Revision aid, not clinical advice. This page is educational material written for exam preparation. It is not a substitute for the current guideline or for clinical judgement, and must not be relied on for the care of any individual. Always check up-to-date national guidance and verify independently before acting on anything here.

GP Diplomas
DRCOG
GP Diplomas

The DRCOG Diploma

A calm, structured route through the Diploma of the Royal College of Obstetricians and Gynaecologists (DRCOG) — the RCOG qualification many GPs and GP trainees take to show a solid, up-to-date grounding in women’s health. Here is exactly how the exam works, plainly explained, alongside the revision toolkit we have built around it. Our timed mock is the real DRCOG shape: 120 single-best-answer questions against a three-hour clock.

120 single-best-answer questions
3 hours · one written paper

This is part of our GP Diplomas track — qualifications GPs commonly take alongside the membership exams. The DRCOG sits on its own track because it is a separate RCOG qualification with its own exam, not part of the AKT or MSRA.

How the exam works

What the DRCOG involves

The DRCOG is awarded by the Royal College of Obstetricians and Gynaecologists (RCOG). It is a single, computer-based written exam sat in person at a test centre — there is no separate clinical or oral component.

The paper

120 SBAs · 3 hours

One computer-based paper of 120 single-best-answer (SBA) questions, each worth two marks, answered over three hours. It is single-best-answer throughout.

Where you sit it

In person, at a test centre

Taken at a Pearson VUE test centre in the UK or Republic of Ireland. It is an in-person exam — not a remote or from-home assessment.

Passing & attempts

Angoff pass mark

The pass mark is set by the modified Angoff method rather than a fixed percentage. You may attempt the exam a maximum of five times.

Fee & sittings

£578 · twice a year

The exam runs twice a year, in the spring and in October. The RCOG currently lists the UK fee as £578 including VAT (Republic of Ireland £482) — the fee is banded by the country of the test centre, not your country of residence. The next sitting is Saturday 3 April 2027 (expression of interest by 16 December 2026, booking 21 January to 4 March 2027), followed by Saturday 2 October 2027.

Who it’s for

  • GPs and GP trainees who want a recognised qualification demonstrating their women’s-health knowledge.
  • It is aimed at those providing women’s healthcare in general practice — it is not a qualification for O&G specialists.
  • The exam is single-best-answer throughout, testing applied knowledge across the RCOG syllabus.

Good to know before you apply

  • You need current GMC or Medical Council of Ireland registration before you can book.
  • You cannot book directly. RCOG runs an Expression of Interest round first, and only candidates who submit one by the deadline are invited to book. Miss the EOI and you cannot sit that diet, however ready you are.
  • Book early. With only two sittings a year (spring and October), the EOI window, the booking window and your revision all need planning around.
  • It is one written exam — there is no separate clinical station or viva to prepare for.
  • Always confirm the current format, fee, dates and eligibility on the RCOG website before booking.

What you’ll be tested on

The DRCOG syllabus

The RCOG sets the DRCOG syllabus in seven modules, spanning the women’s health a GP meets across a career — from contraception and early pregnancy to gynaecology and the menopause.

1

Fertility regulation & sexual health

Contraception (including the UK Medical Eligibility Criteria), sexually transmitted infections, cervical screening and termination of pregnancy.

2

Subfertility

Assessment and management of the couple with difficulty conceiving, and when to refer.

3

Early pregnancy

Miscarriage and ectopic pregnancy, and the early-pregnancy problems presenting in primary care.

4

The pregnant woman

Antenatal care and the medical disorders that arise in pregnancy.

5

The peripartum woman & the neonate

Labour, obstetric emergencies, and postnatal and neonatal care.

6

Urgent & emergency gynaecology

Acute pelvic pain, postmenopausal bleeding and suspected gynaecological malignancy.

7

Non-urgent gynaecology

Menstrual disorders, PCOS, prolapse, incontinence, and the menopause and HRT.

Your DRCOG revision toolkit

Built around the RCOG syllabus

The same toolkit that powers our AKT and MSRA revision, mapped to the DRCOG. Every part of it is built and included with your membership; the content is written and reviewed by clinicians and re-audited against current guidance, with corrections logged and dated.

Question Bank

The DRCOG Question Bank

Single-best-answer questions across all seven modules, each with a plain-English explanation and a deep-dive linked to current guidance — in Practice and Test modes.

Open the question bank →

Revision Guide

The DRCOG Revision Guide

Twelve chapters — contraception and UKMEC, early pregnancy, medical disorders in pregnancy, urgent gynaecology and the menopause.

Open the guide →

Resources

DRCOG Core Resources

Straight from the college — the official exam page, syllabus, key guidance and recommended reading.

Open resources →

Revise & drill

Revise & drill

Short, focused sets weighted to your weakest modules, with spaced repetition to keep the high-yield facts warm between study blocks.

Choose an area →

Timed mock

Timed mock

A full mock in the real DRCOG shape — 120 single-best-answer questions against a three-hour clock — marked instantly with worked explanations.

Sit a mock →

Now live

The DRCOG toolkit is ready

The question bank, topic drills and timed mock are built around the RCOG syllabus and included with your membership — along with the curriculum, Core Lens, Core Tools, Core Compass, Core Calendar, Core Wisdom, the twelve-chapter revision guide and Core Resources.

£49.99 · one-off · 12 months full access

Join Core Revision →

14-day full refund, no questions asked.

You already have the DRCOG — full access.

Open the DRCOG Question Bank →

Exam details from the RCOG (rcog.org.uk); correct at the time of writing — always confirm with the RCOG.

Core Revision is an independent revision resource and is not affiliated with or endorsed by the RCOG.

Try before you buy

Try ten DRCOG questions, free

Ten questions spread across the seven DRCOG modules, with the same explanation members see after every answer: the Core Lens, a Deep Dive and a Founder’s Tip. No sign-up, no timer, nothing saved.

DRCOG · Antenatal CareQuestion 1 of 10 · single best answer

Antenatal screening

Scenario: A 38-year-old woman books late at 16 weeks. She missed the window for first-trimester screening but still wishes to be screened for Down’s syndrome.

Question: Which screening test is most appropriate to offer?

Pick an answer to reveal the explanation.

CorrectIncorrect

The correct answer is D: Quadruple test.

Core Lens: High-Yield Takeaways

  • The second-trimester alternative: when the combined test window has closed, the quadruple test is offered from 14 weeks 2 days to 20 weeks 0 days.
  • Four biochemical markers plus age: alpha-fetoprotein, hCG or free beta-hCG, unconjugated oestriol and inhibin-A, with no ultrasound marker.
  • It screens for less: Down’s syndrome, and Edwards’ syndrome where implemented – Patau’s syndrome is not screened for by the quadruple test.
  • The cut-off is unchanged: 1 in 150 or greater is a higher chance and opens the offer of NIPT or prenatal diagnosis, with NIPT samples taken up to 21 weeks 6 days.
  • Amniocentesis is not a screening test: it is diagnostic, invasive and carries a miscarriage risk of about 1 in 200, so it does not belong as a first offer to an unscreened woman.
Click here for Deep Dive

Booking Late: What Is Still on the Table After 14+1 Weeks

Late booking is common and has many causes – concealed pregnancy, recent arrival in the UK, unrecognised pregnancy on contraception, chaotic circumstances. The exam point is that missing the first-trimester window does not end a woman’s screening options; it changes which test she is offered and narrows what that test can tell her. Knowing the second-trimester pathway is a practical skill, because the woman who has missed her combined test usually asks a GP first.

Why This Is the Right Move

The FASP pathway offers the quadruple test when the crown rump length has exceeded 84.0 mm, that is once the combined test window has closed. The test uses maternal age with four biochemical markers – alpha-fetoprotein, human chorionic gonadotrophin or free beta-hCG, unconjugated oestriol and inhibin-A – measured from 14 weeks 2 days to 20 weeks 0 days. At 16 weeks this woman sits comfortably inside that window and should be offered it without delay, because the window closes at 20+0 and any downstream NIPT sample must be taken by 21 weeks 6 days.

