Mock Obstetric Medicine Module 1

A 28-year-old woman at 32 weeks gestation presents for a routine antenatal review. She reports mild breathlessness on exertion and occasional palpitations but no chest pain or syncope.

Examination reveals a resting heart rate of 92 bpm, blood pressure 108/64 mmHg, and a soft ejection systolic murmur at the left sternal edge.

Echocardiography demonstrates a structurally normal heart with mildly increased right ventricular outflow tract velocity.

Which of the following best explains the physiological cardiac output changes occurring at this gestation?

A 34-year-old primigravida presents at 33 weeks gestation with headache and mild epigastric discomfort.

Her blood pressure is 158/104 mmHg on two readings taken 4 hours apart.

Investigations show:

• haemoglobin 118 g/L
• platelets 92 × 10⁹/L (150–400)
• creatinine 96 µmol/L (45–90)
• AST 78 U/L (<35)
• ALT 82 U/L (<35)
• urine protein:creatinine ratio of 48 mg/mmol (<30)
• uric acid is elevated

Which of the following features most strongly indicates preeclampsia with severe features?

A 30-year-old woman at 28 weeks gestation is referred with hypertension of 146/94 mmHg and a borderline urine protein:creatinine ratio.

There is diagnostic uncertainty about whether she has preeclampsia.

Her clinician requests measurement of the soluble fms-like tyrosine kinase-1 (sFlt-1) to placental growth factor (PlGF) ratio.

Which of the following best describes the appropriate role of the sFlt-1/PlGF ratio in this setting?

A 32-year-old woman presents for her first antenatal visit at 11 weeks gestation.

She has chronic hypertension controlled on labetalol and a previous pregnancy complicated by preterm preeclampsia requiring delivery at 33 weeks.

First-trimester combined screening estimates her risk of preterm preeclampsia at 1:40.

Which of the following interventions is most strongly supported by trial evidence to reduce her risk of preterm preeclampsia?

A 29-year-old woman at 35 weeks gestation is admitted with a blood pressure of 172/116 mmHg, a severe headache, and hyperreflexia with clonus.

Urinalysis shows 3+ protein. She is diagnosed with preeclampsia with severe features.

In addition to magnesium sulfate for seizure prophylaxis, which of the following is the most appropriate antihypertensive agent for acute blood pressure lowering?

A 38-year-old woman presents to her general practitioner five years after a pregnancy complicated by early-onset preeclampsia requiring delivery at 31 weeks.

She is asymptomatic and seeks advice on her long-term health.

Which of the following long-term outcomes is most strongly associated with a history of preeclampsia?

A 31-year-old woman at 34 weeks gestation presents with severe generalised pruritus, worse on the palms and soles and at night, with no rash.

Investigations show:

• Total bilirubin 14 µmol/L (<20)
• ALT 96 U/L (<35)
• AST 88 U/L (<35)
• GGT 42 U/L (<40)
• Fasting bile acids 62 µmol/L (<10)
• Full blood count and coagulation are normal

Which of the following is the most appropriate treatment?

A 27-year-old primigravida at 36 weeks gestation presents with a two-day history of nausea, vomiting, malaise, and jaundice.

Blood pressure is 138/86 mmHg.

Investigations show:

• bilirubin 88 µmol/L (<20)
• ALT 320 U/L (<35)
• AST 298 U/L (<35)
• glucose 2.6 mmol/L (3.5–5.5)
• INR 1.8 (0.9–1.2)
• creatinine 118 µmol/L (45–90)
• WCC 18 × 10⁹/L (4–11)

Which of the following is the most appropriate initial management?

A 33-year-old woman at 30 weeks gestation presents with hypertension, headache, and epigastric pain.

Investigations show:

• haemoglobin 92 g/L
• platelets 68 × 10⁹/L (150–400)
• AST 140 U/L (<35)
• LDH markedly elevated
• low haptoglobin
• schistocytes on blood film
• Creatinine is 105 µmol/L (45–90) 
• urine protein:creatinine ratio is 60 mg/mmol

Which of the following features would most favour HELLP syndrome over thrombotic thrombocytopenic purpura (TTP)?

A 30-year-old woman at 28 weeks gestation presents with pleuritic chest pain and breathlessness.

She has no clinical signs of deep vein thrombosis and no haemoptysis, and pulmonary embolism is not judged to be the most likely diagnosis.

Her D-dimer is 620 ng/mL.

Applying the pregnancy-adapted YEARS algorithm, which of the following is the most appropriate next step?

A 29-year-old woman at 26 weeks gestation with suspected pulmonary embolism is haemodynamically stable.

Her chest radiograph is normal and she has no known lung disease. She is anxious about radiation exposure to her breasts and fetus.

Which of the following statements regarding CT pulmonary angiography (CTPA) versus ventilation-perfusion (V/Q) scanning is correct?

A 32-year-old woman at 24 weeks gestation is diagnosed with an acute pulmonary embolism confirmed on CTPA. She is haemodynamically stable.

Which of the following is the most appropriate anticoagulation strategy?

