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PGIM MD ObGyn study materials
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PGIM MD ObGyn practice questions

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Question 1Obstetrics

A woman has a spontaneous vaginal birth at term. According to the traditional definition used in many obstetric protocols, primary postpartum haemorrhage is diagnosed when blood loss exceeds which volume within 24 hours?

  1. 500 mL Correct answer.
  2. 750 mL
  3. 1000 mL
  4. 300 mL

Explanation

The traditional definition of primary postpartum haemorrhage is blood loss greater than 500 mL after a vaginal birth or greater than 1000 mL after caesarean birth within 24 hours. Many contemporary guidelines also diagnose postpartum haemorrhage at 1000 mL or when there are clinical signs of hypovolaemia, regardless of the measured volume.

Question 2Obstetrics

A woman receiving intravenous magnesium sulphate for eclampsia develops loss of deep tendon reflexes, respiratory depression, and oliguria. Which immediate antidote should be administered?

  1. Naloxone
  2. Calcium gluconate 10% Correct answer.
  3. Flumazenil
  4. Protamine sulphate

Explanation

Magnesium sulphate toxicity is reversed with intravenous calcium gluconate 10%, usually 10 mL given over 10 minutes, while the magnesium infusion is stopped and respiratory support is provided. Calcium antagonises the neuromuscular and cardiac effects of excess magnesium.

Question 3Obstetrics

A pregnant woman with no pre-existing diabetes attends for routine antenatal care. At which gestational age is universal screening for gestational diabetes mellitus best performed?

  1. 11–14 weeks
  2. 32–36 weeks
  3. 6–10 weeks
  4. 24–28 weeks Correct answer.

Explanation

Routine screening for gestational diabetes is performed at 24–28 weeks' gestation, when insulin resistance from placental hormones is most pronounced. Women with major risk factors may be tested earlier, but universal screening at this window detects most cases.

Question 4Obstetrics

During a vaginal birth, the fetal head delivers but the anterior shoulder remains impacted behind the symphysis pubis. After calling for help and explaining the situation, which manoeuvre should be performed first?

  1. Symphysiotomy
  2. Zavanelli manoeuvre
  3. McRoberts manoeuvre with suprapubic pressure Correct answer.
  4. Delivery of the posterior arm

Explanation

The McRoberts manoeuvre, with the mother's hips hyperflexed and abducted, is the first-line manoeuvre for shoulder dystocia and is often combined with suprapubic pressure. It increases the anterior-posterior diameter of the pelvis and rotates the impacted shoulder.

Question 5Obstetrics

A woman at 13 weeks' gestation has chronic hypertension and a previous pregnancy complicated by early-onset pre-eclampsia. Which intervention reduces her risk of recurrent pre-eclampsia?

  1. Low molecular weight heparin
  2. Prophylactic magnesium sulphate
  3. Low-dose aspirin 75–150 mg daily Correct answer.
  4. Strict bed rest

Explanation

Low-dose aspirin, usually 75–150 mg once daily, started before 16 weeks' gestation in women at high risk, reduces the risk of early-onset pre-eclampsia. It should be continued until around 36 weeks unless delivery occurs earlier.

Question 6Obstetrics

A CTG shows a baseline of 140 bpm, moderate variability, and recurrent late decelerations with each contraction. No accelerations are seen over 40 minutes. Which interpretation is most appropriate?

  1. Normal CTG, no action needed
  2. Category I tracing with accelerations absent due to sleep
  3. Category II tracing with features suggesting uteroplacental insufficiency Correct answer.
  4. Category III tracing indicating fetal acidaemia

Explanation

Recurrent late decelerations with moderate variability and no accelerations fit a category II tracing, which suggests uteroplacental insufficiency but is not categorically abnormal. Category III would require absent variability with recurrent late decelerations, a sinusoidal pattern, or fetal bradycardia.

Question 7Obstetrics

A woman is in the third stage of labour after a spontaneous vaginal birth. Which uterotonic regimen is recommended for active management of the third stage in a woman with no contraindications?

  1. Ergometrine 0.2 mg intravenously
  2. Misoprostol 800 micrograms sublingually
  3. Carbetocin 100 micrograms intravenously
  4. Oxytocin 10 IU intramuscularly Correct answer.

Explanation

Active management of the third stage includes a prophylactic uterotonic, controlled cord traction, and uterine massage. Oxytocin 10 IU intramuscularly is the recommended first-line uterotonic for women without contraindications because it is effective and causes fewer side effects than ergometrine.

