Case 14 Questions 1-15

Question 1

A 22-year-old patient presents to her GP after an episode of unprotected sex the night before, on day 13 of her cycle. She is prescribed the emergency contraceptive pill Levonelle and is started on the combined oral contraceptive pill Microgynon 30.

For how long must she abstain from sexual intercourse or use barrier protection in order to be sure of contraceptive cover?

1. 1- 3 weeks
2. 2- 2 days
3. 3- No need to abstain as the patient is covered immediately
4. 4- 7 days
5. 5- 5 days

7 days

For this patient, the combined oral contraceptive pill (COCP) Microgynon 30 was started at the same time as the emergency contraceptive Levonelle. In this scenario, it will take 7 days for the patient to be fully protected against pregnancy. Generally speaking, the COCP requires 7 days for contraceptive coverage to be provided. This does, however, depend both on the type of COCP and the time in the menstrual cycle. Exceptions to the 7-day rule include if the COCP is initiated on day one of the cycles (no additional measures needed) or if the patient is switching from another combined hormonal contraceptive e.g. the combined vaginal ring (no additional measures needed). There may also be exceptions to this rule for patients who are switching from a progesterone-only method of contraception, depending on what that method is/was. The type of COCP is important to bear in mind- in particular, the pills Qlaira and Zoely have different rules and may take longer to become effective. It is important to provide the correct advice in these instances to the patient and as such, it is always worth referencing up-to-date guidelines.

Question 2

An 18-year-old student comes to see you at the GP clinic. She complains of heavy periods that interfere with her daily activities as she is always worried about leaking through her pad. She has a 28-day menstrual cycle and her periods last for 7 days. For the first few days, she has to change her pad every 2 hours by which time it is usually saturated. Her periods are associated with pain especially with the passage of clots but this is managed by regular ibuprofen. Abdominal and pelvic examinations are normal. She is otherwise fit and healthy. She is not sexually active.

What is the best initial management step?

1. 1- Norethisterone
2. 2- Tranexamic acid
3. 3- Mirena coil
4. 4- Mefenamic acid/li>
5. 5- Combined oral contraceptive pill

Mirena coil

The best initial management step is insertion of the Mirena® coil. Menorrhagia is defined as heavy menstrual bleeding in an otherwise normal menstrual cycle. The passage of clots represents heavy flow. 40-60% of those who complain of excessive bleeding have no pathology and this is called dysfunctional uterine bleeding (DUB). Common causes include uterine fibroids (30%) and polyps (10%). Symptoms that may indicate an underlying pathology include: persistent postcoital bleeding, persistent intermenstrual bleeding, dyspareunia, dysmenorrhoea, pelvic pain or pressure symptoms, vaginal discharge. Investigations should include haemoglobin levels. The most common cause of iron deficiency anaemia in women is menorrhagia. TFTs should be considered in anyone if thyroid disease is suspected. Management: First-line: LNG-IUS – Mirena® coil (only if the woman is not trying to conceive). Recommended by NICE. Second-line: tranexamic acid or mefenamic acid. Alternatively, the combined oral contraceptive pill can be tried. Third-line: progestogens e.g. norethisterone, Depo-Provera Surgery may be indicated if there is underlying pathology such as polyps.

Question 3

Sarah, 19, presents to the GP after an episode of unprotected sexual intercourse. She is taking no regular contraceptive and had unprotected sexual intercourse 80 hours ago. She is currently being treated for a vaginal chlamydial infection.

Which of the following would be the most appropriate emergency contraceptive option for this patient?

1. 1- Levenorgestrel (1500mcg tablet, ‘Levonelle’)
2. 2- Ulipristal acetate (EllaOne)
3. 3- Progesterone only pill
4. 4- Combined oral contraceptive pill
5. 5- Copper intrauterine device

Ulipristal acetate (EllaOne)

Ulipristal acetate (EllaOne) is effective for up to 5 days (120 hours) after an episode of unprotected sexual intercourse, whereas levonorgestrel (Levonelle) can be taken up to 72 hours afterwards (being the most effective in the first 24 hours). Given that 80 hours has elapsed, Ulipristal acetate is more appropriate. The copper intrauterine device is effective up to 120 hours after unprotected intercourse, OR up to 120 hours after the expected date of ovulation. However, this is a less appropriate option for this patient as she has a known Chlamydia infection. Intrauterine devices are a risk factor for pelvic inflammatory disease, and insertion should be avoided in known infection where possible. The combined oral contraceptive pill and the progesterone-only pill are not forms of emergency contraception.