A 31-year-old woman has recently delivered by emergency caesarean section following a pregnancy complicated by preeclampsia.

She asks about her risk of venous thromboembolism.

During which period is the risk of venous thromboembolism greatest?

A 34-year-old woman presents with a history of three consecutive miscarriages before 10 weeks gestation.

Investigations reveal a positive lupus anticoagulant and a medium-titre IgG anticardiolipin antibody.

A repeat test 12 weeks later confirms persistence of both.

Which of the following is required to establish a diagnosis of antiphospholipid syndrome in this patient?

A 33-year-old woman with antiphospholipid syndrome, diagnosed on the basis of recurrent miscarriage before 10 weeks and persistent lupus anticoagulant, presents at 6 weeks gestation. She has no history of thrombosis.

According to current guidelines, which of the following is the most appropriate management?

A 29-year-old woman with Sjögren syndrome is pregnant at 20 weeks gestation.

She is positive for anti-Ro (SSA) and anti-La (SSB) antibodies.

A fetal echocardiogram detects fetal bradycardia with a ventricular rate of 55 bpm.

Which of the following best explains this fetal finding?

A 26-year-old woman at 9 weeks gestation presents with palpitations, tremor, and severe nausea and vomiting.

Investigations show TSH <0.01 mIU/L (0.4–4.0), free T4 mildly elevated, and free T3 mildly elevated.

She has no goitre, no eye signs, and thyroid receptor antibodies are negative.

Which of the following is the most likely diagnosis and appropriate management?

A 30-year-old woman with Graves disease requiring antithyroid therapy presents at 7 weeks gestation. She is currently taking carbimazole.

Which of the following is the most appropriate adjustment to her therapy?

A 28-year-old woman at 8 weeks gestation is found on screening to have a TSH of 5.8 mIU/L (0.4–4.0), a normal free T4, and positive thyroid peroxidase antibodies. She is asymptomatic.

Which of the following is the most appropriate management?

A 32-year-old woman with epilepsy is planning pregnancy. She is currently well controlled on sodium valproate.

She also has a history of migraine and takes occasional medications.

Which of the following medications carries the highest teratogenic risk and should be avoided during organogenesis?

A 30-year-old woman with Crohn disease maintained on infliximab is pregnant at 30 weeks gestation.

She asks about the safety of continuing her biologic and whether her infant will require any special precautions.

Which of the following statements about monoclonal antibody biologics in pregnancy is correct?

A 33-year-old woman at 36 weeks gestation is found to have a platelet count of 105 × 10⁹/L (150–400) on routine testing.

She is normotensive with no proteinuria, and her blood film, coagulation profile, and liver function tests are normal. She has no bleeding symptoms.

Which of the following is the most likely diagnosis?

A 34-year-old woman presents three weeks postpartum with progressive dyspnoea, orthopnoea, and peripheral oedema.

Examination reveals an elevated jugular venous pressure, bibasal crepitations, and a displaced apex beat.

Echocardiography shows a dilated left ventricle with an ejection fraction of 32%. There is no prior cardiac history.

Which of the following is the most likely diagnosis?

A 31-year-old woman presents four months postpartum with palpitations, weight loss, and anxiety. TSH is suppressed at <0.01 mIU/L (0.4–4.0) with mildly elevated free T4. Thyroid peroxidase antibodies are positive.

Six weeks later she becomes fatigued and constipated, and her TSH is now elevated at 12 mIU/L.

Which of the following is the most likely diagnosis?

A 30-year-old woman with a history of both rheumatoid arthritis and systemic lupus erythematosus is planning pregnancy and asks how each condition may behave during and after pregnancy.

Which of the following statements is most accurate?

A 29-year-old woman with chronic kidney disease (baseline creatinine 140 µmol/L, 45–90) and proteinuria is planning pregnancy. She has stable hypertension on an ACE inhibitor.

Which of the following is the most appropriate pre-pregnancy advice regarding her medications and risks?

A 27-year-old woman at 30 weeks gestation has routine bloods showing a creatinine of 48 µmol/L (45–90) and urea of 2.8 mmol/L (3.0–8.0). She is well.

Which of the following best explains these findings?

A 33-year-old woman is diagnosed with gestational diabetes at 26 weeks gestation following a 75 g oral glucose tolerance test showing a fasting glucose of 5.3 mmol/L and a 2-hour value of 9.0 mmol/L.

Her glucose is well controlled with diet, and she delivers a healthy infant.

Which of the following is the most appropriate advice regarding her long-term health?

A 28-year-old woman with acetylcholine receptor antibody-positive myasthenia gravis delivers a term infant.

On day two, the neonate develops feeding difficulties, hypotonia, and a weak cry.

Which of the following best explains the neonatal presentation?

A 27-year-old woman at 34 weeks gestation with preeclampsia presents with a severe headache, visual disturbance, and a generalised tonic-clonic seizure. Her blood pressure is 178/118 mmHg.

MRI of the brain shows symmetrical vasogenic oedema predominantly in the parieto-occipital regions.

Which of the following best describes the underlying process and immediate management?