Question 8Obstetrics

A woman at 34 weeks' gestation presents with fever, tachycardia, hypotension, and purulent vaginal discharge. She meets criteria for maternal sepsis. Within what time should broad-spectrum intravenous antibiotics be started after recognition?

  1. Within 1 hour Correct answer.
  2. Within 3 hours
  3. Within 6 hours
  4. Within 12 hours

Explanation

In maternal sepsis, broad-spectrum intravenous antibiotics should be started within 1 hour of recognition, alongside fluids, oxygen, and source control. Each hour of delay is associated with worse maternal outcomes.

Question 9Obstetrics

A woman at 32 weeks' gestation has placenta praevia and two previous caesarean sections. Ultrasound shows loss of the retroplacental clear zone and placental lacunae. Which management plan is most appropriate?

  1. Proceed to emergency caesarean section immediately
  2. Attempt vaginal delivery with standby
  3. Planned caesarean hysterectomy at 34–36 weeks by a multidisciplinary team Correct answer.
  4. Give methotrexate and await placental delivery

Explanation

Placenta praevia with multiple previous caesarean sections and ultrasound features of accreta spectrum carries a high risk of massive haemorrhage. Delivery is planned at 34–36 weeks in a centre with a multidisciplinary team, and caesarean hysterectomy is often required; the placenta should not be forcibly removed.

Question 10Obstetrics

A woman collapses suddenly during labour with hypotension, hypoxia, and disseminated intravascular coagulation. Amniotic fluid embolism is suspected. Which statement about diagnosis is correct?

  1. It is excluded if the woman remains normotensive
  2. It is confirmed by finding fetal squames in maternal pulmonary capillary blood
  3. It is confirmed by a raised serum tryptase level
  4. It is a clinical diagnosis of exclusion supported by the typical triad Correct answer.

Explanation

Amniotic fluid embolism is a clinical diagnosis based on the typical triad of sudden cardiovascular collapse, hypoxia, and coagulopathy during labour or shortly after delivery. There is no sensitive or specific confirmatory test, and fetal squames in maternal blood are neither sensitive nor specific.

Question 11Obstetrics

A woman with a singleton pregnancy attends for a routine dating scan. According to the recommended classification, which gestational age range defines term pregnancy?

  1. 37+0 to 41+6 weeks Correct answer.
  2. 36+0 to 40+6 weeks
  3. 38+0 to 42+6 weeks
  4. 37+0 to 40+6 weeks

Explanation

Term pregnancy is defined as 37+0 through 41+6 weeks of gestation. This range is subdivided into early term, full term and late term, while delivery at 42+0 weeks or beyond is post-term. The definition is used to guide timing of antenatal care and decisions about induction.

Question 12Obstetrics

A woman books for antenatal care and asks about first-trimester combined screening for trisomy 21. Within which gestational age window is this test usually performed?

  1. 14+0 to 16+6 weeks
  2. 10+0 to 12+6 weeks
  3. 12+0 to 14+6 weeks
  4. 11+0 to 13+6 weeks Correct answer.

Explanation

First-trimester combined screening uses nuchal translucency measurement together with maternal serum markers, usually PAPP-A and free beta-hCG. It is performed between 11+0 and 13+6 weeks, when the crown-rump length is approximately 45 to 84 mm. Outside this window the nuchal translucency measurement is less reliable.

Question 13Obstetrics

A woman is planning pregnancy and has a previous child with a neural tube defect. Which daily folic acid dose should be recommended before conception and through the first trimester?

  1. 2 milligrams
  2. 1 milligram
  3. 5 milligrams Correct answer.
  4. 400 micrograms

Explanation

Women with a previous affected pregnancy are advised to take high-dose folic acid, 5 mg daily, starting at least one month before conception and continuing through the first trimester. This reduces the recurrence risk of neural tube defects. The standard 400 microgram dose is for average-risk women.

Question 14Obstetrics

A woman at 30 weeks' gestation has preterm prelabour rupture of membranes and no signs of chorioamnionitis. Which combination of interventions is recommended to improve neonatal outcome while awaiting delivery?

