This Copy is for Dr.

Mohamed ElHodiby
 STRATOG 2015 SBA

Clinical Management
Question 1 of 22

A 16 year old woman presents with secondary amenorrhoea. She is healthy, with no past
medical history. Her BMI is 17. What is the most appropriate initial investigation?

A Thyroid function test

B Karyotype
C Folliclestimulating hormone measurement Correct
D Dehydroepiandrosterone sulphate (DHEAS) measurement
E Bone mineral density scan

The answer is follicle-stimulating hormone measurement. The likely diagnosis is amenorrhoea

caused by weight loss, so follicle-stimulating hormone measurements would be appropriate.
Since she is clinically euthyroid, thyroid function tests would be of limited value.

Question 2 of 22

You are asked to assess a patient who is receiving magnesium sulphate infusions for severe
preeclampsia. They have passed only 5 ml urine in the last 2 hours. Tests demonstrate that
their deep tendon reflexes are absent. What other observation should you take?

A Temperature
B Respiratory rate Correct
C Pulse rate
D Glasgow coma score
E Blood pressure

The answer is respiratory rate. This patient has signs of magnesium toxicity (absent deep
tendon reflexes), which is probably secondary to renal impairment. Respiratory depression is a
sign of increasing magnesium toxicity is; therefore, the most appropriate follow-up would be to
investigate the patient’s respiratory rate.

This Copy is for Dr. Mohamed ElHodiby

 STRATOG 2015 SBA

Question 3 of 22

A cardiotocograph shows type 1 variable decelerations. What is the cause of this feature?

A Umbilical cord compression Correct

B Placental insufficiency
C Fetal movements
D Fetal hypoxia
E Fetal head compression

The answer is umbilical cord compression. Variable decelerations are due to umbilical cord
compression. Early decelerations are caused by compression of the fetal head, and late
decelerations are caused by fetal hypoxia that is secondary to placental insufficiency. Fetal
movements are related to accelerations.

Question 4 of 22

You answer an emergency call for a postpartum haemorrhage. The midwife estimates that
the patient has lost approximately 500 ml of blood. What is the most likely cause of the
bleeding?

A Vaginal tear
B Uterine atony Correct
C Retained placenta tissue
D Coagulopathy
E Cervical trauma

The answer is uterine atony. Approximately 70% of all postpartum haemorrhages are due to
uterine atony.

Question 5 of 22

You answer an emergency call for a postpartum haemorrhage. The midwife estimates that
the patient has lost approximately 1 l of blood. What should you be your first action?

A Site two large bore intravenous cannulae

B Obtain blood for cross match of 4 units
C Catheterise the bladder

This Copy is for Dr. Mohamed ElHodiby

 STRATOG 2015 SBA

D Bimanual compression of the uterus

Assess the patient’s airway, breathing and circulation and administer oxygen at a rate
E of 15 l/min Correct

The answer is assess the patient’s airway, breathing and circulation and administer oxygen at a
rate of 15 l/min. In an acute emergency, one should always assess the airway, breathing and
circulation before addressing the secondary treatment. In practice, this may be talking to the
patient and to see if they respond.

Question 6 of 22

Whilst you are attending to a patient in the antenatal ward, the patient collapses and becomes
unresponsive. You open their airway but they are not breathing. What should you do next?

A Left lateral tilt

B Give a precordial thump
C Get help Correct
D Commence cardiac compressions
E Commence artificial ventilation

The answer is get help. Basic and Advanced Life Support guidelines highlight the need to get
help if a patient has collapsed and is unresponsive. You should then place the patient in left
lateral tilt and commence cardiac compressions at a rate of 30:2. Artificial ventilation is not
mandatory in the ALS guidelines.

Question 7 of 22

A 17 year old woman presents to the sexual health clinic with vulval ulceration and difficulty
in passing urine. She is sexually active and has had unprotected intercourse with her new
boyfriend. She takes the combined oral contraceptive pill. What is the most likely diagnosis?

