MCCQE - Medical Council of Canada Qualifying Examination Common Obstetrical Complications Questions and Answers 1 — Questions and Answers
Question 1: A 32-year-old G1P0 woman at 33 weeks gestation presents with a sudden gush of clear fluid from her vagina. She denies contractions or vaginal bleeding. On sterile speculum examination, pooling of fluid is noted in the posterior fornix, which tests positive for ferning. The fetal heart rate is 140 bpm with moderate variability. Which of the following is the most appropriate next step in management?
- Induction of labor with oxytocin
- Administration of a single course of antenatal corticosteroids (Correct answer)
- Immediate delivery via Cesarean section
- Discharge home with instructions for expectant management
Correct answer: Administration of a single course of antenatal corticosteroids
The patient has preterm prelabour rupture of membranes (PPROM). According to SOGC guidelines, for PPROM between 24 and 34 weeks gestation, a single course of antenatal corticosteroids is recommended to enhance fetal lung maturity and reduce the risk of other complications of prematurity. Induction of labor is generally not indicated unless there are signs of maternal or fetal infection or compromise, and expectant management is preferred to allow the fetus to mature further. Immediate delivery is not warranted in a stable mother and fetus. Outpatient management may be considered in select cases but initial inpatient observation and administration of corticosteroids is standard.
Question 2: A 28-year-old G2P1 woman at 26 weeks gestation is undergoing screening for gestational diabetes mellitus (GDM). According to the preferred screening strategy recommended by Diabetes Canada and the SOGC, what is the initial step?
- A 100g, 3-hour oral glucose tolerance test (OGTT)
- A fasting plasma glucose measurement
- A 50g glucose challenge test (GCT) (Correct answer)
- A random blood glucose measurement
Correct answer: A 50g glucose challenge test (GCT)
The preferred approach for GDM screening in Canada, recommended by Diabetes Canada and the SOGC, is a two-step process. The initial step is a 50g, 1-hour glucose challenge test (GCT), which can be done at any time of day without fasting. If the result of the GCT is abnormal, the patient then proceeds to the second step, which is a diagnostic 75g or 100g oral glucose tolerance test (OGTT).
Question 3: A 38-year-old G3P2 woman at 34 weeks gestation presents with painless, bright red vaginal bleeding. She has had two previous Cesarean sections. A transabdominal ultrasound reveals a placenta completely covering the internal cervical os. What is the most likely diagnosis?
- Placental abruption
- Vasa previa
- Uterine rupture
- Placenta previa (Correct answer)
Correct answer: Placenta previa
The classic presentation of placenta previa is painless, bright red vaginal bleeding in the third trimester. The diagnosis is confirmed by ultrasound showing the placenta covering the internal cervical os. Her history of two previous Cesarean sections is a significant risk factor. Placental abruption typically presents with painful bleeding and uterine tenderness. Vasa previa involves fetal vessels running over the os and bleeding would occur with membrane rupture. Uterine rupture is a rare, catastrophic event usually associated with labor in a scarred uterus.
Question 4: Which of the following is the most significant risk factor for uterine atony, the leading cause of primary postpartum hemorrhage (PPH)?
- Primiparity
- Prolonged second stage of labor
- Overdistention of the uterus (Correct answer)
- History of manual removal of placenta
Correct answer: Overdistention of the uterus
Uterine atony, the failure of the uterus to contract adequately after delivery, is the most common cause of PPH. Overdistention of the uterus is a major risk factor for atony. Conditions leading to overdistention include multiple gestation, polyhydramnios, and fetal macrosomia. The stretched uterine muscle fibers have more difficulty contracting effectively. While other options can be risk factors, uterine overdistention is considered one of the most significant.
Question 5: A 25-year-old woman presents to the emergency department with 6 weeks of amenorrhea, right lower quadrant pain, and light vaginal spotting. Her serum β-hCG is 1800 IU/L. A transvaginal ultrasound shows an empty uterus and a complex adnexal mass. She is hemodynamically stable. According to Canadian guidelines, which of the following is an appropriate management option?
- Immediate diagnostic laparoscopy
- Expectant management with serial β-hCG monitoring
- Uterine curettage to rule out a non-viable intrauterine pregnancy
- Intramuscular methotrexate (Correct answer)
Correct answer: Intramuscular methotrexate
This patient has a suspected ectopic pregnancy. Given that she is hemodynamically stable, has a β-hCG less than 5000 IU/L, and no evidence of fetal cardiac activity on ultrasound, she is a suitable candidate for medical management with intramuscular methotrexate. Immediate laparoscopy is reserved for hemodynamically unstable patients or those who do not meet the criteria for medical management. Expectant management is typically considered for patients with very low and declining β-hCG levels. Uterine curettage is not the first-line diagnostic or therapeutic step in this clear clinical picture.
Question 6: A 36-year-old G1P0 woman at 35 weeks gestation presents with a new-onset headache and a blood pressure of 150/100 mmHg. Her urine dipstick shows 2+ proteinuria. Which of the following findings would classify her condition as severe preeclampsia?
- Platelet count of 120 x 10^9/L
- Serum creatinine of 80 µmol/L
- Systolic blood pressure of 165 mmHg (Correct answer)
- Mild pedal edema
Correct answer: Systolic blood pressure of 165 mmHg
According to the SOGC guidelines, preeclampsia is defined as hypertension (≥140/90 mmHg) presenting after 20 weeks of gestation with proteinuria or one or more adverse conditions. Severe preeclampsia includes one or more severe features. A systolic blood pressure ≥160 mmHg or a diastolic blood pressure ≥110 mmHg is a criterion for severe disease. A platelet count <100 x 10^9/L, elevated creatinine, or other signs of end-organ dysfunction also indicate severe disease, but a systolic BP of 165 mmHg is a direct and clear indicator of severity.
MCCQE - Medical Council of Canada Qualifying Examination Common Obstetrical Complications Questions and Answers 1
A 32-year-old G1P0 woman at 33 weeks gestation presents with a sudden gush of clear fluid from her vagina.
She denies contractions or vaginal bleeding.
On sterile speculum examination, pooling of fluid is noted in the posterior fornix, which tests positive for ferning.
The fetal heart rate is 140 bpm with moderate variability.
Which of the following is the most appropriate next step in management?