  1. Weekly amniocentesis and no antibiotics
  2. Erythromycin and antenatal corticosteroids Correct answer.
  3. Amoxicillin-clavulanate and tocolysis with nifedipine
  4. Immediate oxytocin induction and prophylactic antibiotics

Explanation

For preterm prelabour rupture of membranes remote from term, latency antibiotics such as erythromycin and a course of antenatal corticosteroids improve neonatal outcomes. Co-amoxiclav is avoided because it has been associated with necrotising enterocolitis in this setting. Routine tocolysis and immediate induction are not standard when there is no infection or fetal compromise.

Question 15Obstetrics

A woman at 36 weeks' gestation with pre-eclampsia has a blood pressure of 165/115 mmHg on two occasions. Which blood pressure threshold defines severe hypertension requiring urgent treatment in this context?

  1. Systolic at least 140 mmHg or diastolic at least 90 mmHg
  2. Systolic at least 150 mmHg or diastolic at least 100 mmHg
  3. Systolic at least 170 mmHg or diastolic at least 120 mmHg
  4. Systolic at least 160 mmHg or diastolic at least 110 mmHg Correct answer.

Explanation

Severe hypertension in pre-eclampsia is defined as a systolic pressure of at least 160 mmHg or a diastolic pressure of at least 110 mmHg persisting on two measurements. It requires urgent antihypertensive treatment to reduce the risk of maternal stroke. Delivery is usually indicated once the mother is stabilised.

Question 16Obstetrics

A woman with one previous lower-segment caesarean requires induction of labour at 39 weeks. Which cervical ripening agent is contraindicated because of the risk of uterine rupture?

  1. Misoprostol Correct answer.
  2. Oxytocin infusion
  3. Foley balloon catheter
  4. Dinoprostone vaginal insert

Explanation

Misoprostol is a prostaglandin E1 analogue that is contraindicated for cervical ripening in women with a previous caesarean because it increases the risk of uterine rupture. Mechanical methods such as a Foley balloon are preferred in many protocols, and oxytocin may be used with caution. Dinoprostone is also used cautiously according to local guidance.

Question 17Obstetrics

During a vaginal birth, the membranes rupture and a loop of umbilical cord is felt in the vagina with the fetal head still high. What is the most appropriate immediate action?

  1. Start an oxytocin infusion to expedite vaginal delivery
  2. Apply fundal pressure to deliver the baby quickly
  3. Manually replace the cord into the uterus and continue labour
  4. Elevate the presenting part and deliver by caesarean Correct answer.

Explanation

Cord prolapse is an obstetric emergency in which the presenting part compresses the cord and compromises fetal oxygenation. The immediate priorities are to elevate the presenting part, avoid handling the cord, and arrange urgent delivery, usually by caesarean. Manual replacement, oxytocin and fundal pressure are inappropriate and may worsen fetal compromise.

Question 18Obstetrics

A woman in labour has a CTG abnormality and a fetal scalp blood sample is taken. Which pH value is conventionally considered abnormal and indicates the need for further action or delivery?

  1. pH 7.24
  2. pH 7.28
  3. pH 7.18 Correct answer.
  4. pH 7.35

Explanation

Fetal scalp blood pH of 7.20 or below is conventionally regarded as abnormal and suggests fetal acidosis requiring expedited delivery or further assessment. Values from 7.20 to 7.24 are borderline, while values of 7.25 or above are normal. The result must be interpreted with the clinical context and CTG findings.

Question 19Obstetrics

A woman at 10 weeks' gestation has a history of a previous unprovoked pulmonary embolism. She is not currently anticoagulated. Which management is recommended for venous thromboembolism prophylaxis in this pregnancy?

  1. LMWH antenatally and 6 weeks postpartum Correct answer.
  2. No treatment unless she becomes symptomatic
  3. Aspirin 75 mg daily until delivery
  4. Warfarin antenatally until 36 weeks' gestation

Explanation

A previous unprovoked pulmonary embolism is a strong risk factor for recurrence in pregnancy. Low-molecular-weight heparin is recommended antenatally and should continue for at least six weeks postpartum, with a minimum total duration of three months. Warfarin is avoided antenatally because of teratogenicity, and aspirin alone does not provide adequate thromboprophylaxis.

Question 20Obstetrics

A woman at 12 weeks' gestation has a urine culture that grows more than 100,000 CFU/mL of Escherichia coli, but she has no urinary symptoms. What is the recommended management?