A Syphilis
B Human papillomavirus
C Herpes varicella virus
D Herpes simplex virus Correct
E Candida albicans

This Copy is for Dr. Mohamed ElHodiby

 STRATOG 2015 SBA

The answer is herpes simplex virus. A painful genital ulcer has developed in a sexually active
patient who has not used barrier contraception. Syphilis is usually associated with the presence
of a painless ulcer. Candida is not a sexually transmitted disease and rarely presents with
ulceration. Human papillomavirus causes warts, and herpes varicella zoster causes chicken pox
and shingles.

Question 8 of 22

A primigravid woman presents in spontaneous labour at 39 weeks of gestation. At 18:00h,

her cervical dilatation is 6 cm. A further vaginal examination at 22:00h reveals that cervical
dilatation is still at 6 cm. At 02:10h, the fetus is in the occipitoposterior position and uterine
activity is present. What is the most appropriate action?

A Repeat vaginal examination after 4 hours

B Repeat vaginal examination after 2 hours
C Membrane sweep
D Commence intravenous oxytocin
E Amniotomy Correct

The answer is amniotomy. This case demonstrates slow/no progression during the first stage of
labour and malpositioning of the fetus. The most appropriate initial intervention would be an
amniotomy (artificial rupture of the membranes).

Question 9 of 22

An 18 year old woman presents to an early pregnancy unit with light vaginal bleeding after
10 weeks of amenorrhea. She had taken a pregnancy test 4 weeks ago that had tested positive.
A transvaginal ultrasound scan showed an irregular gestation sac with no fetal pole. What is the
likely diagnosis?

A Threatened miscarriage
B Incomplete miscarriage
C Hydatidiform mole
D Complete miscarriage
E Anembryonic pregnancy Correct

The answer is anembryonic pregnancy. Threatened miscarriage refers to vaginal bleeding in the
presence of a viable pregnancy; however, this pregnancy is not viable. There are products of

This Copy is for Dr. Mohamed ElHodiby

 STRATOG 2015 SBA

conception (gestation sac) that are visible on the scan so this is an incomplete miscarriage,
which is usually associated with heavy vaginal bleeding. In this case, the patient is considered to
be pregnant, although no embryonic tissue is present. Therefore, the most likely diagnosis is
anembryonic pregnancy.

Question 10 of 22

A 55 year old woman presents to the clinic enquiring about the use of hormone replacement
therapy (HRT). She had a hysterectomy 8 years ago for fibroids. She has no contraindications or
other past medical history, except a strong family history of osteoporosis. Her main symptoms
are hot flushes and vaginal dryness. What would be your first treatment option?

A Selective serotonin reuptake inhibitor

B Oral calcium therapy only
C Estrogen-only HRT Correct
D Combined sequential HRT
E A selective estrogen receptor modulator

The answer is estrogen-only HRT. HRT provides the most effective method of treating
climacteric hot flushes and vaginal dryness, as well as postmenopausal osteoporosis. Estrogen-
only HRT is appropriate following a hysterectomy, as the risk of endometrial carcinoma is not
present.

Question 11 of 22

A 68 year old woman presents with two episodes of postmenopausal bleeding. She has a
BMI of 23 and is otherwise healthy. An ultrasound shows that her endometrial cavity is 4 mm
thick, and an endometrial pipelle sample is taken that yields a small volume of tissue. The
pathology report suggests a neoplasm. What is the most likely diagnosis?

A Serous carcinoma Correct

B Endometrioid adenocarcinoma
C Endometrial polyp
D Endometrial hyperplasia
E Leiomyoma

This Copy is for Dr. Mohamed ElHodiby

 STRATOG 2015 SBA

The answer is serous carcinoma. Serous carcinomas are typically seen in postmenopausal
women. The development of these carcinomas is not associated with a raised BMI, diabetes or
hypertension. The uterine tumour can be very small (even in the presence of extra uterine
spread), and therefore, results from an ultrasound and even hysteroscopy can appear normal.

