Obstetrics MCQ

Amanda Leow
AFP NHS Lothian
20 Jan 2021
Question 1: • Rachel is a 21 yo female who is
15 weeks pregnant. She is very
nauseous and has been
vomiting. She comes in today
because of 3 days history of
heavy vaginal bleeding.
• On examination, she looked
unwell. SFH 21cm.
• Beta HCG 100,000 IU/L (high)
• Ultrasound: snowstorm
appearance, fetal parts seen
• What is the diagnosis?
Molar pregnancy
• Symptoms • Investigations
• Irregular vaginal bleeding • HCG very high
• G&S
• Hyperemesis, headache, photophobia
• Pelvic US (snowstorm appearance
• Tachycardia, SOB with or without fetal parts)
• Large for gestational age uterus • Histopathology of biopsy
• Early miscarriage
• Hyperthyroidism- HCG mimics TSH
• RF
• Extremes of age
• Previous GTD
Molar pregnancies
• Complete molar 46 xx or 46xy
• Abnormal diploid
• Empty egg is fertilised by a single sperm, then duplicate, hence all 46
chromosomes are paternal origin
• No fetal part
• Partial molar 69 xxx or 69 xxy
• normal haploid egg fertilised by two sperms, or by one sperm with
duplication of paternal chromosomes.
• DNA both maternal and paternal, usually triploids.
• Fetal parts may be seen.
Molar pregnancies
• Gestational trophoblastic neoplasia (GTN)
• after molar pregnancy removed and treatment with methotrexate, persistent
tissue is left in uterus
• Persistent Gestational Trophoblast Disease (GTD)-> GTN
• 20% risk after GTD
• Choriocarcinoma
• 1:50,000 in UK
• Malignant trophoblast
• Miscarriage (vaginal bleeding, but unlikely to have snowstorm
ultrasound appearance, headache and nausea)
How to treat molar pregnancy?
• Suction removal
• Viable twin- expectant management/ elective termination
• Ongoing management- prophylactic methotrexate + folic acid
• Follow up HCG (usually becomes normal in 3 months)
• Choriocarcinoma (invasive mole) may require hysterectomy
• When can patient conceive again after completing MTX? 1 year after
• What is the risk of GTD in future pregnancy? (1%, x10 more than
baseline risk)
Question 2
• Holly is a 28yo female who is 20 weeks pregnant
• Today, she presents with profuse vaginal bleeding, crampy abdominal
pain
• BP 100/700 HR 114 RR 24
• Vaginal examination: product of conception in cervical os
• Abdominal ultrasound: fetal tissue seen
• What type of miscarriage does she have?
Miscarriage
• Miscarriage <24 weeks pregnant, typically occurs at 6-9 weeks
• Threatened miscarriage- vaginal bleeding, pregnancy may continue
• Inevitable miscarriage- open cervical os, heavy clots, crampy abdominal pain, lead to
incomplete or complete miscarriage
• Incomplete miscarriage- tissue partially expelled, cervical os open
• Complete miscarriage- completely expelled, cervical os closed
• Missed miscarriage- miscarriage was asymptomatic, may be incidental finding in
early pregnancy, dead fetus still in womb without symptoms of expulsion or pain.
When gestational sac >25mm and no fetal part is seen, it is ‘anembryonic pregnancy’.
• Recurrent miscarriage- x3 miscarriages due to antiphospholipid syndrome.
Anticardiolipin antibiodies.
Question 3- same patient
• Holly is a 28yo female who is 20 weeks pregnant
• Today, she presents with profuse vaginal bleeding, crampy
abdominal pain
• BP 100/700 HR 114 RR 24
• Vaginal examination: product of conception in cervical os
• Abdominal ultrasound: fetal tissue seen
• How would you manage her miscarriage?
Management for miscarriages
A. Paracetamol QDS and anti-D immunoglobulin (for all miscarriage, including
threatened miscarriage or complete miscarriage)
B. Manual evacuation using forceps to remove tissue (inevitable or incomplete
miscarriage; also because she has tachycardia, hypotensive, etc because of
production of concept stuck at cervix)
C. Conservative management and follow up in 2 weeks (missed miscarriage-
pregnancy tissue not visualised on US scan)
D. Medical evacuation with misoprostol (incomplete miscarriage, requires follow
up in 2 weeks)
E. Suction evacuation (incomplete miscarriage)
Question 4
Mrs A is a 27 year old who is 28 weeks pregnant. She had 3 previous
caesarean sections. She has been experiencing painless vaginal
bleeding for the past 3 days. She is not experiencing any uterine
contractions. Uterine Doppler US revealed a low-lying placenta where
chorionic villi is attached to decidua basalis and did not invade
myometrium.
What is the most likely diagnosis?
What is your diagnosis?
A. Placenta praevia (chorionic villi attach to
decidua basalis. RF previous 3 CS)
B. Placenta accreta (chorionic villi attach to
myometrium)
C. Placenta increta (chronic villi invade
myometrium)
D. Placenta percreta (chorionic villi invade
myometrium and attach adjoining tissue)
E. Vasa praevia (Fetal vessels lie over cervical
os)
Question 5- same patient
• What is your management plan?
SAME patient (28 weeks gestation, placenta praevia with painless vaginal bleed.
Haemodynamically stable)
A. Resuscitation and stabilisation
B. Administer tranexamic acid
C. Emergency CS
D. Tocolytics + anti-D immunoglobulin
E. Monitor, corticosteroids, REPEAT US and consider future CS if patient deteriorates  
Placenta praevia management

