hllj/quesmed huggingface dataset:
A 26-year-old primiparous woman attends the maternity triage department with four episodes of vaginal bleeding. She is 21+5 weeks pregnant. She describes the bleeding as bright red and painless. Two episodes occurred immediately after intercourse with her regular partner, and two episodes have occurred unprovoked and have been noticed on wiping after using the toilet.

She has no vaginal discharge or other symptoms. She has no past medical history. She has never had a cervical smear test. She has attended both her booking appointment and her 20-week scan, and the pregnancy has been uncomplicated so far.

On examination, her observations are normal. A speculum examination reveals a normal cervix with a slight ectropion and no evidence of unusual vaginal discharge.

What is the most appropriate next step?

Options:
explanation: Intravaginal metronidazole can be used to treat bacterial vaginosis (BV). There is no indication of BV here as the woman does not complain of any unusual vaginal discharge. BV seldom results in vaginal bleeding.
name: Intravaginal metronidazole
label: e
answer: no
explanation: Foetal fibronectin testing is used to detect foetal fibronectin in cervical secretions to rule out preterm labour. This woman has no signs of preterm labour. In addition, foetal fibronectin is usually only performed between weeks 22 and 35 weeks.
name: Perform foetal fibronectin testing
label: d
answer: no
explanation: Since this woman has had a recent normal ultrasound scan, and displays no features of infection, the light bleeding is likely to be as a result of her slight cervical ectropion. This is a normal finding and is not a cause for concern.
name: Reassurance and to return if symptoms worsen
label: a
answer: yes
explanation: This woman would likely have had testing for chlamydia and gonorrhoea at her booking appointment. She has no other symptoms of infection and states she has a regular partner, so sexually transmitted infection is unlikely.
name: Obtain an endocervical swab for chlamydia testing
label: c
answer: no
explanation: Whilst this woman is overdue for her first cervical smear test, smear tests are generally not performed in pregnancy.
name: Perform a cervical smear test
label: b
answer: no

Correct answer: a
A 34-year-old woman presents to accident and emergency with regular contractions at 38+5 weeks gestation.

She is transferred to the maternity department, where a midwife performs an examination. On examination, the abdomen is gravid, and the midwife cannot determine the foetal presentation. A cardiotocograph is difficult to obtain, but the foetal heart on auscultation is 145-160 beats per minute, with a variation of 10-15 beats per minute, and no decelerations. On vaginal examination, a foetal foot can be felt protruding from the cervix, which is approximately 6cm dilated. There is copious amounts of clear liquor draining from the vagina.

What is the most appropriate management?

Options:
explanation: This describes a "footlong" breech presentation where the foetal foot is protruding from an undilated cervix. This is a contraindication to vaginal delivery.
name: Transfer to theatre for an emergency caesarean section
label: a
answer: yes
explanation: Vaginal delivery is contraindicated in footlong breech, so the woman should not be encouraged to push.
name: Advise the woman to push with each contraction to expedite delivery
label: e
answer: no
explanation: Vaginal delivery is contraindicated in a footlong breech presentation.
name: Reposition the cardiotocograph to obtain a reliable reading and proceed with vaginal delivery
label: d
answer: no
explanation: This is management for cord prolapse. In this case, inflating the maternal bladder is unlikely to affect foetal descent, since the foetal foot has already breached the cervix.
name: Inflate the maternal bladder with warm saline
label: c
answer: no
explanation: Footlong breech presentation is a contraindication to vaginal delivery. Intravenous oxytocin would augment contractions in labour.
name: Administer intravenous oxytocin
label: b
answer: no

Correct answer: a
A 29-year-old parous woman attends for her 20-week scan. On examination, her blood pressure is 134/87. Her height is 165cm, and her weight is 97kg. She had a previous baby four years ago who was delivered via forceps delivery at 39+0 weeks gestation and weighed 4.2kg. She has no past medical history; however, her maternal grandmother has type 2 diabetes and breast cancer. Urinalysis is clear.

Which of the following features in her history would prompt glucose tolerance testing at 24 weeks?