Question 12 of 22

A nulliparous woman presents with spontaneous rupture of membranes at 41 weeks of

gestation. At 18:00h, her cervical dilatation is 3 cm. A further vaginal examination at 22:00h
reveals that her cervical dilatation is still 3 cm. At 02:10h, the fetus is in the occipitoposterior
position and uterine activity is present. What is the most appropriate action?

A Repeat vaginal examination after 4 hours

B Membrane sweep
C Commence intravenous oxytocin Correct
D Caesarean section
E Administer prostaglandin per vaginam

The answer is commence intravenous oxytocin. The membranes have ruptured already so
amniotomy is not required. No progression has been made during the first stage of labour.
Therefore, the patient should be administered intravenous oxytocin.

Question 13 of 22

Polyglactin sutures are used extensively in surgical procedures, particularly to ligate vessels.
What are the key features of polyglactin sutures?

A Nonbraided, nonabsorbable and natural

B Nonbraided, absorbable and synthetic
C Nonbraided, absorbable and natural
D Braided, nonabsorbable and synthetic
E Braided, absorbable and synthetic Correct

The answer is braided, absorbable and synthetic. Polyglactin sutures are used to ligate pedicles
and close the uterus during a caesarean section. To achieve this, the sutures are braided to
prevent the knots from slipping.

This Copy is for Dr. Mohamed ElHodiby

 STRATOG 2015 SBA

Question 14 of 22

A 15 year old patient visits her GP requesting a method of contraception. When taking her
history, you discover a personal history of thromboembolic events. She has had three sexual
partners in 5 months. She also complains of dysmenorrhea. You advise on contraception being
mindful of which medical law?

A Abortion Act 1967

B Bolam
C Bolitho
D Fraser Correct
E Gillick

The correct answer is Fraser. This law refers specifically to contraception.

Question 15 of 22

A patient with a previous caesarean section arrives at term to your unit in spontaneous
labour. The midwife reports the cervix is 6 cm dilated, there is a longitudinal lie and the
vertex is well applied to the cervix. The patient is contracting three times in 10 minutes. You
are asked to assess the patient by the registrar on call as he is in theatre. What initial
management would you suggest?

A You immediately perform a fetal blood sample

B You suggest continuous fetal monitoring (CFM) and syntocinon infusion
You suggest continuous fetal monitoring (CFM) and vaginal assessment 2 hours following the
C last VE Correct
D You suggest intermittent monitoring and 1 hourly vaginal assessments
E You suggest mobilisation and a cooks catheter

The best answer is CFM and vaginal assessment 2 hours following the last VE.
Question 16 of 22

A patient with a previous caesarean section arrives at term to your unit in spontaneous
labour. The midwife reports the cervix is 6 cm dilated, there is a longitudinal lie and the
vertex is well applied to the cervix. The patient is contracting three times in 10 minutes. The

This Copy is for Dr. Mohamed ElHodiby

 STRATOG 2015 SBA

contractions stop and there is a fetal bradycardia. What is the most likely diagnosis?

A Placental abruption
B Scar dehiscence
C Scar rupture Correct
D Tetanic uterine contractions
E Uterine atony

The best answer is scar rupture as the fetus is compromised.

Question 17 of 22

A 28 year old primiparous woman is induced at 39+2 for raised BP and proteinuria. She
progresses well to full dilatation, but after pushing for 2 hours there is no vertex visible. On
examination, the head is felt to be OA, at +1 station. A decision is made for an instrumental
delivery, and the baby is delivered via assisted vaginal delivery in theatre. For a ventouse
delivery to be successful, the ventouse cup needs to be applied to the flexion point of the
fetal head. Which of the following statements best describes the location of the flexion point?