A. Resuscitation and stabilisation (Acute, large bleed, hypotensive, high NEWS)

B. Administer tranexamic acid (major haemorrhage: blood transfusion + FFP +
platelets)
C. Emergency CS (Haemodynamically unstable and if not stabilised by resus)
D. Tocolytics + anti-D immunoglobulin (Treatment for preterm labour and rhesus –ve
patient)
E. Monitor, corticosteroids, REPEAT Ultrasound and consider future CS if patient
deteriorates (Low lying placenta may resolve in some patients nearer to term, but
given that she had 3 previous CS, this is unlikely and she is likely to have repeat CS.)
Question 6- same patient
During admission, she reported severe abdominal pain and lower back
pain. She suddenly became unconscious and hypotensive BP 100/60.
Examination revealed a ‘WOODY’ uterus and a large pool of blood.

VSAQ: What is your diagnosis?

Placenta abruption
• Px: haemodynamically unstable, woody uterus
• Plan:
• Activate major haemorrhage protocol
• RESUS and urgent CS, blood transfusion, FFP
• Uterotonics- oxytocin post-placental delivery
• May require hysterectomy
Question 7
Anna is a 24 yo female. She has severe
abdominal pain, N&V, headache, shoulder
tip pain. LMP was 8 weeks ago. Uses condom
as contraceptive. PMH: Chlamydia 2 years
ago.

Pregnancy test +ve

Pelvic US no intrauterine pregnancy

What is the surgery removing?

