular weight heparin from 12 weeks

c) Aspirin from 12 weeks + low molecular weight heparin from 28 weeks

d) Low molecular weight heparin from 12 weeks

e) Low molecular weight heparin from 28 weeks

 

 

Question 7

A 40 year old woman attends the antenatal clinic at 12 weeks gestation in her first pregnancy. She has a 10 year history of systemic lupus erythematosus and conceived during a relapse. Her BMI = 28 kg/m2, BP = 133/67 mmHg and urine analysis shows 3+ proteinuria. Urine protein creatinine ratio = 124 mg/mmol. Serum creatinine = 110 microM but other blood tests are normal.

a) Aspirin + low molecular weight heparin

b) Low molecular weight heparin

c) Aspirin

d) Aspirin at 12 weeks + low molecular weight heparin from 28 weeks

e) Aspirin at 12 weeks + consider low molecular weight heparin from 28 weeks

 

 

Question 8

A 33 year old woman attends the antenatal clinic at 12 weeks gestation in her first pregnancy. She has a 10 year history of rheumatoid arthritis which has been in remission for 2 years. Her BMI = 28 kg/m2, BP = 110/62 mmHg and urine analysis is normal. She has no other significant problems or risk factors.

a) No additional intervention

b) Aspirin

c) Low molecular weight heparin

d) Aspirin + low molecular weight heparin

e) Aspirin + low molecular weight heparin from 28 weeks

 

 

Question 9

A 34 year old woman attends the antenatal clinic at 12 weeks gestation. She has a history of chronic hypertension treated with labetalol 400 mg twice a day. She also developed deep vein thrombosis 10 years ago following a road traffic accident and a fractured pelvis. Her BMI = 26 kg/m2, BP = 133/88 mmHg and urine analysis is normal.

Low molecular weight heparin from 28 weeks

Aspirin + low molecular weight heparin

Aspirin

Consider low molecular weight heparin

Aspirin from 12 weeks + low molecular weight heparin from 28 weeks

 

Question 10

A 23 year old woman with sickle cell disease attends the antenatal clinic at 8 weeks gestation in her first pregnancy. She has a history of painful crises every 6 months, is up-to-date with all immunization and is taking prophylactic penicillin. She is also taking folic acid 5 mg daily. BP = 133/69, urine analysis is normal. She has a viable intra-uterine pregnancy on scan.

a) Low molecular weight heparin from 8 weeks

b) Aspirin from 12 weeks

c) Low molecular weight heparin and aspirin from 12 weeks

d) Low molecular weight heparin from 8 weeks + aspirin from 12 weeks

e) Aspirin from 12 weeks + low molecular weight heparin from 28 weeks

 

Question 11

A 33 year old woman attends the antenatal clinic at 12 weeks gestation in her first pregnancy. She has a history of idiopathic nephrotic syndrome. Her BMI = 25 kg/m2, BP = 125/55 mmHg and urine analysis shows 4+ proteinuria. She has a viable intra-uterine pregnancy.

a) Aspirin

b) Low molecular weight heparin

c) Aspirin + low molecular weight heparin

d) Aspirin from 12 weeks + low molecular weight heparin from 28 weeks

e) Aspirin from 12 weeks + low molecular weight heparin for 6 weeks post-partum

f) Low molecular weight heparin from 28 weeks

 

 

 

Question 12

With respect to antenatal risk assessment for thromboprophylaxis, high risk thrombophilias include

a) Protein C deficiency and anti-phospholipid antibodies

b) Protein S deficiency and anti-phospholipid antibodies

c) Anti-thrombin deficiency, protein S deficiency and protein C deficiency

d) Anti-thrombin deficiency and anti-phospholipid antibodies

e) Anti-thrombin deficiency and Factor V Leiden heterozygote

 

 

Question 13

Which women should be considered for antenatal thromboprophylaxis with low molecular weight heparin?

a) Women with a previous oestrogen-related VTE

b) Women with a previous unprovoked VTE

c) Women with gross varicose veins

d) Women with a single previous VTE related to major surgery

e) Women embarking on a long-haul flight

 

 

Question 14

A 37 year old woman attends the antenatal clinic at 12 weeks gestation. She has 3 previous caesarean sections and her third baby was small for gestational age. She smokes 10-20 cigarettes per day. Her BMI = 38 kg/m2, BP = 124/82 mmHg and urine analysis is normal. Ultrasound scan shows a normal intra-uterine pregnancy.

a) Aspirin, Low molecular weight heparin + serial growth scans

b) Low molecular weight heparin from 28 weeks + glucose tolerance test at 24-28 weeks

c) Serial growth scans + glucose tolerance test at 24-28 weeks

d) Low molecular weight heparin from 28 weeks, serial growth scans and glucose tolerance test at 24-28 weeks

e) Aspirin + serial growth scans + glucose tolerance test at 24-28 weeks

 

