SelfAssessmentin

Obstetricsand
Gynaecology:
Prepareforthe
MRCOG

KeyarticlesfromtheObstetrics,
Gynaecology&Reproductive
Medicinejournal

EditorinChief
PhilipNBakerFRCOG,FMedSci

DirectorNationalResearchCentreforGrowth&Development,ConsultantObstetrician
and

SeniorScientist,ProfessorofMaternalandFetalHealth,TheUniversityofAuckland,New
Zealand
OGRMjournalSpecialtyEditorsforthisebook
AlecMcEwanBABMBChMDMRCOG

ConsultantinFetalandMaternalMedicine,DepartmentofObstetricsandGynaecology,

QueensMedicalCentre,Nottingham,UK

CatherineAikenMB/BChirMAPhDMRCPMRCOG

SpecialistRegistrar(ST5)andAcademicClinicalLecturerinObstetricsandGynaecology,

AddenbrookesHospital,Cambridge,UK

EdinburghLondonNewYorkOxfordPhiladelphiaStLouisSydneyToronto2016

2016ElsevierLtd.Allrightsreserved.

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Thisbookandtheindividualcontributionscontainedinitareprotectedundercopyrightbythe
publisher(otherthanasmaybenotedherein).

Firstedition2016

FirstpublishedinObstetrics,Gynaecology&ReproductiveMedicine:20122015

ISBN9780702068782

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Notices

Knowledgeandbestpracticeinthisfieldareconstantlychanging.Asnewresearchandexperiencebroaden
ourunderstanding,changesinresearchmethods,professionalpractices,ormedicaltreatmentmaybecome
necessary.

Practitionersandresearchersmustalwaysrelyontheirownexperienceandknowledgeinevaluatingandusing
anyinformation,methods,compounds,orexperimentsdescribedherein.Inusingsuchinformationor
methodstheyshouldbemindfuloftheirownsafetyandthesafetyofothers,includingpartiesforwhomthey
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Withrespecttoanydrugorpharmaceuticalproductsidentified,readersareadvisedtocheckthemostcurrent
informationprovided(i)onproceduresfeaturedor(ii)bythemanufacturerofeachproducttobe
administered,toverifytherecommendeddoseorformula,themethodanddurationofadministration,and
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andtotakeallappropriatesafetyprecautions.
Tothefullestextentofthelaw,neitherthepublishernortheauthors,contributors,oreditors,assumeany
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ContentStrategist:PaulineGraham

ContentDevelopmentSpecialist:KimBenson

Designer:MilesHitchen


Preface
TheObstetrics,GynaecologyandReproductiveMedicinejournal(Elsevier;www.obstetrics
gynaecologyjournal.com/),broadlyspeaking,coversallthefascinatingandevolvingelementsof
womenshealthcareovera3yearcycle.Itisaimedatbothtraineestakingpostgraduatemedical
examinations,andestablishedspecialistsseekingtokeepuptodate.Eachmonthlyissuehas
containedaseriesofselfassessmentquestions,basedonthearticleswithinthatissue,tohelpthe
readerdevelopadeeperunderstandingofthesubjectstherein.Thesequestionshavealsobeen
invaluableaidsforpostgraduateexaminationpreparation.Manyofthequestionsweresubmitted
bytheauthorsofthearticles,butatleasthalfwerewrittenbytheeditorialteam,principallyAlec
McEwan.WearedelightedtowelcomeDrCatherineAikenasthetraineeeditoronthejournal.She
has,already,helpedtomodernisetheselfassessmentquestions,whichhavebeenmovingfrom
shortanswerandmultiplechoicequestionstoextendedmatchingandsinglebestanswerquestion
formats,inlinewiththeevolutionofpostgraduateexaminationsworldwide.

ThiseBookcontainsthemajorityoftheselfassessmentquestionsfromtheissuespublished
between2012and2015.Theeditorialteamhavereviewedthemtoensurethattheanswersremain
valid,andmanyofthemultiplechoicequestionshavebeenadaptedtosinglebestanswers.The
bookisdividedintoGynaecologyandObstetrics,andwithineachspecialty,thequestionsare
groupedintosubspecialtyareas,toaidwithrevisionandimprovefocus.Withineachsection,the
singlebestanswerquestionscomefirst,followedbytheextendedmatchingquestionsandfinally
themultiplechoicequestions;therearedetailedanswerstoeachquestionalso.

