MH SAQ study O+G
SAQ 1
A 29 yr old female presents to the ED with lower abdominal pain. Observations
are stable, blood tests are within normal range and her pregnancy test is
negative.
1. Which 4 risk factors suggest pelvic inflammatory disease? (2 marks)
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multiple sexual partners
high frequency sexual intercourse
first sexual intercourse at a young age
cervical instrumentation
2. When should treatment be initiated? (2 marks)
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clinical signs – uterine/ adnexal tenderness, cervical motion tenderness
no other cause can be found – empirical treatment on minimal diagnostic criteria
3. What are the 4 main indications for hospital admission? (2 marks)
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clinically severe PID with temp >38oC
failure to respond to 24-48hrs of outpatient therapy
oral inappropriate – poor compliance or vomiting
surgical emergencies cannot be exluded – ectopic pregnancy/ appendicitis
co-morbidities – diabetes mellitus, immunodeficiency
complications – tubo-ovarian abscess, Fitz-Hugh Curtis syndrome
NB any of the above 4 scores 2 marks
4. What discharge topics should be discussed with the patient? (4 marks)
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sexual practice – safe sex
risk of infertility
public health referral
partner treatment
SAQ 2
A 32 year old lady who is 36 weeks pregnant presented with headache,
drowsiness and her observations and results are as follows:
Pulse 110 bpm
BP180/110mmhg
RR24/min
Sats 96%air;
Hb 9gm/dl
WCC 8 x109/L
PLT 34 x109/L
LFT: AST 120 u/L, ALT 135 u/L,
LDH 750 u/L
1. What is the diagnosis? (2 marks)
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Pre-eclampsia with HELLP variant (haemolysis, elevated liver enzymes and low
platelets)
2. What 2 anti-hypertensive drugs would you consider to treat her blood
pressure? (2 marks)
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Labetalol 10 mg IV followed by IV infusion 1-2mg/min
Hydralazine IV – second line (Hydralazine remains the drug of choice for women
with asthma or congestive heart failure)
NB nifedipine an alternative option
3. You have paged the PICU doctor and obstetrician to your resuscitation room,
however, your patient starts to have a seizure. What are the first four things you
would do? (4 marks)
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Left lateral position and support airway/administer Oxygen
check BSL and treat if low
Magnesium Sulphate 4-6Gram IV (over 5 min) followed by maintenance infusion
1G/hr
Midazolam 3-5mg IV PRN to control seizures
4. What are the 4 signs of maternal toxicity with magnesium sulphate which
would predict either respiratory or cardiac arrest? (2 marks)
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Loss of patellar reflexes
Respiratory rate < 10
Slurred speech, weakness, feeling extremely sleepy, double vision
Muscle paralysis
SAQ 3
The triage nurse rings you regarding a 32 year old with diabetes and bipolar
disorder who is a frequent presenter to your ED. She often presents with
disruptive behaviour but the nurse is concerned that today she appears
disorientated, ataxic and complains of nausea and vomiting for the last two
weeks.
Temp
HR
BP
RR
Sats
37.4
110
90/60
22
97
°C
/min
mmHg
/min
% on air
Her lithium level is 3 mmol/L.
a. List 4 potential causes you would consider in this patient that may have
resulted in lithium toxicity.
pre-renal impairment: dehydration
pregnancy with hyperemesis
UTI
lithium induced nephrogenic diabetes insipidus
DKA/HHS
drug interaction with impaired renal excretion - NSAIDs
hyponatraemia
acute overdose in the setting of chronic ingestion
b. A urine bHCG confirms pregnancy, and a UTI. List four antibiotics used to treat
UTI and discuss why you would or would not use them in pregnancy.
Safe
nitrofurantoin (avoid after 36/40)
amoxycillin (may be resistant, depends on local sens but safe in preg)
trimethoprim (after the first trimester, folic acid antagonist may
increase neural tube defects in first trimester)
cephalexin (broad spectrum but safe in pregnancy)
Less optimal
tetracyclines - tooth discolouration
norfloxacin - renal abnormalities
ciprofloxacin - avoid in pregnancy
c. Your 4th year student asks you about the role of charcoal in lithium overdose.
