Mock Obstetric Medicine Module 2

A 33-year-old woman presents to the emergency department 3 weeks after an uncomplicated vaginal delivery of her second child.

She reports progressive dyspnoea, orthopnoea, and paroxysmal nocturnal dyspnoea over the preceding 10 days, associated with fatigue and palpitations.

She has no prior cardiac history.

On examination, her heart rate is 112 bpm, blood pressure 98/58 mmHg (reference 90–120/60–80 mmHg), respiratory rate 24 breaths/minute, and oxygen saturation 94% on room air.

There are bibasal crepitations, an elevated jugular venous pressure, and an audible third heart sound.

Her ECG demonstrates sinus tachycardia with non-specific T-wave changes.

A transthoracic echocardiogram confirms a left ventricular ejection fraction of 32%.

Which of the following medications is contraindicated in this woman while she continues to breastfeed?

Enalapril

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Metoprolol

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Furosemide

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Bromocriptine

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Digoxin

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A 31-year-old woman with biopsy-proven IgA nephropathy is reviewed pre-conception.

Her serum creatinine is 145 µmol/L (reference 45–90 µmol/L), estimated glomerular filtration rate 42 mL/min/1.73m², urine protein-to-creatinine ratio 85 mg/mmol, and blood pressure 128/78 mmHg on ramipril, which is ceased in favour of labetalol.

She has never been pregnant.

Which single factor is the strongest predictor of an adverse maternal and fetal outcome in this pregnancy?

Baseline estimated glomerular filtration rate

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Level of proteinuria at conception

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Presence of hypertension

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Maternal age

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Underlying histological diagnosis of IgA nephropathy

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A 27-year-old woman at 30 weeks gestation has a routine antenatal full blood count and iron studies.

Which of the following results is inconsistent with the normal physiological adaptation to pregnancy and warrants further investigation?

Platelet count of 95 × 10⁹/L (reference 150–400 × 10⁹/L)

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White cell count of 14 × 10⁹/L (reference non-pregnant 4.0–11.0 × 10⁹/L)

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Haemoglobin of 104 g/L (reference non-pregnant 115–165 g/L)

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Ferritin of 22 µg/L (reference 30–300 µg/L)

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Serum vitamin B12 of 155 pmol/L (reference 150–700 pmol/L)

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A medical student asks about the respiratory changes that render pregnant women more vulnerable to rapid desaturation during apnoea, for example at induction of anaesthesia.

Which combination of physiological changes best explains this reduced apnoeic oxygen reserve?

Decreased functional residual capacity with increased oxygen consumption

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Increased functional residual capacity with increased oxygen consumption

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Decreased tidal volume with decreased oxygen consumption

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Increased residual volume with decreased minute ventilation

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Increased functional residual capacity with decreased oxygen consumption

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A 29-year-old woman at 18 weeks gestation with moderate persistent asthma is reviewed. She uses a low-dose budesonide-formoterol combination inhaler.

She asks how best to protect her baby during pregnancy.

Which management strategy is most likely to optimise both maternal and fetal outcomes?

Continue single maintenance and reliever therapy with budesonide-formoterol and ensure influenza and pertussis vaccination

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Cease inhaled corticosteroids to minimise fetal drug exposure and rely on salbutamol as needed

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Substitute the combination inhaler with montelukast monotherapy

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Defer all vaccinations until after delivery to avoid triggering exacerbations

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Reduce inhaled corticosteroid dose to the lowest possible regardless of symptom control

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A 26-year-old woman at 16 weeks gestation with poorly controlled asthma is being considered for a management approach that titrates inhaled corticosteroids according to the fraction of exhaled nitric oxide (FeNO) in addition to symptom-based control.

Based on the best available randomised evidence, which outcome is most likely with this inflammation-guided strategy compared with symptom-based control alone?

An approximately 50% reduction in asthma exacerbations

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An increase in maternal pneumonia

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A reduction in maternal quality of life

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No difference in exacerbations but increased infant bronchiolitis

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An increase in preterm birth

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A 27-year-old woman with focal epilepsy maintained on carbamazepine attends for contraceptive counselling. She wishes to avoid pregnancy reliably and asks which method is most appropriate.

Which of the following is the most suitable contraceptive choice for this woman?

Copper or levonorgestrel intrauterine device

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Combined oral contraceptive pill

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Progestogen-only pill

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Etonogestrel subdermal implant (Implanon)

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Standard-dose oral emergency contraception as her primary method

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A 24-year-old woman with ileocolonic Crohn’s disease presents having discovered she is 6 weeks pregnant.

Which of these carries the greatest risk of fetal harm and must be ceased immediately?

Methotrexate

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Prednisolone

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Azathioprine

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Mesalazine

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Infliximab

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A 29-year-old woman at 12 weeks gestation presents with fever, sore throat, cervical lymphadenopathy, and malaise.

Serology confirms primary cytomegalovirus (CMV) infection with low IgG avidity and positive IgM.

She is anxious about the outcome for her baby.

Which statement most accurately reflects the likely outcome?