Two caveats belong in the counselling. First, the quadruple test does not perform as well as the combined test, so she should be told that screening later in pregnancy is less sensitive. Second, its scope is narrower: it screens for trisomy 21, and for trisomy 18 where that has been implemented, but not for Patau’s syndrome. Her 18+0 to 20+6 week anomaly scan remains a separate offer and does screen for structural features of Edwards’ and Patau’s syndromes, so the two examinations complement each other. Her age of 38 raises her background chance but does not change which test she is offered.

Why the Other Options Don’t Fit

  • Option A – Amniocentesis: diagnostic rather than screening, usually from 15 weeks, and carrying roughly a 1 in 200 miscarriage risk. It is available to any woman who wants a definitive answer, but offering it as the first step to an unscreened woman inverts the pathway and exposes her to procedural risk unnecessarily.
  • Option B – Anomaly ultrasound scan alone: the 18+0 to 20+6 week scan screens for 11 physical conditions and will detect structural markers, but it is not a screening test for Down’s syndrome and gives no chance figure for trisomy 21.
  • Option C – Combined test: unavailable. Nuchal translucency cannot be reliably measured once the crown rump length exceeds 84.0 mm, and the biochemical algorithm is not validated beyond 14 weeks 1 day.
  • Option E – Repeat booking bloods at 20 weeks: there is no such test, and by 20 weeks the quadruple window has closed. This option exists to catch candidates who assume screening can be deferred indefinitely.

“Red Flags” and Key Decision Points

  • Time is the resource: every step downstream – NIPT by 21+6, then invasive diagnosis, then results – is compressed by late booking, so refer the same day rather than at the next routine slot.
  • Explain the reduced performance honestly: a woman choosing between quadruple testing and going straight to diagnostic testing needs to know the screen is less sensitive than the one she missed.
  • Do not forget the rest of the late booking package: infection screening should be expedited, haemoglobinopathy screening arranged, and dating established by scan.
  • Ask why she booked late: late booking is itself a marker for social vulnerability, domestic abuse, mental illness and insecure immigration status.
  • A normal quadruple test does not exclude structural anomaly: the anomaly scan is still needed and still separate.

Relevance to Primary Care

GPs see late bookers before midwives do, and the single most useful thing a GP can do is to convert the appointment into a same-day referral to the maternity service rather than a routine one. Explain what is still available and what has been lost, arrange dating urgently, and check she has had folic acid, understands the screening offer and has had her infection and haemoglobinopathy screening initiated. Women who book late often assume they have forfeited everything and disengage further; telling her clearly that she can still be screened is often what keeps her in the system.

Founder’s Tip

A woman who books at 16 weeks has not missed her screening – she has missed one test and gained a deadline, so make the referral today rather than putting her in next week’s midwife clinic.

Core Summary: When the combined test window has closed, the NHS offers the quadruple test – alpha-fetoprotein, hCG, unconjugated oestriol and inhibin-A with maternal age – between 14 weeks 2 days and 20 weeks 0 days, screening for Down’s syndrome and, where implemented, Edwards’ syndrome, with a higher-chance result of 1 in 150 or greater leading to the offer of NIPT by 21 weeks 6 days or invasive prenatal diagnosis.

DRCOG · Early PregnancyQuestion 2 of 10 · single best answer

Ectopic pregnancy

Scenario: A 30-year-old woman with a positive pregnancy test at 6 weeks asks about her risk of ectopic pregnancy. She has several possible risk factors in her history.

Question: Which factor is most strongly associated with ectopic pregnancy?

Pick an answer to reveal the explanation.

CorrectIncorrect

The correct answer is E: Previous ectopic pregnancy.

Core Lens: High-Yield Takeaways

  • One in ten, and it is the highest number in the history: UK services quote a recurrence risk of around 10% after one ectopic pregnancy, which outstrips every other single historical factor.
  • The mechanism explains the recurrence: An ectopic usually reflects bilateral tubal damage or dysfunction, so the other tube is rarely normal and the risk factor never goes away.
  • It earns her a different pathway: NICE NG126 asks early pregnancy assessment services to accept self-referral from women with a previous ectopic or molar pregnancy or recurrent miscarriage.
  • Other factors are real but weaker: Previous chlamydial pelvic inflammatory disease, tubal surgery, assisted conception and smoking all raise risk, but none approaches a prior ectopic.
  • Most ectopics have no risk factor at all: Around 1 in 80 UK pregnancies is ectopic and the majority occur in women with a clean history, so absence of risk factors never excludes the diagnosis.
Click here for Deep Dive

One in Ten: Why the Old Ectopic Outweighs Everything Else

Risk factor questions in early pregnancy are really questions about which piece of history should change your threshold for acting. Almost everything that predisposes to ectopic implantation does so by damaging the fallopian tube, slowing ciliary transport so the blastocyst implants before it reaches the cavity. What distinguishes a previous ectopic pregnancy from the rest of the list is that it is not a proxy for tubal damage – it is proof of it, and the damage is usually not confined to the affected side.

Why This Is the Right Move

A woman who has had one ectopic pregnancy carries a recurrence risk in the region of 10% in a subsequent pregnancy, a figure quoted consistently across NHS early pregnancy services, and higher still after two. That is an order of magnitude above the background UK rate of roughly 1 in 80 pregnancies. It matters clinically because it converts an ordinary early pregnancy into one that needs its location confirmed early rather than assumed, and because it carries across both treatment routes – salpingotomy preserves the tube but leaves persistent trophoblast and recurrence risk, while salpingectomy removes one tube and leaves her dependent on the other, which is frequently the same tube that was damaged by whatever caused the first ectopic.

The practical consequence sits in the notes. This woman should be told, while she is well, that in any future pregnancy she should have an early scan and can refer herself directly to the early pregnancy assessment unit as soon as she has a positive test – NICE explicitly asks services to accept those self-referrals. She should also know that mild, vague, one-sided discomfort in a future pregnancy is a reason to be seen the same day, not a reason to wait and see. That advice, given once and coded in the record, is what turns a 10% risk into a diagnosis made before rupture rather than after it.

Why the Other Options Don’t Fit

  • Option A – Body mass index over 30: Raised BMI carries real obstetric risk across pregnancy and complicates scanning, but it is not an established risk factor for ectopic implantation and does not belong on this list at all.
  • Option B – Conception with a copper intrauterine device in situ: The most interesting distractor. CoSRH (formerly FSRH) guidance states that the risk of any pregnancy, including ectopic, during intrauterine contraception use is very low, but that if a pregnancy does occur with a device in situ the likelihood of it being ectopic is greater than if there were no device. That is a conditional proportion in a very small group, not a large risk carried by a woman across her reproductive life, so it does not displace a previous ectopic as the strongest historical predictor. Worth knowing that a previous ectopic is not a contraindication to intrauterine contraception.
  • Option C – Current cigarette smoking: Smoking is a genuine, dose-related risk factor, thought to act through impaired tubal ciliary function and altered tubal protein expression, and it is worth addressing. The magnitude of risk, however, is modest compared with a documented previous ectopic.
  • Option D – Previous chlamydial pelvic inflammatory disease: The commonest identifiable cause of tubal damage in the UK and a strong risk factor in its own right – but it predicts tubal injury indirectly, whereas a previous ectopic demonstrates that the damage has already produced an ectopic implantation once. In a single-best-answer question the demonstrated event beats the surrogate.

“Red Flags” and Key Decision Points

  • Previous ectopic pregnancy: Same-day assessment for any pain or bleeding, and an early location scan even when she is entirely asymptomatic.
  • Tubal surgery or sterilisation: Including reversal and previous salpingotomy; conception after sterilisation carries a high proportionate ectopic risk.
  • Assisted conception: Ectopic and heterotopic pregnancy are both more common after IVF, so an intrauterine sac does not fully exclude a coexisting ectopic in this group.
  • Pelvic inflammatory disease, endometriosis and previous pelvic surgery: All produce the adhesions and tubal distortion that underlie the diagnosis.
  • The commonest scenario remains no risk factor at all: Never use a clean history to talk yourself out of a scan.