WehopeyoufindthiseBookusefulandenjoyable,andthatitprovidesyouwithsomelightrelief
fromtheoverwhelmingsourcesofinformationyouwillundoubtedlybeusingtohelpyouprepare
forexaminationsinthishugelydiverseandrewardingfieldofmedicine.

AlecMcEwanandCatherineAiken

Obstetrics: Prepare for the MRCOG and Gynaecology: Prepare for the MRCOG are also available.

Obstetrics, Gynaecology and Reproductive Medicine Editors

EditorinChief
PhilipNBakerFRCOG,FMedSci

DirectorNationalResearchCentreforGrowth&Development,ConsultantObstetrician
and

SeniorScientist,ProfessorofMaternalandFetalHealth,TheUniversityofAuckland,New
Zealand
Deputy EditorinChief
AlecMcEwanBABMBChMDMRCOG

ConsultantinFetalandMaternalMedicine,DepartmentofObstetricsandGynaecology,

QueensMedicalCentre,Nottingham,UK

Associate Editors
SabaratnamArulkumaranMBBSMDPhDFRCS(Ed)FRCOG

ProfessorofObstetricsandGynaecology,

DepartmentofObstetricsandGynaecology,

St.GeorgesHospitalMedicalSchool,London,UK

ShreelataDattaBSc(Hons)MBBSMRCOGLLM

ConsultantObstetricianandGynaecologist,

KingsCollegeHospital,London,UK

TahirAMahmoodMDFRCOGFRCPIMBAFACOG(Hon)

ConsultantObstetricianandGynaecologist,

VictoriaHospital,Kirkcaldy,Fife,UK

FionaReidMDMRCOG

ConsultantUrogynaecologist,

StMarysHospital,Manchester,UK

MahmoodIShafiMBBChMDDAFRCOG

ConsultantGynaecologicalSurgeonandOncologist,

AddenbrookesHospital,Cambridge,UK
Trainee Editor
CatherineAikenMB/BChirMAPhDMRCPMRCOG

SpecialistRegistrar(ST5)andAcademicClinicalLecturerinObstetricsandGynaecology,

AddenbrookesHospital,Cambridge,UK

Gynaecology
Benign Gynaecology

SBAs
Question1

A36yearoldnulliparouswomanpresentswithabnormaluterinebleedingof2yearsduration.On
questioning,hercycleisregular,9/30days,andshedescribespassinglargeclotsandflooding
throughontoherclothes.

Choosethesinglebestanswerfromthelistbelowtodescribehersymptoms:

A) Heavymenstrualbleeding
B) Menorrhagia
C) Prolonged,heavymenstrualbleeding
D) Prolongedmenstrualbleeding
E) Irregularheavymenstrualbleeding

Question2

A47yearold,recentlyremarried,womanpresentswitha2yearhistoryofmenstrualirregularity
andhotflushes.Shebleedsevery14to40days,andthebleedingcansometimeslastaslongas2
weeks.Sheisotherwisewell,takesnomedicationandisasmoker.Arecentcervicalsmearwas
normal.Atransvaginalultrasoundscanshowsa10cmuteruswithtwosmallintramuralfibroidsand
anendometriumof18mmthickness.Apipellebiopsyshowsnoatypiaormalignantchange.

Ofthetherapeuticoptionsbelow,whichwouldyouadvise?

A) CyclicalHRT
B) Combinedoralcontraceptivepill
C) Endometrialablation
D) LevonorgestrelIUSwithtransdermaloestrogen
E) Tranexamicacidwithcyclicalprogestogens

Question3

A48yearoldwomanwithaBMIof24andnopersonalorfamilyhistoryofnotecomestoseeyouto
seekouttreatmentforseverehotflusheswhichareseriouslyinterferingwithhersleep.Shehas
heavyandirregularperiodsandalsocomplainsofsomediscomfortduringsexualintercourse.

Whichofthefollowingtreatmentoptionswouldbemostappropriateforthiswoman?

A) Tibolone
B) Vaginaloestrogen
 C) Mirenaintrauterinesystemandsystemicoestrogen
D) Venlafaxine
E) ContinuouscombinedHRT

Question4

WhichoneofthefollowingstatementsabouttheconsequencesofHRTusewouldbeincorrectand
inappropriatetosharewiththepatientinquestion3,duringyourcounselling?