 

Question 15

A healthy 23 year old woman attends the antenatal clinic at 12 weeks gestation in her first pregnancy. Her mother developed deep vein thrombosis in pregnancy. BMI – 24 kg/m2, BP = 110/56 and urine analysis is normal.

a) No additional treatment

b) Low molecular weight heparin

c) Low molecular weight heparin from 28 weeks

d) Consider low molecular weight heparin

e) Aspirin now + low molecular weight heparin from 28 weeks

 

 

 

Question 16

A healthy 24 year old woman attends the antenatal clinic at 12 weeks gestation in her first pregnancy. She is known to be a carrier of the Factor V Leiden mutation following deep vein thrombosis in her sister. BMI = 22 kg/m2, BP = 98/52 mmHg and urine analysis is normal.

a) Low molecular weight heparin

b) Low molecular weight heparin from 28 weeks

c) Low molecular weight heparin + serial growth scans

d) No additional treatment

e) Aspirin + low molecular weight heparin

 

 

Question 17

A healthy 33 year old woman attends the antenatal clinic at 8 weeks gestation in her first pregnancy. This is an IVF singleton pregnancy because of male infertility. She is known to be a carrier of the Factor V Leiden mutation. BMI = 37 kg/m2, BP = 112/65 mmHg and urine analysis is normal.

a) Aspirin from 12 weeks

b) Low molecular weight heparin now + aspirin from 12 weeks

c) Aspirin from 12 weeks + serial growth scans

d) Aspirin from 12 weeks + low molecular weight heparin from 28 weeks

e) Serial growth scans + low molecular weight heparin from 28 weeks

Answers Posted by Anuradha M.
1-b 2-a 3-c 4-a 5-c 6-a 7-e 8-a 9-b 10-e 11-a 12-c 13-d 14-a 15-a 16-d 17-e
Answers Posted by PAUL A.

Answers

 

1)   C

2)   A

3)   D

4)   B

5)   A

6)   A

7)   A

8)   A

9)   B

10)                  D

11)                  C

12)                  C

13)                  D

14)                  D

15)                  A

16)                  D

17)                  D

Please explain Posted by Anuradha M.

Q-3 

  • If total score 3 antenatally, consider thromboprophylaxis from 28 weeks. 

  •  

    Previous VTE provoked by major surgery 3 

please explain Posted by Anuradha M.

Q:4 according to RCOG guideline medical comorbidity is score 3 and should consider antenatal thromboprophylaxis from 28 weeks.

please explain Posted by Anuradha M.

Q:7 why is the answer not e?

She has SLE so will need aspirin. and has nephrotic syndrome so gets a score of 3 which means consider thromboprophylaxis from 28 weeks? Please explain.

please explain Posted by Anuradha M.

Q:9 why is the answer not e? 

There seems to be  a pattern that I seem to be missing in these questions. Here Chronic HTN so need aspirin from 12 weeks and Hx of provoked DVT so considered LMWH form 28 weeks as score 3?

 

please hellp Posted by farzana S.

Dear Paul,

Kindly give your valuable explanation to the answers.

We seem to be really confused with the interpretation of new guidelines.

Posted by H K.

Dear paul ,

 answer for last question shd be E as she has 3 risk factors so needs LMWH from 28 weeks and BMI>35 SO NEEDS SERIAL GROWTH SCAN.

KINDLY EXPLAIN,

THANK YOU

 

Posted by PAUL A.
Posted by Anuradha M.
Sat Jul 25, 2015 03:53 pm

Q-3 

  • If total score 3 antenatally, consider thromboprophylaxis from 28 weeks. 

A healthy 32 year old woman attends the antenatal clinic at 12 weeks gestation in her first pregnancy. At the age of 20 years, she suffered a ruptured appendix requiring laparotomy. Three weeks post-operatively, she suffered pulmonary embolism. Her BMI is 25 kg/m2 and she has a singleton pregnancy.

Only risk factor is previous VTE related to major surgery. Guidelines say consider antenatal prophylaxis.  Nowhere in the guidelines does it say 'consider from 28 weeks'.

Posted by PAUL A.
Posted by Anuradha M.
Sat Jul 25, 2015 03:56 pm

Q:4 according to RCOG guideline medical comorbidity is score 3 and should consider antenatal thromboprophylaxis from 28 weeks.

 

Same as above - look at the flow chart in the guidelines. Consider prophylaxis from 28 weeks does not exist. Only statement with the word CONSIDER is in relation to INTERMEDIATE RISK: Consider antenatal prophylaxis with LMWH. There is no gestation age mentioned for the reasons evident in the preceeding box.