Relevance to Primary Care

This question is really about what a GP does with a risk factor once it is known. Two actions follow. The first is preconception and postnatal counselling for any woman who has had an ectopic: tell her the recurrence figure, tell her to test early, and tell her she can self-refer. The second is coding – a previous ectopic pregnancy in the problem list is what makes a future duty doctor, working from a summary screen at eight in the evening, arrange assessment instead of advising paracetamol. Chlamydia prevention and treatment, and smoking cessation, are the population-level levers that reduce the risk in the first place, and both sit squarely in general practice.

Founder’s Tip

Put “previous ectopic pregnancy” on the problem list, not in a consultation entry from four years ago – the point of that code is to change the decision of a colleague who has never met her.

Core Summary: A previous ectopic pregnancy is the strongest historical predictor of ectopic pregnancy, carrying a recurrence risk of around 10% because it demonstrates established tubal damage that is usually bilateral, and it entitles the woman to early location scanning and direct self-referral to an early pregnancy assessment unit under NICE NG126.

DRCOG · Emergency GynaecologyQuestion 3 of 10 · single best answer

Ovarian torsion – urgency and referral

Scenario: A 30-year-old woman attends the surgery with 2 hours of sudden severe right pelvic pain and vomiting. Examination reveals a very tender right adnexal mass. A urinary pregnancy test is negative. You strongly suspect ovarian torsion.

Question: What is the most appropriate management?

Pick an answer to reveal the explanation.

CorrectIncorrect

The correct answer is A: Admit immediately for urgent gynaecological assessment and surgery.

Core Lens: High-Yield Takeaways

  • Suspicion is the indication: torsion is a clinical diagnosis confirmed at laparoscopy, so the referral is made on the story and the examination, not on an image.
  • The ovary is the thing you are trying to save: prompt laparoscopic detorsion conserves the ovary, and modern practice is to untwist and preserve rather than to remove, even when the ovary looks dusky.
  • No community investigation changes the plan: a normal scan will not stop the admission and a delayed scan only delays theatre.
  • Give analgesia and an antiemetic while you arrange transfer: pain relief does not mask the diagnosis, and she should be nil by mouth in anticipation of surgery.
  • Speak to the on-call gynaecology team directly: a telephone handover naming the suspicion of torsion moves her up the queue in a way a letter never will.
Click here for Deep Dive

The Referral You Make on Suspicion, Not on Imaging

There is no UK national guideline dedicated to acute adnexal torsion – RCOG Green-top Guideline No. 62 covers suspected ovarian masses in premenopausal women but states explicitly that the acute presentation of ovarian cysts is outside its scope. What governs practice instead is a straightforward physiological argument that every gynaecologist accepts: the twisted pedicle strangles venous and lymphatic drainage first, the ovary swells, the twist tightens, and arterial supply fails. The longer that runs, the less ovary there is to save. Nothing available to a GP can shorten that clock except an immediate admission.

Why This Is the Right Move

The definitive test and the definitive treatment are the same procedure. Laparoscopy visualises the twisted pedicle and allows the surgeon to untwist it in the same operation, usually with removal or drainage of the causative cyst so the ovary does not simply torts again. Contemporary gynaecological practice strongly favours ovarian conservation: an ovary that looks blue-black at the start of the operation frequently recovers function after detorsion, and oophorectomy is reserved for a frankly necrotic ovary or for a mass that is suspicious of malignancy. That matters enormously to a 30-year-old, for whom the difference between detorsion today and oophorectomy tomorrow is a difference in future fertility and in the age at which she will reach the menopause.

From the surgery, the actions are simple and should be quick. Confirm the pregnancy test result. Record observations. Give adequate analgesia – withholding it is a common and indefensible error – and an antiemetic if she is vomiting. Keep her nil by mouth. Then telephone the on-call gynaecology registrar, state that you suspect ovarian torsion, and arrange transfer by ambulance or, if she is stable and transport is immediate, by a route that gets her there fastest. Send a written summary with the time of onset, because the surgical team will make decisions partly on how many hours have elapsed. Do not wait for a community ultrasound: even where imaging can be obtained rapidly, a normal result does not exclude torsion and should not change the plan.

Why the Other Options Don’t Fit

  • Option B – Arrange an outpatient ultrasound within 2 weeks: by a fortnight the ovary is either dead or the episode has resolved, and neither outcome is one you chose. This is the option that reads most plausibly to a clinician who has not appreciated how short the window is.
  • Option C – Prescribe analgesia and review in 48 hours: analgesia is right, the timescale is catastrophically wrong. Two days of ischaemia leaves a necrotic ovary, and review at 48 hours converts a savable emergency into an oophorectomy.
  • Option D – Prescribe empirical antibiotics for pelvic inflammatory disease: the clinical picture does not meet the BASHH description of PID, which is bilateral pain over days with discharge, deep dyspareunia and cervical motion tenderness. Treating torsion as infection is one of the classic delays, and it feels superficially reasonable because both can produce adnexal tenderness.
  • Option E – Refer routinely to gynaecology: a routine referral is measured in weeks. Even an urgent outpatient referral is too slow; this woman needs a gynaecologist within hours and a theatre list the same day.

“Red Flags” and Key Decision Points

  • Hours, not days: ovarian salvage falls with time from onset, so record the exact time the pain started and pass it on.
  • A negative or equivocal scan: does not overturn a strong clinical suspicion – the assessment is surgical.
  • Peritonism, fever or tachycardia: suggests necrosis or an infarcted ovary and makes the referral more urgent, not less.
  • Pregnancy and fertility treatment: torsion is more common in both, and ovarian hyperstimulation syndrome adds its own risks under RCOG Green-top Guideline No. 5.
  • Recurrent self-resolving episodes: intermittent torsion still warrants gynaecological assessment, because the next episode may not untwist itself.

Relevance to Primary Care

The practical lesson for primary care is about decisiveness. A GP will see suspected torsion a handful of times in a career, and on each occasion the temptation is to seek confirmation before committing to an emergency referral. Resist it. The referral costs the system one assessment; the delay costs the woman an ovary. It also helps to name the diagnosis explicitly in the handover: “query ovarian torsion” triggers a different response from a gynaecology team than “abdominal pain, please assess”. Finally, document the time of onset, the observations, the pregnancy test result and the time of your call, because torsion is a diagnosis where the timeline is later scrutinised.

Founder’s Tip

Time is ovary – when the story fits torsion, pick up the phone before you pick up the ultrasound request form, because the scan that reassures you is the scan that loses her the ovary.

Core Summary: Suspected ovarian torsion, signalled by sudden severe unilateral pelvic pain with vomiting and a tender adnexal mass, requires immediate admission for urgent gynaecological assessment and laparoscopy with a view to ovarian-conserving detorsion, because venous congestion progresses to arterial infarction over hours and no community investigation, including ultrasound, can safely exclude the diagnosis.

DRCOG · Fertility Regulation & Sexual HealthQuestion 4 of 10 · single best answer

Combined hormonal contraception

Scenario: A 26-year-old woman started the combined oral contraceptive pill 3 weeks ago. She now presents with a painful, swollen, tender right calf. There is no history of trauma. She is otherwise well.

Question: What is the most appropriate immediate management?

Pick an answer to reveal the explanation.

CorrectIncorrect

The correct answer is D: Stop the pill and arrange same-day assessment for suspected deep vein thrombosis.

Core Lens: High-Yield Takeaways

  • Unilateral calf swelling on the pill is a DVT until excluded: New, painful, swollen, tender calf with no trauma in a combined contraceptive user needs same-day assessment.
  • Risk is front-loaded: Venous thromboembolism risk with combined hormonal contraception is highest in the first months of use and after restarting.
  • Stop the method: Combined contraception is stopped at the point of suspicion, not after the scan confirms it.
  • Follow the NICE pathway: NG158 uses the two-level DVT Wells score, with proximal leg vein ultrasound within four hours or interim anticoagulation and a scan within 24 hours.
  • Absolute risk in context: Around 2 venous thromboembolisms per 10,000 women per year in non-users, rising to roughly 5 to 12 depending on the progestogen.
Click here for Deep Dive

New Calf Swelling on the Pill: Stop, Refer, Same Day

Ethinylestradiol shifts the coagulation balance towards thrombosis by increasing hepatic production of clotting factors and reducing the natural anticoagulant response. The effect appears within weeks of starting, which is why the risk of venous thromboembolism in combined hormonal contraceptive users is highest in the first few months of use and again after any restart following a break. This woman started three weeks ago, which puts her precisely in the highest-risk window, and she has presented with the textbook picture: unilateral calf pain, swelling and tenderness with no trauma to explain it. The task is not to decide whether she has a clot; it is to get her assessed today.