Options:
explanation: Her weight of 97kg places her at a BMI of over 35. Any woman with a BMI >30 should be screened for gestational diabetes with a glucose tolerance test at 22-28 weeks.
name: Weight of 97kg
label: a
answer: yes
explanation: Previous macrosomia may prompt investigation for gestational diabetes, but not forceps delivery alone.
name: Previous forceps delivery
label: e
answer: no
explanation: A parent or sibling with diabetes would prompt investigation for gestational diabetes with a glucose tolerance test.
name: Maternal grandmother with type 2 diabetes and breast cancer
label: d
answer: no
explanation: Previous baby >4.5kg would prompt screening for gestational diabetes with a glucose tolerance test at 22-28 weeks.
name: Previous baby >4kg
label: b
answer: no
explanation: Women of South Asian, Black, Afro-Caribbean, and Middle-Eastern origin are at increased risk of gestational diabetes and are therefore offered screening at 22-28 weeks with a glucose tolerance test.
name: Irish origin
label: c
answer: no

Correct answer: a
A 40-year-old primigravida at 38+2 weeks gestation presents with a headache unrelieved by analgesia. She has no significant past medical history. On examination, her abdomen is soft and non-tender, with slight ankle swelling and brisk reflexes.



Her observations are as follows:



  - Heart rate: 92 beats per minute
  - Blood pressure: 168/101mmHg
  - Respiratory rate: 20 breaths per minute
  - SpO2: 99% on room air
  - Temperature 36.7°C



CTG is reassuring.



Her full blood count tests are as follows:


||||
|--------------|:-------:|---------------|
|Haemoglobin|129 g/L|(M) 130 - 170, (F) 115 - 155|
|White Cell Count|5.5x10<sup>9</sup>/L|3.0 - 10.0|
|Platelets|385x10<sup>9</sup>/L|150 - 400|






Her liver function tests are as follows:





||||
|---------------------------|:-------:|--------------------|
|Albumin|35 g/L|35 - 50|
|Alanine Aminotransferase (ALT)|40 IU/L|10 - 50|
|Aspartate Aminotransferase (AST)|32 IU/L|10 - 40|
|Alkaline Phosphatase (ALP)|103 IU/L|25 - 115|
|Bilirubin|14 µmol/L|< 17|
|Gamma Glutamyl Transferase (GGT)|20 U/L|9 - 40|
|Lactate Dehydrogenase|168 IU/L|70 - 250 



Urinalysis is positive for protein +++ and is otherwise negative.



What is the most likely diagnosis?

Options:
explanation: Eclampsia is the presence of tonic-clonic seizures on a background of pre-eclampsia (new-onset, persistent hypertension with either proteinuria or evidence of systemic involvement). This woman has signs and symptoms of pre-eclampsia but has not reported any seizures.
name: Eclampsia
label: b
answer: no
explanation: Eclampsia is the presence of tonic-clonic seizures on a background of pre-eclampsia (new-onset, persistent hypertension with either proteinuria or evidence of systemic involvement). This woman has signs and symptoms of pre-eclampsia but has not reported any seizures.
name: Gestational hypertension
label: d
answer: no
explanation: HELLP syndrome is a subtype of severe pre-eclampsia characterised by haemolysis (H), elevated liver enzymes (EL), and low platelets (LP). This woman does not have any evidence of HELLP syndrome.
name: HELLP syndrome
label: c
answer: no
explanation: Pre-eclampsia is defined as new-onset, persistent hypertension with either proteinuria or evidence of systemic involvement. A frontal headache, peripheral oedema and hyperreflexia are other clinical signs.
name: Pre-eclampsia
label: a
answer: yes
explanation: Whilst labour may result in a slight increase in blood pressure and heart rate; this is not usually associated with proteinuria or other symptoms such as headache, peripheral oedema or brisk reflexes.
name: First stage of labour
label: e
answer: no

Correct answer: a

Pre-eclampsia
A 39-year-old multiparous woman has been in the second stage of labour for more than three hours, and has been actively pushing for over an hour. The foetal head can be seen at the peak of each contraction. A cardiotocograph shows decelerations with each contraction, which recover.

A decision is made to perform an instrumental delivery. Local anaesthetic is infiltrated into the perineum and an episiotomy is performed. The forceps are applied and a live female infant is delivered after two contractions.