Ectopic pregnancy
• Symptoms
• Nausea and vomiting
• Abdominal pain
• Shoulder tip pain
• Headache
• RF
• Previous ectopic, previous PID, IUD use
• Examination
• Cervical excitation
• Diagnostic test
• Transvaginal ultrasound is gold standard
• Serial HCG measurement >1500 (If >50% fall each day- resolving ectopic pregnancy or miscarriage)
• Management
• Expectant, medical or surgical
Question 8
• Her day 1 beta-HCG was 1500 IU/L. On day 3, her serum HCG was
2000 IU/L (serum HCG increase of <50%). TVS revealed tubal ectopic
pregnancy. Her BP is now 90/60, HR 110, RR 28.
• What would you do next?
A. Expectant management- ectopic will resolve on its own
B. Methotrexate
C. Surgical management
D. Fluid resuscitation
What would you do next?
A. Expectant management (Asymptomatic and haemodynamically stable, size
<35mm, unruptured, no fetal heartbeat, HCG<1000, decreasing HCG, willing to
comply with follow up)
B. Methotrexate (Clinically stable, <35mm, no significant pain, no fetal heartbeat,
HCG <1500 IU/L, not suitable if there is intrauterine pregnancy. Monitor HCG
for 2-4 weeks, up to 8 weeks)
C. Surgical (Size >35mm, can be ruptured ectopic, pain (symptomatic), visible fetal
heartbeat, Serum HCG >5000 IU/L, MTX contraindicated, if there is another
intrauterine pregnancy)
D. Fluid resuscitation (Her BP is now 90/60, HR 110, RR 28. Give fluid first followed
by laparoscopic salpingectomy)
Question 9: what are the normal values of a
cardiotocograph?
Baseline heart rate Variability Acceleration
A 110–160 0–4 >15 bpm for 15 seconds
B 110–160 >5 >15 bpm for 15 seconds
C 130–180 0–4 >30 bpm for 10 seconds
D 130–180 >5 >30 bpm for 10 seconds
E >160 0–4 >15 bpm for 15 seconds
Question 10
Ms A is a 27 year old primigravida who is 38 weeks gestation. She reported reduced
fetal movement today. She was admitted and CTG was performed as below.
What does the CTG show?
A. Lack of variability
B. Early deceleration
C. Late deceleration
D. Prolonged deceleration
E. Sinusoidal pattern
Ms A is a 27 year old primigravida who
is 38 weeks gestation. She reported
reduced fetal movement today. She was
admitted and CTG was performed as
below.
What does the CTG show?
A. Lack of variability
B. Early deceleration
C. Late deceleration
D. Prolonged deceleration
(Immediately inform consultant
O&G. Emergency CS)
E. Sinusoidal pattern
Question 11
Inspection of vagina shows that the cord has descended into the
vagina. What should you do next?
A. Push the cord up
B. Encourage patient to lie flat
C. Push up the presenting part by finger
D. Induce labour
E. Give oxytocin
Inspection of vagina shows that the cord has descended into the vagina. What
should you do next?
A. Push the cord up (DO NOT HANDLE CORD)
B. Encourage patient to lie flat (Ask patient to lie on left lateral position or knee to
chest)
C. Push up the presenting part by finger or retrofill the bladder (correct. Push
presenting part whilst call for help-> Prompt CS)
D. Induce labour (Prompt CS required, inform neonatal team to prepare for resus)
E. Give oxytocin (Used for PPH. If labour induction- stop oxytocin)
Is this CTG normal?
• DR C BRAVADO
• Determine risk
• Contraction: 2 in 10
minutes
• Baseline rate 120
bpm (normal 110-
160 bpm)
• Variability >5 bpm
(normal 5-25 bpm)
• Acceleration >15bpm
in 15 seconds
• Deceleration (none)
• Overall assessment
Cardio=heart, toco=uterine contraction

• CTG records fetal heart rate (Fetal scalp electrode) and uterine contraction
(pressure monitor)

Causes of abnormal CTG:

• Tachy: prematurity, acidosis, maternal pyrexia, beta-agonist (hypotension->
increase HR)
• Brady: maternal hypotension, fetal acidosis, placenta abruption, uterine rupture
(reduced HR and cardiac output)
• Loss of variability: fetal sleeping (normal up to 40 mins), premature, fetal acidosis,
sedatives (opioids, benzo)
• Late, variable or prolonged deceleration: fetal hypoxia or cord compression
Reduced Variable
variability decelerations

Early decelerations Late decelerations

Prolonged deceleration

Sinusoidal
Classification Baseline HR Variability Acceleration Deceleration
Reassuring 110-160 >=5 Present None
Non-reassuring 100-109 <5 for >=40, Absence - Early deceleration
161-180 but <90 mins - Variable deceleration
- Single prolonged
deceleration up to 3
mins
Abnormal <100 or >180 <5 for for Absence - Prolonged
>=90 mins decelerations >3 mins
- Bradycardia >3 mins

• Normal- all 4 features present (baseline HR, variability, acceleration, deceleration)

• Conservative management- le Suspicious- 1 of 4 features non-reassuring.
• Tx lateral position, fluids (oral or IV), stop oxytocin if being induced
• Pathological- >=2 features non-reassuring, or >=1 feature abnormal
• Mx Fetal scalp sample and deliver as appropriate.
Question 12
Mrs A is a 37 year old lady (G3 P2) who is 38 weeks gestation. She had previous pre-
eclampsia and presented with uterine contraction and vaginal examination revealed
cervical dilatation 3.5 cm and stained meconium liquor. Her CTG presents as below:

• RF: previous pre-eclampsia

• Baseline fetal HR 105
• Variability <5 for 90 mins
• Acceleration Present
• Deceleration Early deceleration only

How would you clarify her CTG?