Why This Is the Right Move

Two things need to happen and both are in the answer. First, stop the combined pill. Continuing it while a thrombosis is being investigated adds ongoing prothrombotic drive for no benefit, and if the diagnosis is confirmed the method is permanently contraindicated anyway – UKMEC 2025 classifies current and past venous thromboembolism as category 4 for combined hormonal contraception. Second, arrange same-day assessment. NICE NG158 sets out the pathway: apply the two-level DVT Wells score; where DVT is likely, arrange a proximal leg vein ultrasound within four hours, and if that cannot be achieved, take a D-dimer, start interim therapeutic anticoagulation and obtain the scan within 24 hours. In most areas this means a direct referral to the ambulatory DVT or same-day emergency care pathway rather than a routine outpatient request.

Put the absolute risk in proportion when you talk to her, because she will ask. Medicines regulators estimate around 2 venous thromboembolic events per 10,000 women per year in non-pregnant non-users, around 5 to 7 with pills containing levonorgestrel, norethisterone or norgestimate, and around 9 to 12 with those containing gestodene, desogestrel or drospirenone, with the patch and ring in between. These are small numbers, but a small probability does not help the individual in front of you who has the symptom, and it never justifies watchful waiting. She will also need contraception afterwards – progestogen-only methods and both intrauterine devices remain available, and she should not be discharged from the episode without a plan.

Why the Other Options Don’t Fit

  • Option A – Advise simple analgesia and review in one week: A week is long enough for a calf thrombus to propagate and embolise. Suspected deep vein thrombosis is a same-day problem.
  • Option B – Continue the pill and arrange a routine D-dimer: Wrong on both counts. The pill should stop, and D-dimer used in isolation, outside the Wells pathway and without a defined time frame, does not safely exclude a DVT.
  • Option C – Reassure that calf pain is an expected early side effect: Unilateral calf pain with swelling is never an expected side effect of the combined pill. It is one of the specific warning symptoms women are counselled to report.
  • Option E – Switch to a lower-dose combined pill: Any combined pill maintains the prothrombotic effect. Changing preparation while a thrombosis is suspected is the opposite of what is needed.

“Red Flags” and Key Decision Points

  • Chest pain, breathlessness or haemoptysis: Suspect pulmonary embolism and arrange emergency admission rather than an ambulatory DVT referral.
  • Immobility, recent surgery, long-haul travel or malignancy: Additional risk factors that raise the Wells score and the index of suspicion.
  • Family history of unprovoked venous thromboembolism: Should have been elicited before starting; it makes combined contraception UKMEC 3 or 4 depending on the detail.
  • Confirmed venous thromboembolism: Combined hormonal contraception becomes permanently UKMEC 4; switch to a progestogen-only or intrauterine method.

Relevance to Primary Care

Almost every one of these presentations starts with a same-day GP appointment or a triage call about a sore leg. The two decisions that matter are made in that first contact: stop the oestrogen and put her on the same-day pathway. Do not let the conversation drift into whether the pill or the leg is the problem – do both. It is also worth reflecting that the quality of the original pill-starting consultation shows up here: a woman told at the outset to report unilateral calf swelling, chest pain or breathlessness is the woman who presents on day one rather than day ten.

Founder’s Tip

A one-sided swollen calf in a woman three weeks into the combined pill buys you no thinking time: stop the oestrogen in the room and put her on today’s DVT pathway, because the scan can always be normal but the delay cannot be undone.

Core Summary: New unilateral calf pain, swelling and tenderness in a woman recently started on combined hormonal contraception is a suspected deep vein thrombosis requiring the pill to be stopped immediately and same-day assessment under the NICE NG158 pathway (two-level Wells score with proximal leg vein ultrasound within four hours, or D-dimer with interim anticoagulation and a scan within 24 hours).

DRCOG · Non-urgent GynaecologyQuestion 5 of 10 · single best answer

Secondary amenorrhoea investigation

Scenario: A 28-year-old woman whose periods have always been regular attends because she has had no menstrual bleeding for 4 months. She is in a relationship and uses condoms intermittently for contraception. She feels well, with no hot flushes, galactorrhoea, weight change or excessive hair growth.

Question: What is the most appropriate first investigation?

Pick an answer to reveal the explanation.

CorrectIncorrect

The correct answer is D: Perform a urinary pregnancy test.

Core Lens: High-Yield Takeaways

  • The rule: In any woman of reproductive age with new secondary amenorrhoea, pregnancy is excluded first, before a single hormone is measured or a single scan is requested.
  • Pregnancy is the commonest cause: By a very wide margin, and it is the one cause where a delayed diagnosis changes options, timing and safety.
  • “Condoms intermittently” is not contraception: A contraceptive history is not a negative pregnancy test, and a patient’s own certainty that she cannot be pregnant is not evidence.
  • Then the panel: Once pregnancy is excluded, the standard second step is FSH and LH, oestradiol, prolactin, thyroid function and total testosterone, with pelvic ultrasound reserved for structural questions.
  • Repeat if it persists: A very early pregnancy can give a negative urinary test; if amenorrhoea continues, repeat before embarking on hormonal treatment.
Click here for Deep Dive

The Test You Do Before You Think: Amenorrhoea in the Reproductive Years

Secondary amenorrhoea is conventionally defined as the absence of menstruation for three to six months in a woman whose cycles were previously regular, or for six to twelve months in a woman with pre-existing oligomenorrhoea. This patient has gone four months with previously reliable cycles, so she is comfortably inside the definition and deserves investigation rather than another period of waiting.

Why This Is the Right Move

The clinical logic is one of consequence, not probability alone. Every other item on the differential list – polycystic ovary syndrome, hyperprolactinaemia, thyroid disease, premature ovarian insufficiency, functional hypothalamic amenorrhoea, Asherman syndrome – can be investigated next week without harm. Pregnancy cannot. Gestational age determines her options if the pregnancy is unplanned, determines the antenatal pathway if it is continuing, and determines whether a symptom such as pain needs an ectopic assessment today. Missing it also invalidates every hormone result you order, because pregnancy raises prolactin, alters thyroid binding and suppresses gonadotrophins.

The second layer is medicolegal and practical. Prescribing a progestogen challenge, starting hormonal treatment, or requesting pelvic imaging in an undiagnosed pregnancy is an avoidable error. A urinary human chorionic gonadotrophin test costs pennies, is done in the room, and gives an answer within minutes – so it is the only investigation that both changes management immediately and can be completed within the same consultation. Ask about symptoms alongside it: breast tenderness, nausea, and any unilateral pain or bleeding, which would move the consultation towards early pregnancy assessment rather than a hormone panel.

Why the Other Options Don’t Fit

  • Option A – Measure serum FSH and LH: A genuinely useful second step, because it separates hypogonadotrophic causes such as functional hypothalamic amenorrhoea from hypergonadotrophic ovarian failure. But it is uninterpretable in pregnancy and answers no urgent question.
  • Option B – Measure serum prolactin: Indicated where there is galactorrhoea, headache or visual symptoms, none of which she has. Pregnancy itself raises prolactin, so an unscreened sample is likely to generate a false trail.
  • Option C – Measure thyroid function: Belongs in the panel, since both hypothyroidism and hyperthyroidism disturb cycles, but she has no thyroid symptoms and the test does not need to precede a pregnancy test.
  • Option E – Refer for pelvic ultrasound: Reserved for suspected structural pathology or for characterising polycystic ovarian morphology. Referring first wastes weeks and would in any case identify a pregnancy that the urine test would have found on the day.