 

Posted by PAUL A.
Posted by H K.
Sun Jul 26, 2015 01:48 pm

Dear paul ,

 answer for last question shd be E as she has 3 risk factors so needs LMWH from 28 weeks and BMI>35 SO NEEDS SERIAL GROWTH SCAN.

KINDLY EXPLAIN,

THANK YOU

 

The correct answer should be 

Aspirin (BMI 37 + first pregnancy) PET

Serial growth scans (BMI > 35) and 

LMWH from 28 weeks (VTE).

 

None of the options was absolutely correct. This is why we post questions here for review before uploading to website. We will edit this question before it is uploaded.

 

Posted by farzana S.

Dear Paul,

If gestational age is not mentioned in the guideline, then what shud be our answer a)from early pregnancy or 28wks? If at all question requires?

 

 

Posted by farzana S.

Dear Paul,

If gestational age is not mentioned in the guideline, then what shud be our answer a)from early pregnancy or 28wks? If at all question requires?

 

 

q10 Posted by UcasLucas L.
Dear paul, why do we start thromboprophylacis from 8wks? Appendix 3 states if vte score 3 consider prophylaxis from 28wks. If score of 4 or more then we start from 8wks. Why do westart from 8wks? I thought she only scored 3
Posted by PAUL A.
Posted by farzana S.
Thu Jul 30, 2015 05:28 pm

Dear Paul,

If gestational age is not mentioned in the guideline, then what shud be our answer a)from early pregnancy or 28wks? If at all question requires?

 

 

q10 Posted by UcasLucas L.
Sun Aug 2, 2015 10:34 pm

Dear paul, why do we start thromboprophylacis from 8wks? Appendix 3 states if vte score 3 consider prophylaxis from 28wks. If score of 4 or more then we start from 8wks. Why do westart from 8wks? I thought she only scored 3

 

That is the problem with a scoring system - it is inaccurate. Look at the flow chart. Intermediate risk (which you describe as score of 3) = antenatal LMWH. No gestation age mentioned. Antenatal LMWH should be started asap (unless it clearly states 28 weeks). Look at the conditions listed - admission to hospital for example. You cannot admit at 8 weeks and start LMWH at 28 weeks. Scoring system is no good.

 

question 9 Posted by Nyan Chin L.

please help explain, as road traffic is a non reqcurrence and a transient episode, why is it not 

aspirin form 12 week and LMWH from 28w then?

Posted by Farrukh G.

 

question 9 Posted by Nyan Chin L.
Mon Aug 10, 2015 06:43 am

please help explain, as road traffic is a non reqcurrence and a transient episode, why is it not 

aspirin form 12 week and LMWH from 28w then?

 

SEE RCOG GUIDELINES / NOTES

 

Intermediate risk – consider antenatal prophylaxis with LMWH

  • Hospital admission
  • Single previous VTE related to major surgery
  • High-risk thrombophilia + no VTE (antithrombin deficiency, protein C or S deficiency, compound or homozygous for low-risk thrombophilia)
  • Medical comorbidities e.g. cancer, heart failure, active SLE, IBD or inflammatory polyarthro-pathy, nephrotic syndrome, type I DM with nephropathy, sickle cell disease, current IVDU
  • Any surgical procedure e.g. appendicectomy
  • OHSS (first trimester only)

IT DOES NOT SAY FROM 28 WEEKS.

 

Post surgery stratification Posted by fiona H.

Dear Paul,

I was hoping you could clarify.  The section 4.2.3 on stratification in women with previous DVT states that LMWH can be withheld till 28 weeks provided no additional risk factors are present. It is level D evidence but i wonder if this changes some of the answers?

Best wishes

Fiona

Posted by PAUL A.
Post surgery stratification Posted by fiona H.
Wed Aug 12, 2015 05:02 pm

Dear Paul,

I was hoping you could clarify.  The section 4.2.3 on stratification in women with previous DVT states that LMWH can be withheld till 28 weeks provided no additional risk factors are present. It is level D evidence but i wonder if this changes some of the answers?

Best wishes

Fiona

Below is the statement 

In women in whom the original VTE was provoked by major surgery from which they have recovered and who have no other risk factors, thromboprophylaxis with LMWH can be withheld antenatally until 28 weeks provided no additional risk factors are present (in which case they should be offered LMWH). They require close surveillance for the development of other risk factors.

 

So if you decided to start LMWH at 28 weeks, which additional CLOSE SURVEILLANCE will you put in place? When you are given the options to start treatment at presentation or at 28 weeks and there are no additional surveillance measures attached to the 28 weeks option, how can that be the better option?