  1. Treat with antibiotics according to sensitivity Correct answer.
  2. No treatment because she is asymptomatic
  3. Perform a renal ultrasound before treatment
  4. Repeat the culture after 2 weeks

Explanation

Asymptomatic bacteriuria in pregnancy is associated with pyelonephritis, preterm birth and low birth weight. Pregnant women should be screened with urine culture and treated with antibiotics guided by sensitivity results. A repeat culture after treatment is useful to confirm clearance.

Question 21Obstetrics

A woman has a spontaneous vaginal birth at term. She remains haemodynamically stable, but the estimated blood loss in the first 24 hours is recorded. Using the widely accepted definition, primary postpartum haemorrhage is blood loss exceeding which volume after vaginal birth?

  1. 300 mL
  2. 500 mL Correct answer.
  3. 1,500 mL
  4. 1,000 mL

Explanation

Primary postpartum haemorrhage is conventionally defined as blood loss of at least 500 mL within 24 hours of vaginal birth, or at least 1,000 mL after caesarean birth. Any volume causing haemodynamic compromise also counts, even if the measured loss is lower. The 500 mL threshold distinguishes primary PPH from ordinary measured blood loss at vaginal delivery.

Question 22Obstetrics

A woman at 28 weeks' gestation is RhD negative and has no anti-D antibodies. Her singleton pregnancy has been uncomplicated and she has had no sensitising events. Which routine antenatal prophylaxis is recommended?

  1. Intravenous immunoglobulin 1 g/kg
  2. No prophylaxis until after delivery
  3. Anti-D immunoglobulin 1,500 IU Correct answer.
  4. Anti-D immunoglobulin 500 IU at 34 weeks only

Explanation

Routine antenatal anti-D prophylaxis is offered to non-sensitised RhD-negative women, commonly as 1,500 IU at around 28 weeks in a single-dose regimen. It reduces the risk of RhD alloimmunisation from silent fetomaternal haemorrhage during pregnancy. Post-delivery prophylaxis is still guided by the baby's RhD status and a Kleihauer test.

Question 23Obstetrics

A woman in early labour has continuous cardiotocography. Which baseline fetal heart rate range is classified as normal on a CTG?

  1. 160–180 bpm
  2. 110–160 bpm Correct answer.
  3. 100–140 bpm
  4. 90–110 bpm

Explanation

A normal baseline fetal heart rate on CTG is between 110 and 160 beats per minute. Rates below 110 bpm are bradycardic and rates above 160 bpm are tachycardic, both requiring evaluation in context. The baseline is assessed over a stable 10-minute segment.

Question 24Obstetrics

A woman at 26 weeks' gestation undergoes a 75-g oral glucose tolerance test for gestational diabetes. Which set of plasma glucose values meets the diagnostic threshold for gestational diabetes using the IADPSG/WHO criteria?

  1. Fasting ≥5.1, 1-hour ≥10.0, 2-hour ≥8.5 mmol/L Correct answer.
  2. Fasting ≥7.0, 1-hour ≥12.0, 2-hour ≥11.1 mmol/L
  3. Fasting ≥6.1, 1-hour ≥11.1, 2-hour ≥10.0 mmol/L
  4. Fasting ≥5.6, 1-hour ≥9.0, 2-hour ≥7.8 mmol/L

Explanation

With the 75-g OGTT, gestational diabetes is diagnosed when any one of these thresholds is met or exceeded: fasting ≥5.1 mmol/L, 1-hour ≥10.0 mmol/L, or 2-hour ≥8.5 mmol/L. These IADPSG/WHO criteria identify women at increased risk of adverse pregnancy outcomes. A single abnormal value is sufficient.

Question 25Obstetrics

A woman at 30 weeks' gestation is in threatened preterm labour and delivery is anticipated within 24 hours. She has no contraindication to corticosteroids. Which regimen is the standard betamethasone course for antenatal fetal lung maturation?

  1. Dexamethasone 6 mg IM every 12 hours for four doses
  2. Betamethasone 12 mg IM, repeated once after 24 hours Correct answer.
  3. Betamethasone 24 mg IM as a single dose
  4. Hydrocortisone 100 mg IV every 8 hours for 48 hours

Explanation

The standard betamethasone regimen is 12 mg intramuscularly, followed by a second 12 mg dose 24 hours later. It accelerates fetal lung maturation and reduces neonatal respiratory distress syndrome, intraventricular haemorrhage, and neonatal death. Dexamethasone 6 mg every 12 hours for four doses is an alternative corticosteroid regimen, not the betamethasone regimen asked about.