You explain that charcoal does not bind lithium. Name 3 classes of drugs seen in
overdose that are not bound by charcoal and give two examples of each.
toxic alcohols - methanol, ethylene glycol, isopropyl glycol, ethanol
heavy metals - iron, lead, potassium, mercury, arsenic, cyanide
acids/alkali
d. What alternative enhanced elimination technique may have a role in lithium
toxicity?
haemodialysis
e. Name 3 toxicokinetic or toxicodynamic features of a drug that make it
amenable or appropriate to this method of enhanced elimination, and 2 other
drugs toxicities where the method plays a role.
carbemazepine
toxic alcohols
sodium valproate
theophylline
phenobarbitone
salicyclate
potassium
f. You find on questioning that it is likely she is 16/40 pregnant, homeless and
with no regular medical care. List and expand briefly on 4 issues that should be
discussed with this woman, including other services that may need to be
involved.
pregnancy medical care - obstetric physician input given ongoing need for
diabetes control and likely lithium requirement during pregnancy lithium being teratogenic (tricuspid valve abnormalities)
Tie in with GP
psychiatric care and support during pregnancy - tie in with maternal
mental health
maternity care, including scans
social supports - social worker involvement
pregnancy advice - safe behaviours/listeria avoidance/drugs in
pregnancy/smoking/alcohol
SAQ 4
A 38 year old woman 35 weeks pregnant comes to the ED with visual
disturbance and headache. Her BP is 165/100 mmHg.
FBC
Hb 8.1
Plt 50
WCC 5.1
poikilocytes seen
WTU
Blood ++
Protein+++
Nitrates -
LFT
Bil
12
AST 1000
GGT 817
a. Describe 2 abnormalities of the FBC and explain them. (2 marks)
Anaemia due to haemolysis
Low platelets due to microangiopathy as part of HELLP syndrome
(Haemolysis, elevated liver enzymes and low platelets)
b. What is the likely diagnosis? (2 marks)
Pre eclampsia and HELLP syndrome
c. To control BP what drug, including dose and route, would you use? (3 marks)
Labetalol 10mg IV or 100mg PO
Can use hydralazine 10mg IV
d. Give 3 other steps in the management of this patient. (3 marks)
Call anaesthetist and senior obstetrician.
Magnesium 4-6mg IV
Arrange to deliver baby.
Treat in darkened, quiet room
You are checking pathology results when you come across a positive chlamydia
result. The pathologist has flagged that this is a notifiable disease.
a. What action should you take? (5 marks)
Recall the notes
Ascertain whether the patient is aware
Contact the patient and organise for appropriate treatment, advice on
barrier precautions, further screening and treatment of sexual partners
(may be via GP)
Notify the Communicable Diseases Department for further action/contact
tracing
Document all actions in patient notes
b. Give three other examples of incidents that require mandatory reporting in the
ED. (5 marks)
May include: Child sexual or physical abuse, elder abuse,
incompetent/negligent/substance-abusing/mentally ill (in some
jurisdictions) colleague, death during anaesthetic, death in care, death
without clear natural cause.
SAQ 5
A 40-year-old female has been brought in following increasing confusion and
agitation at home this morning. She has had no other symptoms. She is day 3
after normal vaginal delivery of a healthy baby at another hospital, but her
antenatal history is unknown.
Ambulance officers report a generalised tonic-clonic seizure in the ambulance
which required 5mg IV midazolam to terminate, followed by ongoing drowsiness
and confusion. On arrival in the ED she begins to seize. ED staff and ambulance
officers activate the ‘arrest call’ button and transfer her to the Resuscitation
Room.
When you arrive she is being nursed on a bed and a provisional trainee is
supporting her airway with jaw thrust. Her intravenous cannula has tissued.
On examination:
Airway: snoring / partly obstructed
RR 40 /min
O2 saturations 95%
HR 130 /min
BP 180/100 mmHg
Generalised tonic-clonic seizure
Afebrile
a. List the causes of seizure you would consider in this patient. (4 marks)
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Eclampsia – timing unusual because post-partum but still
likely
Cerebral venous sinus thrombosis
Meningoencephalitis e.g. post-epidural
Hypoxia e.g. due to pulmonary embolus
Plus at least one not directly related to pregnancy / delivery:
e.g., hypoglycaemia, toxic ingestion, structural intracranial e.g.
bleed, epilepsy
b. What is your initial management? (4 marks)
 Form a team and assign roles
 Address ABCs esp airway: simple adjuncts initially eg
suction, NPA and lie on side
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o Breathing: high flow O2 and nasal CO2 monitor
o Circulation: IV/IO access and send bloods / bedside BSL
Stop the fit: 2nd step of classic status epilepticus regime:
Midazolam IV/IO/IM 5mg
Seek and treat a cause from the list above, esp eclampsia
(see drugs in Q3)
Get help:
o Obstetrics, renal / neurology, ICU
c. If you suspect eclampsia, what initial drugs/ dose/route/rate would you
administer? (2 marks)
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Magnesium sulphate: officially 4G IV over 30 mins is RNS OG
policy, but it comes in 10mmol amps. Closest is 20mmol
(=5G). Safe enough to give over 20 mins provided you dilute it
and watch the BP. Followed by IV infusion.