“Red Flags” and Key Decision Points

  • Galactorrhoea with headache or visual field disturbance: Think prolactinoma; check prolactin on two rested samples and consider pituitary imaging.
  • Hot flushes, night sweats or vaginal dryness under 40: Think premature ovarian insufficiency and measure FSH on two samples four to six weeks apart.
  • Rapid onset hirsutism, deepening voice or clitoromegaly: Suggests an androgen-secreting tumour and warrants urgent referral rather than a routine PCOS work-up.
  • Amenorrhoea after uterine instrumentation, retained products or endometritis: Consider Asherman syndrome; hormones will be normal and hysteroscopy is the diagnostic test.
  • Low BMI, restrictive eating or heavy training: Functional hypothalamic amenorrhoea with bone loss; ask about stress fractures.
  • Unilateral pain or bleeding with a positive test: Early pregnancy assessment unit the same day.

Relevance to Primary Care

This question is really about consultation discipline. The temptation in a busy surgery is to bundle a hormone profile onto a blood form and bring the patient back in a fortnight, which feels thorough and is in fact slower and less safe. Doing the urine test in the room converts a two-week loop into a same-day answer, and lets the rest of the consultation be spent on what actually matters – her contraceptive plan if she is not pregnant, or her options and dating if she is. It also opens the door to a useful conversation about condoms as a sole method, which has a real typical-use failure rate.

Founder’s Tip

Every woman between menarche and menopause who stops bleeding is pregnant until her urine says otherwise, and “we mostly use condoms” is a contraceptive history, not a negative test.

Core Summary: New secondary amenorrhoea in a woman of reproductive age requires a urinary pregnancy test as the first investigation, performed in the consultation and repeated if amenorrhoea persists, because pregnancy is both the commonest cause and the only one whose delayed diagnosis changes management, and because it invalidates the gonadotrophin, prolactin and thyroid results that make up the second-line panel.

DRCOG · Peripartum Care & the NeonateQuestion 6 of 10 · single best answer

CTG concerning features

Scenario: A woman in established labour is being monitored with a cardiotocograph. The obstetric team is reviewing the trace to decide whether the pattern is reassuring or requires action.

Question: Which single feature is most concerning and suggests possible fetal compromise?

Pick an answer to reveal the explanation.

CorrectIncorrect

The correct answer is E: Late decelerations that persist after the contraction has finished.

Core Lens: High-Yield Takeaways

  • Late decelerations are the most worrying deceleration pattern: NICE NG229 grades repetitive late decelerations amber for less than 30 minutes and red for more than 30 minutes, the red category they then share with acute bradycardia, a prolonged deceleration of 3 minutes or more and repetitive concerning variable decelerations lasting over 30 minutes.
  • The timing is the diagnosis: NG229 describes them as slowing of the fetal heart rate with onset mid to end of the contraction, the lowest point more than 20 seconds after the peak of the contraction, and ending after the contraction has finished.
  • The mechanism is uteroplacental: they reflect impaired oxygen delivery during contractions rather than the mechanical head compression of early decelerations.
  • Early decelerations are benign: NG229 calls them uncommon, benign and usually associated with head compression when unaccompanied by other changes.
  • Normal is boring: a stable baseline of 110 to 160, variability of 5 to 25 and accelerations with movement are all normal findings, not warning signs.
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After the Contraction Has Gone: Why Late Decelerations Frighten the Obstetrician

Every contraction is a small ischaemic insult to the fetus. Intramyometrial pressure exceeds the perfusion pressure of the spiral arteries, intervillous blood flow pauses, and the fetus lives for a minute or so on the oxygen reserve held in the intervillous space and its own circulation. A healthy placenta with reserve absorbs this without the heart rate changing at all. When the placenta has no reserve – growth restriction, pre-eclampsia, abruption, hyperstimulation, maternal hypotension after an epidural top-up – the fetus becomes hypoxaemic during the squeeze, chemoreceptors fire, and the heart rate falls. Because the sequence takes time to develop and to recover, the dip lags behind the contraction. That lag is the whole point: a deceleration that is still going when the contraction has ended is telling you the fetus could not keep up.

Why This Is the Right Move

NG229 defines late decelerations precisely: slowing of the fetal heart rate with onset mid to end of the contraction, with the lowest point more than 20 seconds after the peak of the contraction, and ending after the contraction. It grades repetitive late decelerations as amber for less than 30 minutes and red for more than 30 minutes – the red category also holding an acute bradycardia, a single prolonged deceleration lasting three minutes or more, and repetitive variable decelerations with concerning characteristics for more than 30 minutes. Red features are the ones that trigger urgent obstetric review and a plan to expedite birth if the pattern does not resolve.

In practice, recognising them starts a sequence rather than ending one. Look for and correct the reversible causes: stop or reduce oxytocin, turn the woman onto her left side, treat hypotension with fluids and vasopressors after regional analgesia, exclude hyperstimulation, check maternal observations for pyrexia and consider abruption if there is pain or bleeding. Reassess the whole clinical picture, not just the paper: gestation, growth, meconium, how far the labour has to run. If late decelerations persist despite conservative measures, the expected course is birth by the quickest safe route – instrumental if the cervix is fully dilated and the head is low, caesarean if it is not. NG229 makes no recommendation on fetal blood sampling because of limited evidence. The red categorisation exists precisely because delay here is what converts a hypoxaemic fetus into an acidotic one.

Why the Other Options Don’t Fit

  • Option A – A stable baseline of 140 beats per minute: squarely inside the normal band of 110 to 160. A stable baseline is one of the most reassuring things on a trace.
  • Option B – Accelerations occurring with fetal movement: accelerations are a normal and reassuring finding and are the classic marker of an intact fetal autonomic response. Their absence is of interest only alongside other features; their presence is good news.
  • Option C – Baseline variability of 5-25 beats per minute: this is the normal range under NG229. Candidates sometimes pick it because 25 sounds high, but wide variability within this band is normal; it is variability below 5 for a sustained period, or a genuinely sinusoidal pattern, that causes concern.
  • Option D – Early decelerations that mirror contractions: NG229 describes early decelerations as uncommon, benign and usually associated with head compression, with onset early in the contraction and return to baseline at its end. The mirror-image timing is exactly what distinguishes them from the answer.

“Red Flags” and Key Decision Points

  • Acute bradycardia or a prolonged deceleration of three minutes or more: call for immediate help; NG229 expects birth to be expedited if it persists for nine minutes, or sooner where risk factors are present.
  • Variable decelerations with concerning characteristics: lasting over 60 seconds, reduced variability within the deceleration, failure to return to baseline, or loss of shouldering – these escalate an otherwise ordinary pattern.
  • Excessive uterine activity: five or more contractions in ten minutes with reduced resting time, or hypertonus (NG229), are a correctable cause of decelerations and should be looked for before anything else.
  • Context beats pattern: the same trace means something different in a growth-restricted fetus at 41 weeks with thick meconium than in a well-grown fetus at term with clear liquor.

Relevance to Primary Care

Few GPs read cardiotocographs, but many explain them. Women who had an emergency caesarean “because of the trace” often come to the surgery angry or bewildered, and being able to say what late decelerations are, and why the team could not wait, turns a grievance into an understanding. GPs also recognise the antenatal conditions that make late decelerations likely – fetal growth restriction, pre-eclampsia, reduced movements, diabetes – and referring those women promptly is the primary-care contribution to avoiding this scenario. And in any community emergency, a fetal heart that dips and is slow to recover after a contraction is a reason to call 999, not to recheck in ten minutes.

Founder’s Tip

Decelerations that finish before the contraction does are usually the head being squeezed; decelerations that are still running when the uterus has relaxed are the placenta telling you it has nothing left in reserve.

Core Summary: Late decelerations – beginning mid to late in the contraction, nadir more than 20 seconds after its peak and recovery after the contraction has ended – are graded amber by NICE NG229, and red once repetitive for more than 30 minutes, because they signal uteroplacental insufficiency and fetal hypoxaemia, and they require immediate correction of reversible causes, urgent obstetric review and expedited birth if they persist.

DRCOG · SubfertilityQuestion 7 of 10 · single best answer

Rubella status in fertility care

Scenario: A 32-year-old woman having preconception and subfertility checks is found to be rubella non-immune on serology. She is not currently pregnant and is using condoms.

Question: What is the most appropriate management?

Pick an answer to reveal the explanation.

CorrectIncorrect

The correct answer is B: Give the MMR vaccine and advise avoiding pregnancy for 1 month.