A) Herriskofcoronaryheartdiseasewillnotincreaseoverthenext10years
B) Herriskofvenousthromboembolismwillincrease
C) Herriskofhavinganosteoporoticfracturewillbereduced
D) Herriskofdementiawillbereducedinthelongterm
E) Herriskofbreastcancerwillincrease

Extended Matching Questions

Question5

Belowisalistofevidencebasedtreatmentoptions(AK)commonlyavailabletopatientswith
vulvodynia.Fromthislist,selectthemostappropriateoptionsforthestatementsgivenafterwards
(iv).Eachoptionmaybeusedonce,morethanonce,ornotatall.

A) Biofeedbackofthepelvicfloormuscles
B) Nortryptyline
C) Acupuncture
D) Gabapentin
E) Lignocaine5%ointment
F) Vaginaltrainers
G) Vaginalmassage
H) Botoxinjectionsintothepelvicfloormuscles
I) Cognitivebehaviouraltherapy
J) Triggerpointtherapyofthepelvicfloor
K) Vestibulectomy

i) Listfourfirstlinetreatmentsusedforprovokedvulvodynia(vestibulodynia)
ii) Listthreefirstlinetreatmentsusedforunprovokedvulvodynia
iii) Listtwotreatmentsthatdealwiththecentralsensitisationofpain
iv) Listfivetreatmentsthathelpovercomelevatormusclehypertonicity
v) Listthreesecondlinetreatments

Question6

Thefollowing(AL)havebeendemonstratedtobeeffectivetreatmentsinthenonpsychosexual
managementofsomeoftheelementsofdyspareunia.Pleaseselectthemostappropriateoptionfor
eachclinicalscenario(ivi).Eachoptionmaybeusedonce,morethanonce,ornotatall.

A) Fentonsprocedure
 B) Laparoscopy
C) Vaginaloestrogencream
D) Vaginallubricants
E) Laparoscopicexcisionofendometriosis
F) Vaginaltrainers
G) Sildenafil
H) GnRHanalogueswithaddbacktherapy
I) Laparoscopicdivisionofadhesions
J) Amitryptiline
K) AnalgesicsandNSAIDmedications
L) Systemictestosterone

i) A29yearoldwomanwithchronicpelvicpain.Examinationandpreliminaryinvestigations
includingpelvicultrasoundandvaginalswabshavesofarbeennormal

ii) A23yearoldwomaninanewrelationshipwithalongstandinghistoryofvaginismus
withoutanyclearprecipitatingfactors

iii) A65yearoldwomanwithsuperficialdyspareuniaandpostcoitalbleedinginwhomvaginal
ultrasoundandbiopsyarenormal

iv) A35yearoldwomanwithwidespread,laparoscopicallyproven,endometriosis

v) A32yearoldwomanwhohashadsuperficialdyspareuniasincethebirthofherlastchild,
whichwasbyforceps.Onexaminationshehasasmalldegreeofintroitalnarrowing
wheretheepisiotomywassited

vi) A38yearoldwomanwithvulvodyniainwhomsimpleanalgesiahasbeenfoundtobe
ineffective

Question7

Belowisalistofimagingmodalities(AF)thatmightbeusedintheinvestigationofgynaecological
pathology.Fromthislist,pickthemostappropriateinvestigationforthesituationsdescribed
thereafter(iviii).Eachanswermaybeusedonce,morethanonce,ornotatall.

A) Transabdominalultrasound
B) PET/CT
C) CT
D) AbdominalXray
E) MRI
F) Transvaginalultrasoundscan

i) Theprimaryimagingmodalityforsuspectedgynaecologicalpathologyinanobesewoman
ii) Theimagingmodalityofchoiceforcongenitalanomalies
iii) Aninvestigationthatisusefulinthedetectionofdistantmetastasesfromgynaecological
cancers
iv) Theinvestigationofchoiceforstagingcervicalcancer
 v) Theimagingmodalityofchoicewhenultrasoundfindingsareindeterminate
vi) Afunctionaltechniquewhichmaybeemployedtodetectcancerrecurrences
vii) Theimagingmodalityofchoiceforstagingovariancancer
viii) Theinitialinvestigationforsuspectedbowelobstructionindisseminatedovariancancer

Question8

Belowisalistofcausesofvulvalpruritus(AJ).Fromthislist,choosethemostappropriateanswers
tothequestionslistedafterwards(iv).Eachanswermaybeusedonce,morethanonce,ornotat
all.