The midwife examines the woman's perineum following active management of the third stage of labour. The episiotomy is neat, and extends only to the perineal muscles and fascia, the anal sphincter is intact.

What is the correct management?

Options:
explanation: Surgical repair is required in third and fourth-degree tears. This is usually performed by an experienced obstetric clinician. This is usually the obstetric registrar, however may also be performed by a consultant.
name: Surgical repair by the obstetric consultant
label: c
answer: no
explanation: A one-off dose of broad-spectrum antibiotics is often given at the time of repair of perineal tears.
name: One week course of broad-spectrum antibiotics
label: d
answer: no
explanation: First-degree tears with minimal blood loss may not require suturing as they are superficial with no muscle involvement and are likely to heal quickly. This tear is a second-degree tear, which does require repair.
name: Conservative management
label: e
answer: no
explanation: Episiotomy is generally regarded as the same anatomical involvement as a second-degree tear, i.e. involving the perineal muscles and fascia but with the anal sphincter intact. Second-degree tears will require suturing as they involve perineal muscle. This may be carried out by an experienced midwife.
name: Suturing of the perineum by an experienced midwife
label: a
answer: yes
explanation: Surgical repair is required in third and fourth-degree tears. This is usually performed by an experienced obstetric clinician.
name: Surgical repair in theatre by the obstetric FY2
label: b
answer: no

Correct answer: a
A 22-year-old woman is in the second stage of labour and has just delivered the foetal head. The midwife notes that restitution does not occur. She is unable to deliver the anterior shoulder and pulls the emergency buzzer.

What is the most appropriate action?

Options:
explanation: Where first and second-line manoeuvres and internal rotation have not been successful, the woman should be prepared for theatre for e.g. symphysiotomy (dividing the anterior symphyseal ligament) or the Zavanelli manoeuvre (replacing the foetal head into the vagina in preparation for a caesarean section).
name: Prepare for theatre
label: e
answer: no
explanation: Forceps are not used where the foetal head has already been delivered, as overzealous pulling can lead to foetal trauma.
name: Apply forceps to the foetal head to aid traction
label: d
answer: no
explanation: In cases of shoulder dystocia, the mother should be encouraged to stop pushing, as this can worsen shoulder impaction.
name: Ask the woman to hold her breath and bear down at least three times with each contraction
label: b
answer: no
explanation: Also known as McRobert's manoeuvre, the mother can be assisted to hyperflex and abduct her legs. This is the first-line manoeuvre in shoulder dystocia. It serves to increase the relative anterior-posterior diameter of the pelvis and is reported to be successful in up to 90% of cases of shoulder dystocia.
name: Hyperflexion and abduction of the mother's legs
label: a
answer: yes
explanation: Fundal pressure should not be applied during a shoulder dystocia, as this can precipitate uterine rupture. McRobert's manoeuvre may be augmented by moderate suprapubic pressure.
name: Apply fundal pressure
label: c
answer: no

Correct answer: a
A 39-year-old woman is scheduled for an elective caesarean section due to a previous caesarean section at 38+4 weeks gestation.

A lower uterine segment caesarean section is performed and a live male infant is delivered. Following delivery of the infant, there is brisk bleeding from the placental site, and the placenta is found to be adherent to the uterine wall.

Bleeding is unable to be controlled and the lower uterine segment is closed and a total hysterectomy is performed.

Pathology reports an abnormally adherent placental with the placental villi adhering directly onto the superficial myometrium.

What is the most likely reason for this patient's postpartum haemorrhage?

Options:
explanation: Placenta increta occurs where the placental villi invade into, but not through, the myometrium.
name: Placenta increta
label: b
answer: no
explanation: Placenta praevia occurs where the placenta overlies the cervical os. This can result in antepartum haemorrhage, and is usually diagnosed antenatally.
name: Placenta praevia
label: d
answer: no
explanation: Vasa praevia occurs where the foetal vessels run near to or across the internal cervical os, unsupported by the umbilical cord or placental tissue. This can cause antepartum haemorrhage due to rupture of the foetal vessels during rupture of membranes.
name: Vasa praevia
label: e
answer: no
explanation: Placenta percreta occurs where the placental villi invade through the full thickness of the myometrium to the serosa.
name: Placenta percreta
label: c
answer: no
explanation: Placenta accreta occurs where the placental villi adhere directly to the superficial myometrium. In placenta accreta, the placental villi do not penetrate into the myometrium itself. Placenta accreta is the most common placental implantation abnormality, and is typically diagnosed antenatally.
name: Placenta accreta
label: a
answer: yes

Correct answer: a
A 37-year-old nulliparous woman attends for her first antenatal appointment at approximately eight weeks gestation. She is routinely screened for HIV, syphilis and hepatitis B.