Abnormal CTG
• Variability <5 in 90 mins
• Fetal blood sampling and deliver as appropriate (two or more non-
reassuring trace, or one abnormal trace)
• Inform consultant O&G (if any abnormal CTG trace)
• Expedite birth if FBS cannot be obtained and no accelerations are
seen as a result of scalp stimulation.
• Remember the 'Rule of 3' for fetal bradycardia:
• 3 minutes – call for help (abnormal CTG)
• 6 minutes – move to theatre
• 9 minutes – prepare for assisted delivery
• 12 minutes – aim to deliver the baby.
Fetal scalp sampling

What should you do next?

pH <7.2 Deliver!
FBS result (pH) Interpretation
Normal FBS result. Repeat after 1 hour if CTG
≥7.25
remains the same
Borderline FBS result. Repeat after 30
7.21–7.24
minutes
≤7.20 Abnormal FBS result. Consider delivery
BREAK TIME 
Question 13: name the forcep

A.Wrigley’s forcep
B. Neville Barnes
C. Simpsons
D.Kielland's forceps
1. Wrigley’s forcep (outlet
forcep), also used in
Caesarean section to lift
out fetus
2. Neville Barnes, Andersons,
Simpsons (low or mid
cavity forceps)
• When fetal head 1/5th
palpable
• Rotation <45 degrees
3. Rotational forceps, e.g.
Kielland's forceps
• Note the hand holder is
different
• Rotation >45 degrees
Question 14:Which of the following is NOT a pre-
requisite for forcep delivery?

A. Full dilatation
B. Ruptured membrane
C. Station below spine
D. Face presentation
E. Known position of head
Answer: D. Face presentation is
contraindicated
F- Full dilatation
O- O/5 or 1/5 palpable
R- Ruptured membrane
C- Contractions adequate, Consent
E- Empty bladder
P- Presentation and position known
S- Station (spines below)
Satisfactory analgesia
Ms X is a 26 year old primiparous who Question 15
is 35 weeks gestation. During her Which of the following would you
antenatal appointment today, she administer for her hypertension?
mentioned she had been having A. Labetolol IV
headache with some visual B. Labetolol oral
disturbances and abdominal pain for C. Nifedipine
past 2 days. FHx of pre-eclampsia.
D. Methyldopa
She has a PMH of asthma E. Hydralazine
 
On examination, both legs
oedematous. BP 150/95. BMI 25.

Urinalysis 1g protein in 24 hours

(<0.3g)
Preterm labour
• No effective management
• Cervical cerclage can be considered in high-risk women (not in labour)
• Progesterone not shown to have benefit
• Cervical dilatation >=2cm and Fibronectin +ve
• Corticosteroid for lung maturation
• Magnesium sulphate (neuroprotection)
• In utero transfer to neonatal facilities if <32 weeks
• Tocolysis (but tocolysis not established as long term effective- does not alter
mortality or survival but shown to help delay labour by a few hours)
C. Nifedipine
• Admit for hospital monitoring (CTG, Doppler) and start anti-hypertensives
• NICE guideline:
• Offer labetalol to treat hypertension in pregnant women with pre-eclampsia.
• Offer nifedipine for women in whom labetalol is not suitable, and methyldopa if labetalol or nifedipine are not suitable.
• Give magnesium sulphate (seizure PPHx)
• Corticosteroids for fetal lung maturation
• Delivery
• <34 weeks- prolong pregnancy is beneficial for fetus
• 34-36 weeks- case by case decision
• 37 weeks- deliver

• Severe pre-eclampsia BP>160/110

• IV labetalol
• Consider delivery
Important
• What are the pitfalls in pre-eclampsia?
 Hypertension can be absent: beware of proteinuria
• BP and urinalysis (every antenatal appointment!) for all women
• Those at high-risk of developing pre-eclampsia (e.g. GDM)
• Aspirin 75mg after 12 weeks
Question 16- same patient

On admission, the lady became more breathless and What is her diagnosis?
had worsening RUQ abdo pain, N&V. She had dark
A. Eclampsia
urine. On examination, she had brisk tendon reflexes.
  B. HELLP
Repeat blood samples: C. Acute fatty liver of
Hb 70 Platelet 50 x 10^9/L pregnancy
Bilirubin >20 mg/dL (1.2) AST 250 IU/L (70)
LDH 1200 IU/L (600)
D. Obstetric cholestasis
PT/PTT prolonged E. Gestational hypertension
Fibrinogen 2 micromol/L (<2.94)
Low haptoglobin
Blood film: schistocytes
Question 17- same patient
She is currently on IV labetolol, magnesium sulphate, and given
corticosteroids. What would you do next? You can select more than one
answer.