A) Vulvovaginalcandidiasis
B) Lichensclerosus
C) Vulvarfolliculitis
D) Vulvalintraepithelialneoplasia
E) Psoriasis
F) Tineacruris
G) Eczema
H) Lichensimplexchronicus
I) Allergicdermatitis
J) Lichenplanus

i) Twovulvalconditionstreatedwithfluconazoleorclotrimazole
ii)Fourconditionstreatedwithtopicalsteroids
iii)
Aconditionsometimestreatedbysurgicalexcision
iv)Threeconditionswhereenvironmentalfactorsortriggersareparticularlyimportantto
consider
v) Aconditionthatshouldrespondwelltoantibiotics

Question9

Foreachoftheultrasoundscanreportsgivenbelow(ivi),choosethesinglebestchoicefromthelist
ofleiomyomaclassifications(AK).Eachoptionmaybeusedonce,morethanonceornotatall.

A) AUBLSM0
B) AUBLSM1
C) AUBLSM2
D) AUBLO3
E) AUBLO4
F) AUBLO5
G) AUBLO6
H) AUBLO7
I) AUBLO8
J) AUBL25
K) AUBLSM8

 i) A5cmfibroidisseenontheouteraspectoftheanterioruterinewallextendingintothe
myometriumby10%
ii) Thereisasubmucosalfibroidontheposterioruterinewall,whichis2cmindiameter.It
extendsintotheendometrialcavityanddoesnotinvolvemuchofthemyometrium
iii) Thereisa7cmmassintheabdominalcavity;itappearstobeseparatefromtheovariesand
maybeattachedtotheuterusbyastalk.
iv) Thecervixcontainsa3cmfibroid,distortingthecervicalcavity
v) Alargeanteriorfibroidisdistendingtheuterinecavityandextendsthroughoutthe
myometriumtobecomesubserosalinnature
vi) Thereisa3cmintramuralfibroidthatcontactstheendometriumbutdoesnotdistendthe
cavity

Question10

Belowisalist(AK)ofprobabilities/proportions.Fromthislist,choosethenearestvalueappropriate
forthequestionsgivenafterwards(ivii).Eachanswercanbeusedonce,morethanonce,ornotat
all.

A) 1in2(50%)
B) 1in4(25%)
C) 1in67(15%)
D) 1in10(10%
E) 1in20(5%)
F) 1in40(2.5%)
G) 1in70(12%)
H) 1in150(0.007%)
I) 1in200(0.005%)
J) 1in500(0.002%)
K) 1in1000(0.001%)
L) 1in4000(0.00025%)
M) 1in10,000(0.0001%)

i) Theriskofdeathwithin6weeksfollowingahysterectomy
ii) Theriskofurinarytractdamageatthetimeofhysterectomy
iii) Thereductioninmenstrualbloodlosswithmefenamicacid
iv) Theriskofovariancancerfollowingtotalabdominalhysterectomywithovarianconservation
v) Theriskofbloodtransfusionassociatedwithhysterectomy
vi) Theriskofcyclicalbleedingfromthecervixfollowingsubtotalhysterectomy
vii) Theproportionofwomenbecomingamenorrhoeicfollowingasecondgeneration
endometrialablation

Question11

Foreachcasesummarybelow(iv),choosethemostsuitableinvestigation(s)fromthelistbelow(A
J).Eachoptionmaybeusedonce,morethanonce,ornotatall.
 A) VonWillebrand'sfactor
B) Endometrialbiopsy
C) Pelvicultrasoundscan
D) Serumoestradiollevel
E) Outpatienthysteroscopywithendometrialbiopsy
F) Serumandrogenmeasurement
G) Serumprolactin
H) Thyroidfunctiontests
I) Plateletcount
J) MagneticResonanceImagingoftheabdomenandpelvis

i) A29yearoldnulliparahasirregularperiodswhichoccurapproximatelyevery6months.She
alsogivesahistoryofgalactorrhoeaandheadaches.Sheisnotsexuallyactive.Whichkey
singleinvestigationshouldbeperformed?
ii) A14yearoldisadmittedwithveryheavybleedingduringherfirstperiod.Whichtwokey
investigationswouldyoudotofindacause?
iii) A30yearoldnulliparahasahistoryofirregularbleedingoccurringapproximatelyevery3
months.Shegivesahistoryofrecentweightgainandworseningacne.Whichtwo
investigationswouldyouchoosefromthelistabove?
iv) A51yearoldpresentswithahistoryoferraticbleedingwithnopattern.Herperiodswere
previouslyfairlyregular.
v) A42yearoldpara3withalonghistoryofheavyregularperiodsovermanyyearshashadan
ultrasoundscanwhichconfirmsmultipleuterinefibroids.Shewishestohaveuterineartery
embolisationandhasbeensterilisedinthepast.Whichinvestigationshouldbeperformed
beforeschedulingherforthistreatment?