Her HIV test is reported as positive, and a confirmatory test is carried out.

What is the most appropriate management?

Options:
explanation: Peginterferon alfa and ribavirin are used in the management of chronic hepatitis C infection.
name: Peginterferon alfa and ribavirin once weekly
label: d
answer: no
explanation: Zidovudine monotherapy is used for post-exposure prophylaxis in an infant born to a low-risk mother (i.e. low viral load, <50 HIV RNA copies/mL). Zidovudine is also used for the management of untreated women presenting in labour at term, and is given intravenously throughout labour.
name: Start daily zidovudine immediately
label: b
answer: no
explanation: All pregnant women who have been diagnosed with HIV should start antiretroviral therapy (ART) during pregnancy and be advised to continue lifelong treatment. Tenofovir disoproxil/emtricitabine is a common first-line regime.
name: Start daily tenofovir disoproxil/emtricitabine immediately
label: a
answer: yes
explanation: All pregnant women should be commenced on ART immediately. Tenofovir disoproxil monotherapy is sometimes used to treat pregnant women with hepatitis B infection.
name: Plan to start tenofovir disoproxil daily in the third trimester
label: c
answer: no
explanation: Benzathine penicillin is the recommended treatment option for syphilis infection
name: Benzathine penicillin immediately, with a repeat dose in one week and in two weeks
label: e
answer: no

Correct answer: a
A 45-year-old woman attends accident and emergency feeling generally unwell. She is undergoing fertility treatment and has just undergone oocyte retrieval the day prior, which yielded 14 oocytes.

On examination, her observations are as follows:

- Temperature: 37.6°C
- Respiratory rate: 25 breaths per minute
- Heart rate: 110 beats per minute
- Blood pressure: 115/62mmHg
- Oxygen saturations: 97%

Her abdomen is distended, tense and uncomfortable. She has peripheral oedema evident in her feet. Her lungs are clear; however the bases of both lungs are dull to percussion.

What is the most likely diagnosis?

Options:
explanation: Ectopic pregnancy is unlikely to occur in the context of fertility treatments, as woman are usually advised to abstain from intercourse during ovarian stimulation. Ectopic pregnancy often presents with unilateral pain, associated with haemodynamic instability. It would be unusual to present with peripheral oedema and pleural effusion.
name: Ectopic pregnancy
label: d
answer: no
explanation: Whilst ovarian torsion is a likely diagnosis, associated with ovarian stimulation, it typically presents with unilateral pain which is sudden in onset and not usually associated with peripheral oedema or pleural effusion.
name: Ovarian torsion
label: e
answer: no
explanation: Whilst oocyte retrieval carries a risk of pelvic infection, this woman is apyrexial and does not complain of any pelvic pain or unusual vaginal discharge.
name: Pelvic infection
label: b
answer: no
explanation: Whilst intraabdominal haemorrhage may present with abdominal discomfort and tachycardia, this would be an unusual complication of oocyte retrieval. In addition, this is unlikely to cause peripheral oedema or pleural effusion.
name: Intraabdominal haemorrhage
label: c
answer: no
explanation: Ovarian hyperstimulation syndrome (OHSS) is a clinical diagnosis based on a typical history and examination findings. OHSS typically occurs following treatment with follicle-stimulating hormone (FSH), which promotes follicular maturation during fertility treatments. OHSS is associated with an excessive ovarian response, leading to fluid shift into the extravascular spaces, hence causing peripheral oedema, ascites and pleural effusion. The management is typically supportive.
name: Ovarian hyperstimulation syndrome
label: a
answer: yes

Correct answer: a
A 22-year-old woman attends the maternity unit in established labour. She has a past medical history of epilepsy, and has been seizure-free throughout pregnancy on a stable dose of 500mg levetiracetam twice daily.