Core Lens: High-Yield Takeaways

  • Test so you can vaccinate: NICE NG257 recommendation 1.20.1 offers rubella status testing to those concerned about their fertility so that susceptible people can be offered vaccination.
  • The interval: The UKHSA Green Book states that pregnancy should be avoided for one month following the last dose of MMR.
  • It is a live vaccine: MMR is not given in pregnancy as a precaution, although there is no evidence that rubella-containing vaccines are teratogenic.
  • Inadvertent vaccination is not a disaster: A woman immunised in pregnancy can be reassured, and it is not a reason to recommend termination.
  • Immunoglobulin has no preventive role: Human normal immunoglobulin is not routinely used for post-exposure protection against rubella because there is no evidence it works.
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The Window Before Conception: Closing the Rubella Gap While You Can

Congenital rubella syndrome is one of the most devastating and most completely preventable outcomes in obstetrics. Maternal infection in the first trimester, and particularly in the first ten weeks, carries a high risk of fetal damage: sensorineural deafness, cataract and other eye disease, congenital heart lesions such as patent ductus arteriosus and pulmonary artery stenosis, microcephaly and learning disability. There is no treatment once infection has occurred, and there is no way to protect the fetus of a susceptible woman during the pregnancy itself, because the only effective protection is a live vaccine that pregnancy rules out. The entire opportunity therefore lies before conception, which is exactly why NG257 puts rubella testing into the fertility assessment.

Why This Is the Right Move

NG257 recommendation 1.20.1 offers testing for rubella status to those concerned about their fertility who have not been vaccinated, or are uncertain whether they have been, so that those who are susceptible can be offered vaccination. This woman has been tested and is non-immune, she is not pregnant, and she is using condoms – a near-perfect set of circumstances in which to act. Vaccinate her with MMR, because monovalent rubella vaccine is no longer available in the UK and MMR is the vehicle for rubella protection; the measles and mumps components are a bonus rather than a complication, and prior immunity to either is not a contraindication.

The one-month interval comes from the Green Book, which states that pregnancy should be avoided for one month following the last dose. The reasoning is precautionary rather than evidential. MMR contains live attenuated virus, and live vaccines are avoided in pregnancy on principle; but the Green Book is careful to add that there is no evidence that rubella-containing vaccines are teratogenic, and that those inadvertently immunised in pregnancy can be reassured and that such an incident would not be a reason to recommend termination of pregnancy. That second half of the message is as important as the first, because a woman who conceives three weeks after her MMR needs calm reassurance, not a crisis. Give her clear practical advice: continue reliable contraception for the month, then try. If she needed two doses to complete the schedule, the interval runs from the last dose. Check her serology is documented in the record, and remember that post-vaccination serological testing is not routinely required.

Why the Other Options Don’t Fit

  • Option A – Advise that rubella status is not relevant to fertility: Strictly, rubella immunity does not affect the chance of conceiving – but NG257 places rubella testing squarely within the fertility assessment because this is the last reliable moment to protect a future pregnancy. Dismissing it wastes the only window that exists.
  • Option C – Give the MMR vaccine and advise that conception can be attempted immediately: Half right and therefore the most tempting distractor. The vaccination is correct; omitting the one-month interval ignores the standard precaution applied to live vaccines and the explicit Green Book advice.
  • Option D – Give rubella immunoglobulin: Not a preventive strategy. The Green Book states that human normal immunoglobulin is not routinely used for post-exposure protection from rubella since there is no evidence that it is effective, and it confers no lasting immunity in any case.
  • Option E – Offer the MMR vaccine only during the first trimester: Directly contrary to guidance. MMR should not be given in pregnancy, and the first trimester is both the period of maximum fetal vulnerability to wild rubella and the point at which the live vaccine is most firmly avoided.

“Red Flags” and Key Decision Points

  • Immunosuppression: MMR is a live vaccine and is contraindicated in significant immunosuppression, including some biologic and high-dose steroid regimens – check before giving it.
  • Already pregnant: Defer MMR and give it postpartum, ideally before discharge from maternity care; advise avoidance of contact with anyone who has a rubella-like rash.
  • Rash illness in a susceptible pregnant woman: Discuss urgently with the local health protection team and arrange serology – parvovirus B19 and measles also need to be considered.
  • Uncertain vaccination history: Two documented doses of MMR is the standard; where records are missing, vaccinating is safer than assuming immunity.
  • Use the whole preconception opportunity: Folic acid, smoking, alcohol, BMI, cervical screening, medication review and chronic disease optimisation belong in the same consultation.

Relevance to Primary Care

Rubella susceptibility is now found mainly in women who missed childhood immunisation, those born or raised in countries without an established rubella programme, and the cohort affected by the collapse in MMR uptake in the early 2000s. Routine antenatal rubella screening was withdrawn in England some years ago precisely because it identified susceptibility at a point when nothing could be done about it, which shifts the responsibility firmly onto preconception and postnatal care – and in practice onto general practice. When a non-immune woman who wants to conceive is sitting in front of you, vaccinate in that appointment rather than deferring it; the single commonest reason this gets missed is that the plan was made and the patient never came back.

Founder’s Tip

A non-immune woman planning pregnancy should not leave the surgery without the MMR in her arm and a month in her diary – and if she conceives inside that month anyway, reassure her properly, because there is no evidence the vaccine harms the fetus and panic does far more damage.

Core Summary: Rubella testing is part of the fertility and preconception assessment under NICE NG257 so that susceptible women can be vaccinated before pregnancy, and because MMR is a live vaccine the UKHSA Green Book advises avoiding pregnancy for one month after the last dose, while reassuring that inadvertent vaccination in pregnancy is not an indication for termination.

DRCOG · Antenatal CareQuestion 8 of 10 · single best answer

Pre-conception care

Scenario: A 34-year-old woman attends for pre-conception advice. She has epilepsy managed with lamotrigine, a BMI of 33 kg/m2, and coeliac disease. She is keen to conceive.

Question: Which single recommendation regarding folic acid is most appropriate?

Pick an answer to reveal the explanation.

CorrectIncorrect

The correct answer is C: Folic acid 5 mg daily until 12 weeks.

Core Lens: High-Yield Takeaways

  • The antiepileptic settles it: NICE NG247 lists medicines that affect how folate is absorbed or metabolised – antiepileptic drugs are given as the worked example – among the indications for 5 mg.
  • Raised BMI alone no longer qualifies: NG247 (January 2025) removed obesity from the high-dose list; a BMI in the obesity range now warrants 5 mg only when another risk factor is present.
  • The dose does not stack: one qualifying indication and three qualifying indications both lead to the same 5 mg daily until 12 weeks.
  • Folic acid does not interact with lamotrigine: there is no contraindication, and withholding it would be the most harmful answer on the list.
  • Lamotrigine needs its own plan: NICE NG217 advises pre-conception referral to the epilepsy specialist team, a baseline drug level, and monitoring with dose adjustment in pregnancy as clearance rises.
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Stacking Risk Factors Does Not Stack the Dose

This question looks like an arithmetic problem and is not one. A woman may collect several reasons to be offered high-dose folic acid, but 5 mg is the ceiling; there is no 10 mg tier and no extension past 12 weeks for the woman who qualifies three times over. The examiner is testing two things at once: that you know which features genuinely trigger the high dose, and that you do not respond to an accumulation of risk factors by escalating a dose that has only one level above baseline.

Why This Is the Right Move

NICE NG247 advises offering high-dose folic acid (5 mg a day) to anyone planning pregnancy or in the first 12 weeks who has an increased risk of a baby with a neural tube defect or other congenital malformation, and gives as examples a personal, partner or family history of neural tube defect or other congenital malformation, a previously affected pregnancy, type 1 or type 2 diabetes, a haematological condition requiring folate supplementation such as sickle cell anaemia or thalassaemia, and medicines that affect how folic acid is absorbed or metabolised – naming antiepileptic and anti-HIV medicines. Her lamotrigine places her squarely in the last group, and that single fact decides the answer.