Question 26Obstetrics

A woman at 38 weeks' gestation is in active labour and is known to be colonised with group B Streptococcus. She has no penicillin allergy. Which intrapartum antibiotic is first-line for prevention of early-onset neonatal group B streptococcal disease?

  1. Intravenous penicillin G Correct answer.
  2. Intravenous gentamicin
  3. Oral erythromycin
  4. Oral amoxicillin

Explanation

Intravenous penicillin G is the first-line intrapartum antibiotic for GBS colonisation in women without penicillin allergy. It provides high maternal and fetal levels and is narrow-spectrum, reducing selection pressure. Ampicillin is an alternative, and clindamycin or vancomycin is used for penicillin allergy according to susceptibility.

Question 27Obstetrics

A woman at 29 weeks' gestation is in established preterm labour, and delivery is expected within the next 24 hours. Which intervention is recommended specifically to reduce the risk of cerebral palsy in the preterm infant?

  1. Oral nifedipine
  2. Intramuscular betamethasone
  3. Intravenous antibiotics
  4. Intravenous magnesium sulphate Correct answer.

Explanation

Antepartum magnesium sulphate given when preterm birth is imminent reduces the risk of cerebral palsy in the child, particularly before 32 weeks' gestation. It is used for fetal neuroprotection in addition to, not instead of, antenatal corticosteroids. The usual approach is a loading dose followed by infusion until birth or for up to 24 hours.

Question 28Obstetrics

A woman at 32 weeks' gestation has intense generalised pruritus, no rash, and a serum total bile acid concentration of 120 micromol/L. She has intrahepatic cholestasis of pregnancy. Which delivery timing is recommended because of the stillbirth risk associated with this bile acid level?

  1. Expectant management until 41 weeks
  2. Delivery at 32 to 33 weeks
  3. Delivery at 39 0/7 to 39 6/7 weeks
  4. Delivery at 36 0/7 to 36 6/7 weeks Correct answer.

Explanation

In intrahepatic cholestasis of pregnancy, total bile acids of 100 micromol/L or more are associated with a substantially increased stillbirth risk. Delivery is therefore recommended at 36 0/7 to 36 6/7 weeks after corticosteroids if needed. Lower bile acid levels are managed with delivery at 36 to 39 weeks depending on severity and local protocol.

Question 29Obstetrics

A woman with a previous caesarean birth is planning a subsequent pregnancy. Which type of uterine incision carries the highest risk of rupture in a later pregnancy or trial of labour?

  1. Classical upper-segment incision Correct answer.
  2. Low vertical lower-segment incision
  3. Unlaboured caesarean with a transverse incision
  4. Low transverse lower-segment incision

Explanation

A classical caesarean incision extends into the upper contractile uterine segment and carries the highest subsequent rupture risk, often quoted at around 4–9% or more. For this reason, a subsequent trial of labour is generally contraindicated. Low transverse and low vertical incisions carry substantially lower rupture risks.

Question 30Obstetrics

A woman at 16 weeks' gestation has a history of three consecutive second-trimester pregnancy losses associated with painless cervical dilatation. She has no infection or uterine anomaly. Which management is most appropriate?

  1. Vaginal pessary placement
  2. History-indicated cervical cerclage Correct answer.
  3. Strict bed rest until term
  4. Weekly intramuscular progesterone

Explanation

A history of three or more second-trimester losses related to painless cervical dilatation supports a history-indicated cerclage, usually placed at 12–14 weeks. Cerclage is considered for recurrent painless mid-trimester loss or advanced cervical shortening in selected women. Bed rest and pessary are not standard replacements for cerclage in this high-risk history.

Question 31Obstetrics

A woman at 12 weeks' gestation has chronic hypertension and a previous pregnancy complicated by pre-eclampsia at 30 weeks. Which drug should be offered to reduce her risk of recurrent pre-eclampsia?

  1. Low-dose aspirin Correct answer.
  2. Subcutaneous heparin
  3. Magnesium sulfate
  4. Nifedipine

Explanation

Women at high risk of pre-eclampsia, including those with chronic hypertension or previous early pre-eclampsia, should be offered low-dose aspirin from 12 weeks until delivery. Aspirin reduces the risk of pre-eclampsia and fetal growth restriction. Antihypertensives treat existing high blood pressure but do not prevent pre-eclampsia.