A. Immediately deliver with induction of labour

B. Immediately deliver with caesarean section
C. Monitor with CTG
D. Blood+ platelet+ FFP transfusion + anti-D immunoglobulin
HELLP
• A-E
• Immediately deliver, blood transfusion, anti-D immunoglobulin
• Presentation
• Haemolysis- dark urine
• Elevated liver enzyme- abnormal clotting, RUQ pain, N&V, malaise (liver)
• Low platelet- easy bleeding
• Hypertension and proteinuria (due to pre-eclampsia)
• Breathlessness (pulmonary oedema)
• Severe cases- placenta abruption, AKI, fetal death
• Ix
• Haemolysis, low platelet, abnormal LFT
• Coombs +ve, low haptoglobin, blood film schistocytes
Question 18
A 25 year old primigravida presents at 32 weeks What is her diagnosis?
gestation. She is unwell, has abdominal pain and A. HELLP
vomiting for the past 3 days, and feeling malaise
B. Obstetric cholestasis
for a week. She looks jaundiced.
C. Acute fatty liver of pregnancy
 
Bilirubin 62 µmol/l (14)
D. Pre-eclampsia
BP is 149/90 ALP 640 u/l (40-70) E. Eclampsia
Abdo exam RUQ tenderness. ALT 196 u/l
γGT 185 u/l
  Albumin 24 g/l
INR 3.2
PT 30s (14s)
APTT 50s (30s)
Glucose 3 mmol/l (<4)
Differentials of abnormal LFT
• HELLP (abdo pain, N&V, bleeding, haemolysis, schistocytes on blood
film)
• Obstetric cholestasis (itch is main symptom)
• Acute fatty liver of pregnancy (unwell and have liver and renal
impairment)
• Pre-eclampsia (has proteinuria, hypertension can cause end organ
damage)
• Eclampsia (has hypertension and seizure)
Acute fatty liver of pregnancy
• Symptoms
• Abdominal pain ± N&V (abnormal LFT)
• Jaundice
• Lethargy
• Encephalopathy
• Hypoglycaemia (liver failure)
• Ix
• FBC, U+E, LFT
• Urinalysis, ACR, PCR
• Clotting screen (INR, PT/PTT)
• Blood glucose (hypoglycaemia due to liver failure)
• BP
• Mx
• PROMPT delivery despite gestational age
• Beware of coagulopathy and hypoglycaemia
Annie is a 40 year old (G2 P1) who is 30 weeks gestation who came to
your clinic today because she has been feeling very itchy for the past
week. She does not drink or smoke. She has PMH of hepatitis C.
On examination, she looks slightly jaundiced, she is still itching but has
no rash. She has abnormal LFTs.

Question 19: What would you like to investigate next?

Question 20: How would you treat her severe itch?

Obstetric cholestasis
• 1st Ix: Bile Acids (impaired bile flow, bile accumulates in placenta and
skin)
• Tx
• Mild itch- antihistamine, cholestyramine
• Severe itch- ursodeoxycholic acid
• Monitor LFT weekly
• If worsening LFT, deliver preterm. Increased risk of stillbirth.

• Postnatal
• After 6 weeks, re-check LFT
Question 21: Spot diagnosis
Polymorphic eruption of pregnancy

• Self-limiting and benign rash, first appear in abdo striae

• Pruritus, usually associated with last trimester
• Umbilical sparing
• Normal LFT
• Symptom relief- emollient, topical steroids, antihistamine
• Differential diagnosis: pemphigoid gestationitis
• Pruritic, blistering lesions
• Periumbilical and spread to trunk, back, buttocks, arms
• 2nd and 3rd trimester
• Tx oral corticosteroids
Question 22
Mrs A is currently 24 weeks pregnancy and has SFH of 30 cm. She has
been feeling thirsty and needing to use the toilet more often. Her BMI
is 30. She has had previous GDM.

Fasting plasma glucose 8 mmol/L (<5.1)

2h plasma glucose 15 mmol/L (<8.5)

How would you treat her gestational diabetes?