A Approximately 3 cm anterior (in front) of the anterior fontanelle Correct

B Directly over the anterior fontanelle
C Directly over the posterior fontanelle
D On the sagittal suture line, approximately 2 cm posterior (behind) the posterior fontanelle
E On the sagittal suture line, approximately 3 cm anterior (in front) of the posterior fontanelle

The best answer is on the sagittal suture line, approximately 3 cm anterior (in front) of the
posterior fontanelle.

Question 18 of 22

A 28 year old primiparous woman is induced at 39+2 for raised BP and proteinuria. She
progresses well to full dilatation, but after pushing for 2 hours there is no vertex visible. On
examination, the head is felt to be OA, at +1 station. A decision is made for an instrumental
delivery, and the baby is delivered via assisted vaginal delivery in theatre. (Same scenario
as question above.) Shortly after delivery, you examine the perineum. Your episiotomy has
extended, and the tear involves approximately 60% of the external anal sphincter. The
internal anal sphincter and anal mucosa are intact. How would you classify this perineal
trauma?

This Copy is for Dr. Mohamed ElHodiby

 STRATOG 2015 SBA

A Second degree tear

B 3a degree tear
C 3b degree tear Correct
D 3c degree tear
E Fourth degree tear

The best answer is a 3b degree tear. Note the the risk of perineal tearing after instrumental
delivery is 7% for forceps and 4% for ventouse.

Question 19 of 22

A 54 year old woman presents to her GP with malaise, a history of recent weight loss and
bloating. On examination the GP notes a large pelvic mass. He sends her for an urgent
abdminal ultrasound scan and initiates a 2weekwait referral. This patient is discussed at an
MDT meeting and it is decided to proceed with a laparatomy. During the laparotomy, a full
examination is performed to look for possible metastatic spread. If this cancer is presumed
to be ovarian, which lymph nodes would you expect the disease to drain to first?

A External iliac lymph nodes

B Hypogastric lymph nodes
C Inguinal lymph nodes
D Internal iliac lymph nodes
E Para-aortic lymph nodes Correct

The best answer is para-aortic lymph nodes.

Question 20 of 22

A 30 year old primigravida who is pregnant after IVF attends the Early Pregnancy Unit with
severe right sided abdominal pain. An ultrasound scan shows an empty uterus. βhCG levels
are 5,500 iu/L. What is the appropriate course of action?

A Expectant management, evaluate after 48 hours with repeat hCG levels

B Laparoscopy and salpingectomy if there is an ectopic pregnancy Correct
C Laparoscopy and salpingotomy if there is an ectopic pregnancy
D Methotrexate injection
E Repeat scan in 7 days

This Copy is for Dr. Mohamed ElHodiby

 STRATOG 2015 SBA

The correct answer is laparoscopy and salpingectomy if there is an ectopic pregnancy.

Question 21 of 22

The midwife has asked you to review a 34 year old multigravida who is 7 cm dilated and
progressing well. The CTG shows a variability of <5. She was given pethidine when she was 6
cm dilated. A fetal blood sampling is done and reveals a pH of 7.23. What will be your next
line of management?

A Delivery is indicated
B Reassure the patient
C Repeat FBS after 1 hour
D Repeat FBS if fetal heart rate abnormality persists
E Repeat FBS within 30 minutes Correct

The correct answer is repeat FBS within 30 minutes.

Question 22 of 22

A 75 year old woman presents with increased weight, loss of hair and a dislike of cold weather.
She was noted to have a high prolactin and normal electrolytes. She is otherwise fit and well.
What is the likely cause of the high prolactin?

A Antiemetic use
B Hypothyroidism Correct
C Neuroleptic use
D Prolactinoma
E Renal failure

The correct answer is hypothyroidism.

This Copy is for Dr. Mohamed ElHodiby

 STRATOG 2015 SBA

This Copy is for Dr. Mohamed ElHodiby