Most infants will be born without clinically apparent abnormality

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The majority of infected infants will be symptomatic at birth

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Universal antiviral therapy in pregnancy eliminates the risk of transmission

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The risk of transmission is highest in the first trimester and lowest at term

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Sensorineural hearing loss is present at birth in the majority of infected infants

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A 30-year-old woman at 16 weeks gestation has routine bloods performed.

Which of the following parameters would be expected to decrease compared with her non-pregnant baseline?

Serum creatinine

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Cardiac output

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Glomerular filtration rate

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Renal blood flow

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Circulating blood volume

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A 31-year-old woman is reviewed at 10 weeks gestation to assess her risk of pre-eclampsia and determine eligibility for aspirin prophylaxis.

Which of the following features from her history confers the greatest single risk of developing pre-eclampsia in this pregnancy?

Pre-eclampsia in a previous pregnancy

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Nulliparity

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Pre-existing type 2 diabetes mellitus

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Multiple (twin) pregnancy

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First-degree family history of pre-eclampsia

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A researcher describes the paradoxical epidemiological relationship between maternal cigarette smoking and pre-eclampsia.

Which of the following statements is false?

Smoking is associated with an increased risk of pre-eclampsia

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Maternal smoking is associated with a reduced risk of pre-eclampsia

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Cigarette smoke reduces soluble fms-like tyrosine kinase-1 (sFlt-1) in vitro

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Smoking increases the risk of fetal growth restriction and placental abruption

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The observed effect does not justify smoking in pregnancy given other harms

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A 33-year-old woman with chronic hypertension is seen at 11 weeks gestation. She has no contraindication to antiplatelet therapy.

Which intervention has the strongest evidence for reducing her risk of preterm pre-eclampsia?

Low-dose aspirin 150 mg nightly commenced before 16 weeks

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Vitamin C and E supplementation

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Therapeutic-dose low molecular weight heparin

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Fish oil supplementation

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Calcium supplementation regardless of dietary intake

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A 28-year-old woman at 9 weeks gestation presents with palpitations, heat intolerance, and a 4 kg weight loss.

Examination reveals a diffuse goitre, a fine tremor, and mild proptosis.

Thyroid-stimulating hormone is suppressed at less than 0.01 mIU/L (reference 0.4–4.0 mIU/L) and free T4 is elevated.

Which is the most likely cause of her thyrotoxicosis?

Graves' disease

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Gestational transient thyrotoxicosis

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Toxic multinodular goitre

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Subacute (de Quervain) thyroiditis

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Factitious thyrotoxicosis

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A 26-year-old woman with Graves’ disease is planning pregnancy and is currently taking carbimazole. She asks how her treatment should be managed.

Which statement is most accurate regarding antithyroid drug therapy across her pregnancy?

Propylthiouracil is preferred in the first trimester due to a lower risk of embryopathy

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Carbimazole should be continued throughout pregnancy as it is the safest agent

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Radioactive iodine is the treatment of choice during the first trimester

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Both carbimazole and propylthiouracil are absolutely contraindicated in pregnancy

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Antithyroid drugs should be ceased entirely once pregnancy is confirmed

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A 34-year-old woman with recurrent first-trimester miscarriage is investigated.

Which of the following autoantibodies is most strongly associated with an increased risk of miscarriage even when thyroid function is normal?

Thyroid peroxidase antibody

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Anti-Ro (SSA)

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Anti-Jo-1

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Anti-centromere

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Anti-double-stranded DNA

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A 32-year-old woman asks when she is at greatest risk of venous thromboembolism during and after pregnancy.

At which period is the risk of pulmonary embolism highest?

The first six weeks postpartum

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First trimester

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Second trimester

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Third trimester

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Preconception

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A 29-year-old woman with no personal history of thrombosis is found to have an inherited thrombophilia during family screening.

Which of the following confers the highest risk of venous thromboembolism during pregnancy?

Homozygous factor V Leiden

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Heterozygous factor V Leiden

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Protein C deficiency

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Protein S deficiency

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Heterozygous prothrombin G20210A mutation

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A 30-year-old woman at 34 weeks gestation, on bed rest for gestational hypertension, develops acute pleuritic chest pain and dyspnoea.

Observations show heart rate 118/minute, respiratory rate 28/minute, and calf tenderness. Arterial blood gas on room air reveals PaO₂ 66 mmHg, PaCO₂ 28 mmHg, and pH 7.51.

CT pulmonary angiography confirms pulmonary embolism, and she is commenced on therapeutic low molecular weight heparin. She delivers uneventfully and intends to breastfeed.

Which is the most appropriate anticoagulation plan for the postpartum period?

Continue low molecular weight heparin for a total treatment duration of at least three months

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Commence rivaroxaban immediately postpartum

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Commence warfarin and continue lifelong

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Commence aspirin as monotherapy

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Discontinue anticoagulation at delivery as the provoking factor has resolved

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A 30-year-old woman at 34 weeks gestation has liver function and biochemical tests performed as part of an antenatal review.

Which of the following results is inconsistent with normal physiological pregnancy?