Diagnosis of GDM
• GDM usually diagnosed at 24-28 weeks gestation
• SIGN guideline recommends 2h OGTT at 24-28 weeks gestation
• Fasting plasma glucose 5.1 mmol/L
• 2-hour plasma glucose 8.5 mmol/L following a 75 g oral glucose load
• OGTT at booking if previous GDM
• BMI>30, previous GDM, previous macrosomia, PCOS, maternal age>40
• HbA1c at booking if high risk diabetes
• If the level is <42, do OGTT at 28 weeks
• If level >42-47 do an OGTT. If abnormal, refer to diabetic clinic. 
• If level >48, patient has pre-existing diabetes. Refer to diabetic clinic.
Pregnancy and diabetes
• Diabetes is diagnosed in pregnancy if either
• Fasting glucose >=5.6 mmol/l
• 2 hour glucose >= 7.8 mmol/l
• If fasting glucose <7 mmol/l trial of diet + exercise should be offered
• If glucose targets not met in 2 weeks, metformin should be started
• If glucose targets still not met, insulin should be added
• If time of diagnosis fasting glucose >7 mmol/l, insulin should be started
• If plasma glucose at diagnosis is between 6-6.9 mmol/l, and there is evidence of
macrosomnias or hydramnios, insulin should be offered
• Glibenclamide (oral hypoglycaemic) should only be offered for those who fail to
meet their glucose targets with metformin, but decline insulin treatment
• SIGN guideline for GDM on when to add metformin/ oral glucose
lowering tx (e.g. glibencamide)
• ≥5.5 mmol/l preprandial, or ≥7 mmol/l two hours postprandial on monitoring at
≤35 weeks
• ≥5.5 mmol/l preprandial or ≥8 mmol/l two hours postprandial on monitoring at
>35 weeks, or
• any postprandial values are >9 mmol/l.
• Do not give Sulphonylurea! Neonatal hypoglycaemia!
• Postnatal
• Postnatal testing for diabetes or IGT at 6 weeks after delivery
• Annual HbA1c testing for diabetes
Management of pre-existing diabetes
• Weight loss for women with BMI >27 kg/m2
• Stop oral hypoglycaemia, apart of metformin, commence insulin
• Folic acid 5mg/ day from pre-conception to 12 weeks gestation
• Aspirin 75mg/ day from 12 weeks until day of birth to reduce risk of pre-eclampsia
• Detailed anomaly scan at 20 weeks including four-chamber view of heart and outflow
tracts
• Tight glycaemic control reduces complication rates
• Treat retinopathy as can worsen during pregnancy

What is the HbA1C target for diabetic pregnant women?

• <53 mmol/mol (<7%) to reduce risk of congenital malformation (SIGN guideline)
Pregnancy and thyroid disease
• Hypothyroid
• Increased levothyroxine 25-50 microgram once pregnancy is confirmed (fetal
mental and motor development)
• Newly diagnosed hypothyroid: start 100 microgram T4 daily
• Check TFT every 4-6 weeks during pregnancy
• After pregnancy, return to pre-pregnancy dose
• Breastfeeding is safe whilst taking levothyroxine
Pregnancy and thyroid disease
• Hyperthyroidism, Grave’s disease
• TRAB+ve; TSH receptor antibodies
• Propylthiouracil – first line for pregnancy women. Small risk of liver problems,
itching, yellowing of eyes.
• Radioactive iodine- first line for Graves but cannot give if active eye disease/
pregnancy/ cannot have children contact for 3 weeks. Avoid pregnancy 6
months after treatment.
• Carbimazole- oral treatment for non-pregnant. Risk of agranulocytosis, rash,
sore throat, fever. Folate antagonist.
• Beta blocker- suitable for symptomatic management. Labetalol licensed for
pregnancy.
• Thyroidectomy- if proprylthiouracil inffective or not tolerated
Pregnancy and thyroid disease
• Postpartum thyroiditis
• 2-6 months post-delivery
• Hypertyroid-> transient hypothyroid
• Symptoms: depression, anxiety, tiredness
• Differentials: Graves (TRAB), Hashimoto (TPO)
• Refer to endocrine specialist
• Check TFT 4-8 weeks after thyrotoxic phase, screen for hypothyroid phase
• Annual TFT after resolution of PPT