Hydralazine: 5mg IV over 10 mins, can repeat.
SAQ 6
A 35 year old woman who is 30 weeks gestation, is brought to your emergency
department after a witnessed cardiac arrest.
(a) What are 4 leading causes of maternal death in pregnancy ? (2 marks)
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Trauma (homicide, MVA, suicide)
Pulmonary embolism (thrombus)
haemorrhage (placental abruption/ placenta praevia)
Maternal cardiac disease (AMI, peripartum cardiomyopathy,
dysrhythmia)
(b) List 4 airway and ventilation issues that may occur as a result of pregnancy.
(4 marks)
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Increased risk of aspiration – due to decreased lower oesophageal sphincter
tone, increased abdominal pressure, decreased gastric emptying.
More oedematous airways – tongue and supraglottic airways oedematous, and
more friable (therefore more likely to bleed and swell) (may need to use smaller
ETT)
Decreased FRC and increased O2 consumption – develop hypoxia more quickly,
less tolerant of apnoeic periods.
Mask ventilation more difficult due to low FRC, elevated diaphragms, and raised
intra abdominal pressure.
Obesity relatively common in pregnancy, causing relative neck extension when
supine (causing greater anterior placement of larynx). Also shorter neck in
obese gravid women
Large breasts, causing difficult larygoscopy
When ventilating, significant respiratory alkalosis should be avoided as this can
cause decreased uterine blood flow.
(c) What are the indications for a perimortem caesarean section? (2 marks)
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Cardiac arrest in mother, gestational age >24 weeks (age of feus in weeks
corresponds to the distance in cm from fundus to symphysis pubis from 18-30
weeks).
 Preferably within 5 minutes of arrest, up to 20 minutes – survival of infant
directly related to the time elapsed from maternal arrest to delivery. Poorer
neurological outcomes for child if performed > 5mins post arrest.
(May benefit maternal outcome also – as it removes the aortocaval compression, and
decreases abdominal pressure.
CPR should continue during and after the procedure.
Consent not required)
SAQ 7
A 38 yr old pregnant woman 35 weeks pregnant presents with visual disturbance and
headache. Her Blood pressure is 165/100.
Some of her investigation results are listed below:
CBE
UA
LFT
Hb
8.1
Blood ++
Bil
12
Plt
50
Protein+++
AST 1000
WCC 5.1
Nitrates GGT 817
poikilocytes seen
a) List the possible complications of her likely diagnosis. (4 marks)
=HELLP syndrome
Placental abruption
Spontaneous splenic/hepatic haemorrhage
Endorgan failure
ICH
IUFD
Raised ICP/cerebral oedema/seizures
b) What is the definitive treatment for her primary pathological condition? (1 mark)
Delivery of the fetus.
c) Outline the management priorities for her emergent management. (5 marks)
 Control BP/reduce risk of seizures
MgSo4 IV bolus 4gm over 5 mins plus repeat 2 g, followed by 2gm/hour infusion
(monitor serum levels (2.0-3.0 mmol/L and clinically loss of reflexes and resp depression
indicate toxicity)
if diastolic remains >105
Hydralazine (5-10mg over 2-4mins, followed by infusion 5-10mg/hr aiming for
adequate perfusion of mother and fetus and improved mental status/ improved
symptoms
Nimodipine/labetolol third line
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thrombocytopaenic/coagulopathy (HELLP)
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-platelets, FFP replacement as indicated, avoidance of central access in
noncompressible sites
analgesia
explanation to patient/partner
early involvement obstetrics/neonatology and ICU
consider steroids for fetal lungs maturity in view of potential imminent delivery
SAQ 8
A 25 year old woman has been rushed in to your resuscitation room. She has just
delivered
a baby in the passenger seat of a car being driven by her husband. The baby was 38
weeks
gestation and appears to be well. The placenta was delivered in the car.
The woman is experiencing heavy vaginal blood loss.