Which of the following is likely to be administered to her as part of her labour management?

Options:
explanation: Long-acting benzodiazepines such as clobazam may be considered in high-risk epileptics such as those who have had recent seizures, have a history of seizure provocation by stress or sleep deprivation, or have suffered seizures in a previous labour.
name: Oral clobazam 20mg daily
label: d
answer: no
explanation: Intravenous lorazepam is used to treat seizures, and would not be an appropriate routine part of labour management.
name: Intravenous lorazepam at a dose of 0.1 mg/kg
label: b
answer: no
explanation: Intramuscular vitamin K should be administered to all babies born to women with epilepsy to prevent haemorrhagic disease of the newborn. It should not be adminstered to the mother.
name: Intramuscular vitamin K, 1 mg
label: e
answer: no
explanation: Women should continue taking their regular anti-epileptic drugs orally during labour where tolerated.
name: Oral Levetiracetam 500mg twice daily
label: a
answer: yes
explanation: Intravenous therapy may be used where oral therapy is not tolerated in labour. There is no indication in this stem that the patient is unable to take her regular medication.
name: Intravenous Levetiracetam 500mg twice daily
label: c
answer: no

Correct answer: a
A 43-year-old woman attends her general practitioner with three episodes of bleeding after sex.

She has a regular male partner and has a progestogen-only implant for contraception which has been in situ for two years. She is amenorrhoeic and denies any symptoms of vaginal discharge or pelvic pain.

Her cervical smear tests are up to date, and her last cervical smear was reported as normal. She is due her next one in 3 months time.

What is the most appropriate management?

Options:
explanation: Whilst post-coital bleeding may be a sign of cervical cancer, in the absence of any other signs or symptoms, and where the cervix appears normal, it is prudent to rule out other causes of post-coital bleeding such as sexually transmitted infection
name: Refer to gynaecology under the two week wait
label: d
answer: no
explanation: Regardless of the fact this woman is in a regular relationship, one of the most common causes of post-coital bleeding is sexually transmitted infection, so this is important to rule out.
name: Test for sexually transmitted infections
label: a
answer: yes
explanation: Cervical smears are a screening test and, as such, are indicated in accordance with screening protocol - this is every 3-5 years in the UK, depending on age and location. Opportunistic smear tests are not indicated or encouraged.
name: Routine cervical smear
label: b
answer: no
explanation: Progestogen-only contraception is associated with irregular bleeding and spotting, however is not usually associated with post-coital bleeding. Replacement of the implant early is not indicated in this case.
name: Replace her contraceptive implant
label: e
answer: no
explanation: Whilst this woman may merit referral to colposcopy, routine tests such as testing for sexually transmitted infections should be performed in primary care first.
name: Refer to colposcopy
label: c
answer: no

Correct answer: a
A 24-year-old woman calls her general practice with problems breastfeeding. She is three days postpartum, having delivered a baby boy by spontaneous vaginal delivery.

She describes both nipples as painful and it's uncomfortable for her to breastfeed. There is no unusual nipple discharge, swelling or redness, and the skin is intact. She is otherwise well.

What is the most appropriate advice?

Options:
explanation: Difficulties in breastfeeding are common in the first few days and weeks. Women should be supported and encouraged to continue breastfeeding where possible.
name: She should switch to bottle feeding indefinitely
label: e
answer: no
explanation: Ideally the women should continue either breastfeeding or expressing milk by hand to encourage further milk production.
name: She should stop breastfeeding for three days and re-attempt
label: b
answer: no
explanation: There is no indication of abscess or breast pathology that merits imaging in this case.
name: Refer to hospital for an ultrasound of both breasts
label: d
answer: no
explanation: This is the treatment for a thrush infection. There is no indication here of a thrush infection, and the discomfort is likely caused by poor attachment.
name: Clotrimazole 1% applied to the nipples twice daily
label: c
answer: no
explanation: In most cases, nipple discomfort in the first few days is due to poor nipple attachment, in which case breastfeeding support can benefit.
name: Speak to her midwife for breastfeeding support
label: a
answer: yes

Correct answer: a