Question 4

Diedre, 21, presents to the sexual health clinic after an episode of unprotected sexual intercourse. She wishes to have emergency contraception. She has a regular 28-day cycle. It is now day 16 of this cycle, and she had unprotected sex 6 days ago.

What is the most appropriate management for this patient?

1. 1- Insert the copper intrauterine device
2. 2- Insert the Mirena intrauterine device
3. 3- Prescribe the EllaOne (Ulipristal Acetate) emergency contraceptive
4. 4- Advise the patient that she may be pregnant, arrange suitable follow-up and counselling

1- Insert the copper intrauterine device

Neither the EllaOne nor the Levonelle emergency contraceptives would be suitable in this case, as the windows of use have elapsed. Both of these tablets work by preventing ovulation. EllaOne (ulipristal acetate) must be used within 120 hours of unprotected sexual intercourse (UPSI), and Levonelle (levonorgestrel) must be used within 72 hours of UPSI. The copper intrauterine device can be used up to 120 hours of UPSI, OR within 5 days of the earliest expected date of ovulation. Given that Diedre has a regular 28-day cycle, ovulation would be expected around day 14. She presented on day 16 and as such is within the window for insertion of the copper coil. The copper coil works by preventing sperm from surviving in the uterus and fallopian tubes and helps to prevent implantation. The Mirena intrauterine device is not an emergency contraceptive.

Question 5

Definition of the start of the second stage of labour is regular expulsive contractions with cervical dilation of:

1. 1- 0 cm
2. 2- 4 cm
3. 3- 6 cm
4. 4- 8 cm
5. 5- 10 cm

10 cm

Stage 1 – 0-10 cm dilation. Latent phase. Active phase: Stage 2 – 10cm with expulsive contractions. Stage 3 – From delivery of baby to delivery of the placenta.

Question 6

What is this ladies BISHOP score:

Dilation – 6cm

Consistency – Firm

Length of cervix – <1cm

Position – Posterior

Station of presenting part – Below spines

1. 1- 5
2. 2- 11
3. 3- 15
4. 4- 9
5. 5- 10

9

High bishops score = higher chance of vaginal delivery Table is here – https://gpnotebook.com/simplepage.cfm?ID=899284994

Question 7

29-year-old woman, G2P1, presents to delivery suite at 41+1 weeks for induction of labour. She began to experience contractions and over the last 5 hours she has dilated from 3cm to 4cm with no change in frequency of contractions.

Which of the following describes her situation best?

1. 1- Normal labour
2. 2- Failure of progression of first stage
3. 3- Failure of progression of second stage
4. 4- Failure of progression of third stage
5. 5- Failed induction

Failure of progression of first stage

Stages of Labour:

Stage 1 0-10 cm dilation Latent phase – cervix usually dilates slowly for the first 4cm. This may take several hours. Active phase – cervical dilatation and occurs at a rate of 1cm per hour in nulliparous women and 2cm per hour in multiparous women.

Stage 2 – 10cm with expulsive contractions The passive – cervix is fully dilated when the head reaches the pelvic floor and the woman experiences the desire to push. This can be a few minutes but can take much longer. Active – a woman is pushing- the pressure of the head on the pelvic floor causes the irresistible desire to bear down, although epidural anaesthesia may prevent this. The average duration is 40 minutes for nullips and 20 minutes for multips.

Stage 3 – From delivery of baby to delivery of placenta Uterine muscle fibres contract to compress the blood vessels formally supplying the placenta (which has shed away from the uterine wall). This normally lasts around 15 minutes. Routinely administer IM syntocinon to increase uterine contractions.

Question 8

Define pre-term labour

1. 1- Onset of labour before 37 weeks of pregnancy
2. 2- Onset of labour before 28 weeks of pregnancy
3. 3- Onset of labour before 32 weeks of pregnancy
4. 4- Onset of labour before 35 weeks of pregnancy
5. 5- Onset of labour before 30 weeks of pregnancy

Onset of labour before 37 weeks of pregnancy

Question 9

Which is not a maternal risk from assisted delivery?

1. 1- Hemorrhage
2. 2- Third degree tear
3. 3- Lacerations
4. 4- Risk of blood clots
5. 5- Hypoxia

Hypoxia

Maternal: Haemorrhage (>500ml -> transfusion) Lacerations/ trauma Third degree tears

Foetal: Bruising (cephalohaematoma on babies head)/ facial nerve injury/ skull fractures Foetal lacerations in ventouse Hypoxia if prolonged injury

Question 10

A 28-year-old female has unfortunately had a perineal tear during the second stage of her labour. Upon PR examination, the obstetrician notices that the tear is a third degree.