The other two features need thinking about rather than counting. NG247 explicitly changed practice on obesity: a BMI in the obesity range is no longer an indication for high-dose folic acid in the absence of other risk factors, so her BMI of 33 does not contribute here. Coeliac disease is not named in NICE’s list, but it is a malabsorptive condition and Coeliac UK advises 5 mg on precautionary grounds where gut damage may reduce absorption; it is a reasonable supporting reason rather than the deciding one. Either way the destination is the same: 5 mg daily, until 12 weeks.

Why the Other Options Don’t Fit

  • Option A – Folic acid 400 micrograms daily until 12 weeks: the correct duration with a dose that ignores her antiepileptic. This is the answer given by anyone who assumes lamotrigine is “one of the safer ones” and therefore exempt.
  • Option B – Folic acid 400 micrograms daily until delivery: wrong dose and wrong duration, and it inverts the rule – in higher-risk women it is the dose that rises, not the stopping point that moves.
  • Option D – Folic acid 5 mg daily until delivery: the tempting distractor for a woman with three apparent indications. Nothing about accumulated risk extends supplementation past 12 weeks, because the neural tube has closed.
  • Option E – Folic acid is contraindicated with lamotrigine: false, and dangerous. The confusion arises from older enzyme-inducing antiepileptics acting as folate antagonists, which is an argument for more folate, not less. Folic acid does not reduce lamotrigine efficacy.

“Red Flags” and Key Decision Points

  • Never stop or switch an antiepileptic in primary care because of pregnancy: uncontrolled seizures carry real maternal and fetal risk, including sudden unexpected death in epilepsy. Refer, do not deprescribe.
  • Lamotrigine levels fall as pregnancy advances: clearance increases, seizures can break through, and doses usually need adjusting upward and then reducing after delivery.
  • Check what else she has ever taken: sodium valproate carries a regulatory pregnancy prevention programme and must be addressed explicitly, not assumed absent.
  • The BMI still matters, just not here: obesity remains relevant to gestational diabetes, pre-eclampsia, thromboembolism and scan quality, even though it no longer drives the folate dose.
  • Register the pregnancy: encourage enrolment with the UK Epilepsy and Pregnancy Register once she conceives.

Relevance to Primary Care

Women with epilepsy are usually stable and reviewed in general practice, and pre-conception counselling frequently lands with the GP. The practical sequence is: 5 mg folic acid on prescription now, urgent referral to the epilepsy service for a pre-conception medication review and baseline level, an explicit instruction not to alter or stop the lamotrigine herself, and contraception maintained until that review has happened. Getting the folic acid dose right is easy marks; getting her seen by the epilepsy team before she conceives is the part that changes her pregnancy.

Founder’s Tip

When a woman on antiseizure medication tells you she wants a baby, write 5 mg folic acid and an urgent epilepsy referral in the same consultation – and tell her plainly that stopping her tablets is far more dangerous to the pregnancy than taking them.

Core Summary: An antiepileptic drug is a NICE NG247 indication for high-dose folic acid 5 mg daily from pre-conception until 12 weeks, the dose does not escalate further however many indications coexist, raised BMI alone was removed from the high-dose list in January 2025, and the accompanying priority is urgent pre-conception review of the antiseizure medication rather than any change to it in primary care.

DRCOG · Early PregnancyQuestion 9 of 10 · single best answer

Haemodynamic red flags

Scenario: A 31-year-old woman who is 8 weeks pregnant telephones the duty GP about vaginal bleeding that started this morning. You are trying to decide how urgently she needs to be seen.

Question: Which feature most strongly warrants emergency (999) assessment?

Pick an answer to reveal the explanation.

CorrectIncorrect

The correct answer is D: Presyncope with light-headedness on standing.

Core Lens: High-Yield Takeaways

  • Postural symptoms are volume loss until proved otherwise: NICE NG126 lists dizziness, fainting and orthostatic hypotension among the features that should make a clinician think of ectopic pregnancy.
  • The vaginal loss does not measure the bleeding: In a ruptured ectopic most of the blood is in the peritoneal cavity, so the pad tells you almost nothing about how much she has lost.
  • Presyncope beats a normal blood pressure: A young woman maintains her supine blood pressure until late; symptoms on standing are the earliest clinical marker of a meaningful deficit.
  • This is a 999 call, not an EPAU referral: NG126 sends women who are haemodynamically unstable, or in whom there is significant concern about the pain or bleeding, directly to emergency care.
  • Do not stand her up to prove it: If the history describes presyncope on standing, act on the history. A provocative postural blood pressure risks a syncopal collapse.
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Standing Up Is the Test: Postural Symptoms as Occult Blood Loss

Telephone triage in early pregnancy is a sorting exercise with three destinations: expectant management at home, an early pregnancy assessment unit appointment, or an ambulance. Nearly all of the information that decides between them is in the history, because you cannot examine the patient. The single most useful question is not about the bleeding at all – it is about what happens when she stands up.

Why This Is the Right Move

Compensated hypovolaemia is the trap in this age group. A fit 31-year-old defends her cardiac output with tachycardia and peripheral vasoconstriction, so a supine blood pressure can remain entirely normal after losing a litre into the abdomen. What fails first is the ability to maintain cerebral perfusion against gravity. Light-headedness or near-fainting on standing is therefore an early, sensitive and clinically free marker of a deficit that has not yet shown up in the numbers you would measure lying down. In a bleeding early pregnancy it points to either substantial revealed loss or, more dangerously, concealed intraperitoneal bleeding from a ruptured tubal ectopic.

The bleeding that started this morning is a red herring in terms of volume. In ectopic rupture the vaginal loss is characteristically light and dark, because it is decidual shedding rather than the haemorrhage itself; the litre that matters is behind the peritoneum where nobody can see it. That is exactly why NG126 builds its emergency threshold out of systemic features – dizziness, fainting, pallor, tachycardia above 100 beats per minute, hypotension below 100/60 mmHg, shock or collapse – rather than out of an estimate of how much blood is on the pad. Faced with presyncope on the telephone, the correct action is an emergency ambulance with a pre-alert to gynaecology, not an appointment.

Why the Other Options Don’t Fit

  • Option A – A closed cervical os reported at a recent examination: A closed os is, if anything, the more reassuring finding, and it certainly does not exclude ectopic pregnancy, in which the os is usually closed. A historical examination finding never outranks current systemic symptoms.
  • Option B – Brown vaginal spotting for the past 2 days: Brown loss is old, altered blood and is extremely common in early pregnancy. It warrants early pregnancy assessment in a woman at 8 weeks, but on its own it is not an emergency and it carries no information about circulating volume.
  • Option C – Mild intermittent suprapubic cramping: Mild central cramping accompanies most threatened and inevitable miscarriages and is expected. It moves her out of expectant management and into EPAU assessment, but it is not the feature that forces a 999 call. Severe, unilateral or escalating pain would be a different matter.
  • Option E – Slight breast tenderness: This is a normal symptom of pregnancy driven by rising hormones and has no bearing on urgency at all. Its loss is sometimes noticed as a pregnancy fails, but its presence is simply background.

“Red Flags” and Key Decision Points

  • Ask the standing question in every early pregnancy bleed: “When you stand up, do you feel faint, grey or as if you might black out?” A yes changes the destination.
  • Shoulder tip pain: Referred diaphragmatic irritation from free intraperitoneal blood. Emergency assessment, same call.
  • Pain that has become one-sided or severe: Especially with amenorrhoea and only light vaginal loss.
  • Rectal pressure or pain on opening the bowels: Blood collecting in the pouch of Douglas, and an easily missed history.
  • Never rely on a normal lying blood pressure: In a young woman it is the last thing to go, not the first.

Relevance to Primary Care

Duty doctors and care navigators triage these calls daily, and the protective habit is a fixed set of questions asked of every bleeding early pregnancy: how many weeks, is there pain and where, is there shoulder tip pain, does she feel faint on standing, how heavy is the loss, and has she ever had an ectopic pregnancy. Presyncope, shoulder tip pain or severe unilateral pain go straight to 999. Pain or bleeding with normal systemic features go to the EPAU. Bleeding alone under 6 weeks without pain or risk factors can be watched with a repeat urine test. Writing those questions into the practice template turns a judgement call made under pressure into a checklist, which is how this diagnosis stops being missed.

Founder’s Tip

On the phone to a bleeding early pregnancy, ask what happens when she stands up – the woman who goes grey on the way to the kitchen is bleeding into her abdomen, whatever the pad looks like.