Question 32Obstetrics

A woman at 9 weeks' gestation with hyperemesis gravidarum is dehydrated and ketotic. She is prescribed intravenous fluids containing dextrose. Which vitamin should be administered before the dextrose infusion to prevent Wernicke encephalopathy?

  1. Folic acid
  2. Vitamin K
  3. Thiamine Correct answer.
  4. Pyridoxine

Explanation

Thiamine should be given before or alongside dextrose-containing fluids in hyperemesis gravidarum. Glucose administration can precipitate Wernicke encephalopathy in a thiamine-deficient patient. Pyridoxine is used for nausea and vomiting but does not prevent Wernicke encephalopathy.

Question 33Obstetrics

During a vaginal birth at term, the fetal head delivers but the anterior shoulder does not; the midwife calls for help. Which manoeuvre should be performed first?

  1. Symphysiotomy
  2. Zavanelli manoeuvre
  3. Fundal pressure
  4. McRoberts' position Correct answer.

Explanation

The first manoeuvre for shoulder dystocia is McRoberts' position, which flattens the sacral promontory and rotates the symphysis pubis cephalad. Suprapubic pressure is added next, and more invasive manoeuvres are reserved for failure. Fundal pressure is contraindicated because it can worsen impaction and cause uterine rupture.

Question 34Obstetrics

A woman at 7 weeks' gestation has a transvaginal scan showing a 2.5-cm unruptured tubal ectopic pregnancy with no fetal cardiac activity. She is haemodynamically stable and her serum hCG is 1,200 IU/L. Which management is most appropriate?

  1. Expectant management
  2. Single-dose methotrexate Correct answer.
  3. Emergency laparotomy
  4. Laparoscopic salpingectomy

Explanation

A stable woman with an unruptured tubal ectopic pregnancy, no fetal cardiac activity, hCG below 5,000 IU/L and a small mass is suitable for single-dose methotrexate. Methotrexate avoids surgery and preserves the tube. Expectant management is reserved for very low and falling hCG levels.

Question 35Obstetrics

A woman at 33 weeks' gestation presents with painless bright red vaginal bleeding. Ultrasound shows a placenta covering the internal cervical os. She is haemodynamically stable. Which is the most appropriate initial step?

  1. Digital vaginal examination to assess cervical dilatation
  2. Artificial rupture of membranes to reduce uterine pressure
  3. Speculum examination to visualize the cervix
  4. Resuscitation, IV access and continuous fetal monitoring Correct answer.

Explanation

In a stable woman with placenta praevia and vaginal bleeding, initial management is resuscitation and monitoring: intravenous access, blood group and cross-match, and continuous fetal monitoring. Digital and speculum examinations are avoided until placenta praevia is excluded because they can provoke severe haemorrhage. Delivery is by caesarean section if bleeding is heavy or fetal compromise occurs.

Question 36Obstetrics

A woman at 37 weeks' gestation with a singleton breech presentation has no contraindication to vaginal breech birth and wishes to discuss options. When should external cephalic version normally be offered?

  1. 36-37 weeks Correct answer.
  2. 32 weeks
  3. 34 weeks
  4. 40 weeks

Explanation

External cephalic version is usually offered at 36-37 weeks' gestation for a singleton breech pregnancy without contraindications. At this gestation, spontaneous version is less likely and the fetal size is suitable, while the procedure remains before the onset of labour. Earlier attempts have a higher chance of reversion.

Question 37Obstetrics

A woman at 39 weeks' gestation in active labour has a temperature of 39.0°C, uterine tenderness, and foul-smelling amniotic fluid. Which intravenous antibiotic regimen is most appropriate initially?

  1. Vancomycin plus metronidazole
  2. Ampicillin plus gentamicin Correct answer.
  3. Ceftriaxone alone
  4. Metronidazole alone

Explanation

Intrapartum chorioamnionitis is treated with broad-spectrum intravenous antibiotics, commonly ampicillin plus gentamicin. Delivery should also be expedited, and clindamycin or metronidazole is added if caesarean section is performed. Single-agent regimens may not cover the polymicrobial flora adequately.

Question 38Obstetrics

A woman with primary hypothyroidism is taking levothyroxine 100 micrograms daily and has a confirmed intrauterine pregnancy at 6 weeks. Her TSH was normal before conception. What is the most appropriate advice?