1. In the section below, list 6 possible causes of her vaginal bleeding.
For each cause give:
- one cardinal finding of examination that would support that cause
- one cardinal principle of management of that cause
(18 marks)
Cause 1 _____________________________________________________
Examination Feature
_____________________________________________________
_____________________________________________________
Management Principle
_____________________________________________________
_____________________________________________________
Cause 2 _____________________________________________________
Examination Feature
_____________________________________________________
_____________________________________________________
Management Principle
_____________________________________________________
Cause 3 _____________________________________________________
Examination Feature
_____________________________________________________
_____________________________________________________
Management Principle
_____________________________________________________
_____________________________________________________
Cause 4 _____________________________________________________
Examination Feature
_____________________________________________________
_____________________________________________________
Management Principle
_____________________________________________________
Cause 5 _____________________________________________________
Examination Feature
_____________________________________________________
_____________________________________________________
Management Principle
_____________________________________________________
_____________________________________________________
Cause 6 _____________________________________________________
Examination Feature
_____________________________________________________
_____________________________________________________
Management Principle
_____________________________________________________
Cause Retained products of conception / placenta
Examination incomplete placenta, non-contracted uterus
Management OT for manual removal, oxytocin
Cause uterine atony
Examination non-contracted uterus
Management uterine massage, oxytocin, empty bladder
Cause trauma – vaginal/cervical laceration
Examination direct inspection / speculum examination shows laceration
Management surgical correction
Cause uterine rupture
Examination severe abdominal tenderness
Management surgical correction in OT
Cause uterine inversion
Examination visual inspection of perineum shows inverted uterus, fundus too low
Management uterine re-location - OT
Cause coagulopathy
Examination no other cause obvious, blood not clotting
Management correct coagulopathy with blood products
PASS 12/18 corrects to 6.5/10
SAQ 9 (A 34 year old G7P6 30/40)
1. Complete the following table indicating the likely need for neonatal resuscitation if
she delivers.
Give four (4) four features in each column.
Maternal
Foetal
Intrapartum
2. List the features that would be used to determine the Apgar score.
3. List five specific treatments (with doses as appropriate) that may be required within
the first ten minutes of delivery.
Answers
Q1
Maternal
PROM
Antepartum haemorrhage
Hypertension/eclampsia
Diabetes mellitus
Substance abuse
Foetal
Multiple gestation
Post-term
Pre-term
Intra-uterine
retardation
Polyhydramnios
Intrapartum
Foetal distress
Abnormal presentation
Precipitate labour
growth Prolonged labour
Maternal infection or chronic Congenital abnormalities
illness
Absence of antenatal care
Thick staining of amniotic
fluid
Instrumental delivery
LSCS
Q2
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colour
tone
heart rate
respiratory effort
reflex irritability
Q3
 cpap ventilation/intubation
 Warming (drying, cling film wrap, beanie, radiant heater). Aim for normothermia
 vascular access (IO insertion, umbilical catheter with 5F catheter)
 adrenaline (0.1ml/kg 1:10000 via IO or umbilical catheter, 0.1ml/kg via ETT)
 naloxone (0.1mg/kg IV or IO)
dextrose (5mg/kg 10% dextrose IV)
SAQ 10
A 35 year old lady presents to your emergency department via ambulance.
She delivered a healthy term baby 2 hours ago at home but has had
significant PV bleeding since. She is conscious but her BP is 70/40.
1. What are the four (4) categories of causes for post partum haemorrhage?
Give 2 examples of each.
Category
Example
2. Describe six (6) steps you would take to stop this woman’s bleeding.
Your attempts at stopping the bleeding in the emergency department are
unsuccessful. You contact the O&G registrar who states he is busy in theatre
for the next 2 hours and is unable to attend.
3. Describe your response.
SAQ 25 (Graeme Thomson)
Q1.
To pass:
For the 4 categories of causes of PPH; Tone plus 2 of the 3 others
(Trauma, Tissue, Thrombin).
Then 2 examples for each of those, giving 6/8 examples.
I allowed 5/8 if the categories were correct.
Better answer:
All 4 categories with 2 examples from each. There are many
examples to choose from.
Q2.
To pass:
An oxytocic plus 4 other steps that could reasonably be expected to
reduce bleeding in ED.
I discounted multiple similar steps, like multiple oxytocic drugs.
Better answer:
6 steps, especially the most important ones (deliver remaining
placental tissue, massage uterus, oxytocic, empty bladder, control
bleeding point, replace clotting factors).
Q3.
To pass:
Escalation to an O&G consultant.
Better answer:
To include continuing resuscitation of the patient.
Altogether there were 16 points that I wanted for a top answer (8
in Q1, 6 in Q2 and 2 in Q3).
To get a 5, a candidate needed to get around 11 points but scores
varied up and down if the most important points were included or
missed.