Elevated alanine aminotransferase

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Elevated alkaline phosphatase

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Elevated serum cholesterol

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Reduced serum albumin

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Elevated serum caeruloplasmin

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A 29-year-old woman originally from Hong Kong is 28 weeks pregnant and hepatitis B surface antigen positive. Her first child acquired hepatitis B despite immunoprophylaxis. She is asymptomatic.

Her hepatitis B virus DNA is 10⁸ IU/mL, AST 29 U/L (reference 10–35 U/L), and ALT 20 U/L (reference 10–35 U/L).

In addition to neonatal immunoprophylaxis at birth, what is the most appropriate management to minimise vertical transmission?

Commence maternal tenofovir at 28–32 weeks gestation

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Repeat hepatitis serology in two months

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Continue to monitor liver function without intervention

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Administer maternal hepatitis B immunoglobulin now

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Commence interferon-alfa immediately

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A baby is born to a mother who is a chronic hepatitis B carrier.

What is the most effective strategy to prevent vertical transmission to the neonate?

Hepatitis B immunoglobulin at birth plus the hepatitis B vaccine series over the first six months

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Hepatitis B immunoglobulin at birth alone

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Maternal lamivudine alone

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A single dose of hepatitis B immunoglobulin at six months of age

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Hepatitis B vaccine at birth alone

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Which route of hepatitis B virus acquisition in a non-immunised individual is most likely to result in chronic infection?

Perinatal (vertical) transmission to a newborn

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Needlestick injury in a 21-year-old

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Blood transfusion to a 60-year-old

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Horizontal transmission to a 5-year-old sibling

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A bite to a 2-year-old

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In a hepatitis B surface antigen-positive pregnant woman, which serological or virological marker carries the greatest risk of vertical transmission to the neonate?

High hepatitis B virus DNA level

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Hepatitis B surface antigen positivity

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Hepatitis B core antigen

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Hepatitis B e antibody

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Hepatitis B surface antibody

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A 31-year-old primigravida at 35 weeks gestation presents with malaise, nausea, and right upper quadrant pain.

Which clinical or biochemical feature most reliably distinguishes acute fatty liver of pregnancy from HELLP syndrome?

Profound hypoglycaemia

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Onset in the third trimester

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Elevated transaminases

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Coagulopathy

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Elevated lactate dehydrogenase

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Which of the following is a leading cause of direct maternal death in Australia and New Zealand?

Amniotic fluid embolism

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Pituitary apoplexy

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Postpartum haemorrhage from uterine atony alone

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Ectopic pregnancy in the third trimester

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Anaphylaxis

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Which of the following haemostatic changes does NOT contribute to the prothrombotic state of pregnancy?

Reduced total plasminogen activator inhibitor activity

Correct Incorrect Correct answer

Increased factors II, VII, VIII, and X

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Increased fibrinogen and fibrin formation

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Reduced overall fibrinolysis

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Reduced protein S activity and acquired activated protein C resistance

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A 30-year-old woman at 30 weeks gestation has confirmed mild-to-moderate chronic hypertension (blood pressure 150/95 mmHg). She is commenced on antihypertensive therapy.

Which of the following outcomes is antihypertensive treatment LEAST likely to influence?

Perinatal mortality

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Progression to severe hypertension

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Maternal stroke

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Need for hospital admission

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Development of severe-range blood pressure requiring escalation

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A 34-week pregnant woman presents with epigastric and right upper quadrant pain and nausea. Blood pressure is 140/85 mmHg.

Investigations show:

AST 150 IU/L (reference 15–45)
prothrombin time 14 seconds (reference 11–15)
bilirubin 25 µmol/L (reference 14–22)
platelets 75 × 10⁹/L (reference 150–400)
haemoglobin 90 g/L (reference 110–130)
Serum creatinine, uric acid, and glucose are normal.

Ultrasound shows gallbladder sludge.

What is the most likely diagnosis?

HELLP syndrome

Correct Incorrect Correct answer

Acute fatty liver of pregnancy

Correct Incorrect Correct answer

Hyperemesis gravidarum

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Thrombotic thrombocytopenic purpura

Correct Incorrect Correct answer

Hepatic infarction

Correct Incorrect Correct answer

A 29-year-old primigravida at 29 weeks gestation presents with drowsiness, right upper quadrant pain, and vomiting.

She has poor peripheral perfusion, pulse 96/minute, blood pressure 170/110 mmHg, right upper quadrant tenderness, and brisk reflexes.

Investigations show:

bilirubin 14 µmol/L (reference 2–14)
ALP 200 U/L (reference 40–130)
GGT 15 U/L (reference 1–35)
AST 630 U/L (reference 8–35)
ALT 550 U/L (reference 8–40)
urine dipstick 1+ protein.
serum creatinine 150 µmol/L (reference 45–90)

Which is the most appropriate immediate intervention?

Intravenous magnesium sulphate

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Oral methyldopa

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Intravenous phenytoin

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Oral ramipril

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Ursodeoxycholic acid

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Mock Obstetric Medicine Module 2

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