  1. Reduce the dose by half and recheck in 4 weeks
  2. Stop levothyroxine until the second trimester
  3. Continue the same dose and check TSH in 4-6 weeks
  4. Increase the dose by 20-30% and recheck TSH Correct answer.

Explanation

Thyroid hormone requirements increase in early pregnancy because of increased thyroid-binding globulin and placental transfer of thyroxine. Most women on levothyroxine need an increase of about 20-30% as soon as pregnancy is confirmed. TSH should be checked every 4-6 weeks and the dose adjusted to maintain normal trimester-specific ranges.

Question 39Obstetrics

A woman at 28 weeks' gestation has a routine ultrasound that shows the umbilical cord inserting into the membranes over the internal cervical os, with fetal vessels crossing the os. She is asymptomatic. Which management plan is most appropriate?

  1. Planned caesarean section at 34-36 weeks Correct answer.
  2. External cephalic version at 36 weeks
  3. Expectant management with vaginal delivery at term
  4. Amniotomy at the onset of labour

Explanation

Vasa praevia carries a high risk of fetal exsanguination if the vessels are torn during labour or membrane rupture. Planned caesarean section before labour, usually at 34-36 weeks, is recommended after corticosteroids for fetal lung maturity. Vaginal delivery and amniotomy are contraindicated because they can rupture the unprotected vessels.

Question 40Obstetrics

A woman at 10 weeks' gestation has a uterus larger than dates, hyperemesis, and a snowstorm appearance on ultrasound with no fetus. Histology after evacuation shows hydropic villi and trophoblastic proliferation. Which karyotype is most characteristic of this condition?

  1. 46,XX Correct answer.
  2. 69,XXY
  3. 45,X
  4. 47,XX,+21

Explanation

A complete hydatidiform mole typically arises from an empty ovum fertilized by a haploid sperm that duplicates, giving a 46,XX karyotype in most cases. It is associated with a markedly elevated hCG, a snowstorm ultrasound appearance, and a risk of gestational trophoblastic neoplasia. Partial moles are usually triploid (for example, 69,XXY) and may have a fetus.

Question 41Obstetrics

A nulliparous woman at term has an epidural and reaches full cervical dilatation. According to standard obstetric criteria, a prolonged second stage is diagnosed after how many hours without progress?

  1. 4 hours Correct answer.
  2. 3 hours
  3. 2 hours
  4. 1 hour

Explanation

For a nulliparous woman with an epidural, the second stage is considered prolonged after 4 hours without progress. Without an epidural, the threshold is 3 hours in nulliparous women. Multiparous women have shorter thresholds.

Question 42Obstetrics

A previously normotensive woman at 24 weeks' gestation has blood pressure 148/96 mmHg on two occasions. Urine protein is negative, and platelets, creatinine, and liver enzymes are normal. She has no symptoms. Which diagnosis is most appropriate?

  1. Chronic hypertension
  2. Gestational hypertension Correct answer.
  3. Preeclampsia without severe features
  4. White-coat hypertension

Explanation

New hypertension after 20 weeks without proteinuria or end-organ dysfunction defines gestational hypertension. Chronic hypertension would require elevated blood pressure before pregnancy or before 20 weeks. White-coat hypertension requires evidence of normal blood pressure outside the clinic.

Question 43Obstetrics

At 1 minute after a term birth, a newborn has a heart rate of 90/min, slow irregular respirations, some flexion of the limbs, grimace to suction, and blue hands and feet with a pink trunk. What is the Apgar score?

  1. 9
  2. 7
  3. 3
  4. 5 Correct answer.

Explanation

Each of the five components scores 1 point here: heart rate below 100/min, slow irregular breathing, some flexion, grimace, and acrocyanosis. The total is 5. A score of 5 at 1 minute indicates moderate depression and prompts continued resuscitation assessment.

Question 44Obstetrics

A woman at 30 weeks' gestation has preterm prelabour rupture of membranes. She has no contractions, no clinical infection, and a reassuring cardiotocograph. Which intervention has the strongest evidence for prolonging latency?

  1. Ampicillin plus azithromycin Correct answer.
  2. Rescue cerclage after membrane rupture
  3. Maintenance tocolysis until 34 weeks
  4. Immediate delivery regardless of fetal status

Explanation

Antibiotic prophylaxis with a regimen such as ampicillin plus azithromycin for 7 days prolongs latency and reduces infection in preterm prelabour rupture of membranes. Antenatal corticosteroids and group B streptococcal prophylaxis are also indicated, but they do not primarily prolong latency. Maintenance tocolysis and rescue cerclage are not standard for this presentation.