Which of the following best describes a third-degree perineal tear?

1. 1- A deep tear which reaches the depth of the perineal muscles
2. 2- A superficial tear in the vagina
3. 3- A deep tear which includes the anal mucosa
4. 4- A deep tear which reaches the anal sphincter
5. 5- Multiple minor tears in to the fourchette

A deep tear which reaches the anal sphincter

1st degree tear: Minor damage to the fourchette.

2nd degree tear: Involvement of perineal muscles (this is the equivalent depth of an episiotomy).

3rd degree tear: Involvement of the anal sphincter.

4th degree tear: Involvement of the anal mucosa.

Question 11

1. 1- Descent -> Engagement -> Flexion -> Ext. Rotation -> Restitution -> Extension -> Delivery
2. 2- Descent -> Engagement -> Flexion -> Ext. Rotation -> Extension -> Restitution -> Delivery
3. 3- Engagement -> Descent -> Flexion -> Int. Rotation -> Extension -> Restitution -> Delivery
4. 4- Descent -> Engagement -> Flexion -> Int. Rotation -> Restitution -> Extension -> Delivery
5. 5- Engagement -> Descent -> Flexion -> Int. Rotation -> Extension -> Restitution -> Delivery

Engagement -> Descent -> Flexion -> Int. Rotation -> Extension -> Restitution -> Delivery

Mechanism of normal labour: Engagement (Head–> Pelvis) ->Descent (w/ contractions)-> Flexion (Tucks chin down)-> Internal Rotation-> Extension (Baby starts being delivered)-> Restitution (Head turns as it comes out/ext. rotation)-> Delivery of anterior shoulder then posterior-> Delivery of body.

Question 12

Which of the following arises from the ectoderm?

1. 1- Liver
2. 2- Nervous system
3. 3- Musculoskeletal system
4. 4- Reproductive tracts
5. 5- Muscular layer of stomach and intestine

Nervous system

Liver – derived from the endoderm along with: epithelial lining of digestive and respiratory tracts, the lining of the reproductive system and pancreas

Nervous system – Derived from the ectoderm- nervous system begins to form in week 3 from the ectoderm. The ectoderm is the layer formed by epiblast cells that remain in position and do not migrate through the primitive streak. The ectoderm is also involved in the epidermis of the eye, cornea and lens of the eye.

Musculoskeletal system- derived from the mesoderm along with the notochord and circulatory system

Reproductive tracts – derived from the endoderm along with: epithelial lining of digestive and respiratory tracts, liver and pancreas

Muscular layer of stomach and intestine – derived from the mesoderm

Question 13

How many cells is a morula comprised of?

1. 1- 24
2. 2- 8
3. 3- 4
4. 4- 16
5. 5- 32

16

Question 14

The process of gastrulation occurs during which week of development?

1. 1- Formation of the blastocyst occurs during week 1
2. 2- Trophoblast and embryoblast cells divide into specialized cells. The trophoblast divides into the syncytiotrophoblast and cytotrophoblast. The embryoblast divides into the epiblast and hypoblast, forming a two-layered structure; the bilaminar disk.
3. 3-Gastrulation occurs during week 3. It is easy to remember as three germ layers are formed, so the number ‘3’ is key.
4. 4- neurulation occurs at the end of week 4
5. 5- brain and cerebellum development

Gastrulation occurs during week 3. It is easy to remember as three germ layers are formed, so the number ‘3’ is key.

Question 15

1. 1- Neural crest
2. 2- Notochord
3. 3- Primitive Streak
4. 4- Neural tube
5. 5- Neuroderm cells

Notochord

Neural crest- Specialised cell population which give rise to melanocytes, craniofacial cartilage and bone, smooth muscle, peripheral and enteric neurons and glia

Notochord- This is the correct answer. The notochord secretes growth factors which simulate the differentiation of the overlying ectoderm into neuroectoderm – forming a thickened structure known as the neural plate.

Primitive Streak – groove in the epiblast layer of the bilaminar disk in which epiblast cells migrate through to become the trilaminar embryonic disc.

Neural tube- structure formed by the fusion of the neural folds – it is a precursor to the brain and spinal cord

Neuroderm cells- differentiate into neurons and glial cells in week 5