Core Summary: Presyncope or light-headedness on standing in a woman with bleeding in early pregnancy signals significant revealed or concealed blood loss, most dangerously from a ruptured ectopic pregnancy, and under NICE NG126 haemodynamic compromise mandates immediate emergency transfer by 999 ambulance rather than an early pregnancy assessment unit appointment.

DRCOG · Emergency GynaecologyQuestion 10 of 10 · single best answer

Acute pelvic pain – differential diagnosis

Scenario: A 22-year-old woman presents with sudden-onset sharp right iliac fossa pain that began at the midpoint of her cycle. The pain is now easing. She is systemically well, afebrile and haemodynamically stable, with only mild localised tenderness. A urinary pregnancy test is negative.

Question: What is the single most likely diagnosis?

Pick an answer to reveal the explanation.

CorrectIncorrect

The correct answer is E: Ruptured ovarian cyst.

Core Lens: High-Yield Takeaways

  • Timing is the diagnosis: sudden sharp unilateral pain at the midpoint of the cycle points to an event at the ovary – follicular rupture or rupture of a functional cyst.
  • Pain that is already easing is reassuring: a torted ovary and an inflamed appendix both get worse over hours; a ruptured functional cyst typically peaks quickly and then settles.
  • The negative pregnancy test does the heavy lifting: it removes ectopic pregnancy, which is the only diagnosis on this list that would demand same-day imaging in a woman who is otherwise well.
  • Rupture and mittelschmerz sit on one spectrum: both are the physiological consequence of ovulation; the label depends on how much fluid or blood escapes and how much peritoneal irritation it causes.
  • Most need nothing but analgesia: the minority that bleed significantly – usually a haemorrhagic corpus luteum – declare themselves through worsening pain and cardiovascular signs.
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The Follicle That Bursts: Mid-Cycle Pain That Peaks Early and Fades

Every ovulatory cycle ends with a follicle rupturing and releasing a small volume of follicular fluid, sometimes with a little blood, into the peritoneal cavity. In most women this passes unnoticed; in some it produces a sharp, well-localised, unilateral pain that arrives abruptly, is worst in the first minutes to hours and then fades. Because the follicle can also persist and enlarge into a functional cyst before it ruptures, the clinical picture ranges from a few hours of grumbling discomfort to a dramatic sudden pain that brings a woman to the surgery convinced something has burst – which, accurately, it has.

Why This Is the Right Move

The pattern in this stem is close to textbook. Sudden onset localises the event in time, which points to rupture or torsion rather than to an inflammatory process that builds. Mid-cycle timing points to the ovary. The fact that the pain is already easing points away from torsion, where an ischaemic ovary produces relentless, escalating pain with vomiting, and away from appendicitis, where the pain migrates, intensifies and is joined by anorexia and fever. She is afebrile, systemically well, has only mild localised tenderness and no peritonism – all consistent with a small volume of peritoneal irritant that is being absorbed.

The negative urinary pregnancy test is the other half of the reasoning. Without it, the same presentation would be a possible ectopic pregnancy and would need an early pregnancy assessment service scan the same week; with it, ectopic pregnancy is excluded and the remaining differential contains nothing that mandates urgent imaging in a well woman. RCOG Green-top Guideline No. 62 reminds clinicians that when an ovarian cyst presents acutely with pain, the “accidents” to consider are torsion, rupture and haemorrhage – although the guideline itself explicitly excludes the acute presentation from its scope, which is why there is no single UK national guideline that tells you how to manage a ruptured functional cyst. In practice, management is analgesia, explanation and safety-netting, with a scan arranged if the pain persists or a mass is felt.

Why the Other Options Don’t Fit

  • Option A – Acute appendicitis: appendicitis does not start suddenly at maximal intensity and then improve. The expected story is 12 to 24 hours of poorly localised central pain that migrates to the right iliac fossa and worsens, with anorexia, nausea and a low-grade fever – none of which is present here.
  • Option B – Ectopic pregnancy: excluded by the negative urinary pregnancy test. Modern urine hCG assays are highly sensitive, and a negative test in a woman with pain is the standard way UK early pregnancy services exclude an ectopic. Without that test, this option would be the one to fear.
  • Option C – Ovarian torsion: torsion produces severe, often colicky pain that persists or escalates, characteristically with repeated vomiting, and usually a tender adnexal mass. Pain that is settling within hours, in a woman who is systemically well with only mild tenderness, argues strongly against an ischaemic ovary.
  • Option D – Pelvic inflammatory disease: PID is an infection, not an event: BASHH describes bilateral lower abdominal pain of recent onset over days, with abnormal discharge, deep dyspareunia, adnexal tenderness and cervical motion tenderness, and fever in moderate to severe disease. A sudden unilateral mid-cycle pain with no discharge and no cervical excitation does not fit.

“Red Flags” and Key Decision Points

  • Pain that worsens rather than settles: reconsider torsion, a bleeding corpus luteum or appendicitis and arrange same-day assessment.
  • Pallor, tachycardia, syncope or shoulder-tip pain: these point to haemoperitoneum and need emergency admission, not review.
  • A palpable adnexal mass: arrange a pelvic ultrasound rather than assuming a simple functional cyst has ruptured.
  • Any doubt about the pregnancy test: repeat it, particularly if conception could have occurred within the previous two weeks.

Relevance to Primary Care

The GP’s job here is to make a positive diagnosis rather than a diagnosis of exclusion by default. Take the cycle history properly – the date of the last period, the usual cycle length and where in the cycle the pain fell – because that single question converts a vague “abdominal pain” into a recognisable pattern. Explain the mechanism to the woman: something normal happened, a little fluid escaped, the lining of the abdomen does not like it, and it will settle. Offer paracetamol and an anti-inflammatory if she can take one, and give explicit return advice. Recurrent, predictable, troublesome mid-cycle pain in a woman who wants it to stop can be abolished by suppressing ovulation with combined hormonal contraception, which is a neat and often-forgotten therapeutic option in primary care.

Founder’s Tip

Sudden, one-sided, mid-cycle and already improving is the ovary behaving badly rather than the ovary in danger – but say out loud what would change your mind, because the same story that is settling at noon can be a haemoperitoneum by teatime.

Core Summary: Sudden-onset unilateral mid-cycle pelvic pain that is already easing in a systemically well, afebrile, haemodynamically stable woman with a negative urinary pregnancy test is a ruptured functional ovarian cyst, managed with analgesia, explanation and explicit safety-netting rather than urgent imaging, with escalation only if the pain worsens or cardiovascular signs appear.

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Quick answers about the DRCOG

Checked against the RCOG's own pages on 16 October 2026.

When is the next DRCOG exam?

Saturday 3 April 2027. Submit the expression of interest by Wednesday 16 December 2026. Booking then runs from Thursday 21 January to Thursday 4 March 2027. The sitting after that is on Saturday 2 October 2027.

How much does the DRCOG cost?

£578 including VAT at UK test centres and £482 in the Republic of Ireland. The fee follows the centre where you sit, not where you live.

What is the DRCOG exam format?

One computer-based exam of 120 single-best-answer questions in three hours, each worth two marks. You sit it in person at a Pearson VUE test centre in the UK or the Republic of Ireland.

Who can sit the DRCOG?

Doctors with full, limited or provisional registration with the GMC or the Medical Council of Ireland. No course or portfolio is needed.

What is the DRCOG pass mark?

There is no fixed pass mark. A panel sets it for each sitting by a modified Angoff method, against the standard of a competent GP trainee. There is no quota.

How many attempts do I get at the DRCOG?

Five. The RCOG regulations say no candidate may attempt the DRCOG more than five times.

What do I get with Core Revision's DRCOG access?

850 single-best-answer questions across the seven RCOG modules, a timed mock of 120 questions in three hours and the twelve-chapter revision guide. You also get Core Tools, the Core 10 and the Core Calendar. Access is £49.99 for 12 months as a one-off payment. You can try ten questions free first.

Our free guides to the DRCOG

Dates, fees, format and revision plans, checked against the college’s own pages. Newest first. Still choosing a diploma? Compare all eight side by side.