Question 45Obstetrics

A woman at 36 weeks' gestation has blood pressure 150/100 mmHg, platelet count 90 × 10^9/L, and serum creatinine 1.2 mg/dL. She has no headache or visual symptoms. Which diagnosis best fits these findings?

  1. Preeclampsia with severe features Correct answer.
  2. Preeclampsia without severe features
  3. Gestational hypertension without proteinuria
  4. Chronic hypertension with superimposed pre-eclampsia

Explanation

Preeclampsia with severe features is present when there is new hypertension after 20 weeks plus a severe feature such as platelets below 100 × 10^9/L or creatinine above 1.1 mg/dL. The blood pressure alone is not in the severe range, but the haematological and renal abnormalities qualify. Delivery is generally indicated at this gestation.

Question 46Obstetrics

A woman at 32 weeks' gestation has a singleton fetus with an estimated fetal weight below the 10th centile. Which umbilical artery Doppler finding indicates increased placental vascular resistance and warrants close surveillance?

  1. Decreased umbilical artery resistance
  2. Absent umbilical artery end-diastolic flow Correct answer.
  3. Normal systolic-to-diastolic ratio
  4. Increased pulsatility index with preserved forward flow

Explanation

Absent end-diastolic flow in the umbilical artery reflects high placental vascular resistance and is a warning sign in fetal growth restriction. It requires intensified surveillance and may prompt delivery depending on gestational age and other findings. Reduced resistance and normal ratios are not concerning in this context.

Question 47Obstetrics

A woman at 39 weeks' gestation has one prior low-transverse caesarean birth and an unfavourable cervix. She requests induction of labour. Which cervical ripening method is preferred?

  1. Misoprostol 25 micrograms vaginally
  2. Oxytocin infusion without cervical ripening
  3. Transcervical Foley balloon Correct answer.
  4. Dinoprostone gel

Explanation

Mechanical ripening with a transcervical Foley balloon is preferred in women with a prior caesarean because it avoids prostaglandin exposure and lowers the risk of uterine rupture. Prostaglandins are generally avoided in this setting. Oxytocin alone is less effective when the cervix is unfavourable and should not replace ripening.

Question 48Obstetrics

During active labour, a woman suddenly becomes hypotensive and cyanotic, has a generalised seizure, and develops coagulopathy shortly after amniotomy. Which diagnosis best explains this constellation?

  1. Pulmonary embolism
  2. Eclampsia
  3. Amniotic fluid embolism Correct answer.
  4. Anaphylaxis to prophylactic antibiotics

Explanation

Amniotic fluid embolism classically presents with sudden hypoxia, hypotension, and coagulopathy during labour or immediately postpartum, often with seizure-like activity. Eclampsia is associated with hypertension and proteinuria, which are not described. The timing and coagulopathy make the other diagnoses less likely.

Question 49Obstetrics

A woman at 34 weeks' gestation has placenta previa, two prior caesarean births, and ultrasound features suggesting placenta increta. Which delivery management is most appropriate?

  1. Prophylactic uterine artery embolization alone
  2. Planned caesarean hysterectomy, placenta left in situ Correct answer.
  3. Vaginal delivery with active management of the third stage
  4. Attempt manual removal of the placenta after birth

Explanation

Suspected placenta accreta spectrum with previa and prior caesarean births is best managed by a planned caesarean hysterectomy with the placenta left in situ at a centre with an experienced multidisciplinary team. Attempting placental removal can cause catastrophic haemorrhage. Embolization alone does not remove the invasive placental tissue.

Question 50Obstetrics

A woman at 20 weeks' gestation with a singleton pregnancy has a transvaginal cervical length of 18 mm. She has no history of preterm birth. Which intervention reduces her risk of preterm birth?

  1. Routine prophylactic antibiotics
  2. Elective cervical cerclage
  3. Vaginal progesterone Correct answer.
  4. Strict bed rest until delivery

Explanation

Vaginal progesterone is recommended for a short cervix of 25 mm or less in a singleton pregnancy without prior preterm birth. Cerclage is generally reserved for selected women with prior preterm birth or other specific indications. Bed rest and routine antibiotics do not reduce preterm birth in this setting.