Question12

Foreachcasesummarybelow(iv),choosethemostsuitablemanagementoption(s)fromthelist
below(AJ).Eachoptionmaybeusedonce,morethanonce,ornotatall.

A) Endometrialablation
B) Hysterectomy
C) MirenaIUS
D) Uterinearteryembolisation
E) Combinedoralcontraceptivepill
F) Mefenamicacid
G) Tranexamicacid
H) Metformin
I) Desmopressin
J) Myomectomy

i) A19yearoldnulliparapresentswithahistoryofheavyregularperiodswithanormalpelvic
ultrasoundscan.Sheisnotsexuallyactiveatthemoment,buthasbeeninthepast.Which
fourmanagementoptionswouldyouoffer?
ii) A28yearoldpara1describesahistoryofheavyregularperiodsthathaveresultedin
significantanaemiarequiringbloodtransfusion.Abdominalexaminationrevealsa28week
sizeduterinemassandultrasoundscanconfirmsmultipleuterinefibroidsintheintramural
andsubserosallayersoftheuterus.Sheiskeenonhavinganotherbabyinthefuture,butis
 notactivelytryingatthemoment.
iii) A32yearoldpara3,whohasbeensterilisedpreviously,attendsforheavyperiods.Clinical
examinationrevealsanormalsizeduterus.Listfiveoptionsopentoher.
iv) A17yearoldwithahistoryofvonWillebrandsdiseaseisreferredbyherhaematologistfor
controlofherperiods.Whichthreeoptionswouldyoudiscusswithher?
v) A50yearoldpara2presentswithahistoryofirregularbleeding.Shehashada
hysteroscopyandendometrialbiopsy,revealingcomplexhyperplasiaoftheendometrium
withatypia.Sheisfitandotherwisewell.

Question13

Fromthelistbelow(AL)ofvulvaldisorders,choosethemostlikelydiagnosisfortheclinical
scenariosdescribedafterwards(iv).Eachanswermaybeusedonce,morethanonce,ornotatall.

A) Contactdermatitis
B) Folliculitis
C) Lichenplanus
D) Hidradenitissuppuritiva
E) Herpessimplex
F) Psoriasis
G) Lichensclerosus
H) Behetsdisease
I) Erythrasma
J) Pemphigus
K) Molluscumcontagiosum
L) Tineacruris

i) Aconditionwheregenitalulcerationisoftenfoundwithocularinflammation,suchasuveitis
ii) Aninfectiouscondition,causingvulvalerythematousplaques,whereskinscrapingsmay
showTrichophyton
iii) Anoninfectiousautoimmuneconditioncausingsevereitchingandshinywhitepatcheson
thevulva
iv) AvulvalinfectioncharacterisedbyacoralpinkfluorescenceunderaWoodslight
v) Avulvalconditionofunknowncausethatoftenpresentswithpurplepapulesand
abnormalitiesoftheskin,hairandoralmucosa

Question14

Withregardstothemedicaltreatmentofdysmenorrhoea,foreachstatementbelow(iviii)choose
themostsensiblechoicefromthelistgiven(AK).Eachoptionmaybeusedonce,morethanonceor
notatall.

A) Ibuprofen

B) Aspirin
 C) COCP

D) GnRHanalogues

E) VitaminE

F) Magnesium

G) MirenaIUS

H) TricyclingCOCP

I) Thiamine

J) Omega3oil

K) Ibuprofenandparacetamol

i) Firstlinetreatmentina15yearoldgirlwithdysmenorrhoea

ii) Idealtreatmentfora40yearoldsmokerwithconcomitantmenorrhagia

iii) Aconservativedietarysupplementthatcanreducepainandbloodflow

iv) Adietarysupplementwhichmaycausenausea,vomitingandworsenacne

v) Couldbeusedastrialofbenefitofoophorectomywheresymptomsarerefractorytomore
conservativetreatments

vi) Secondlinetreatmentforprimarydysmenorrhoea

vii) Atreatmentfordysmenorrhoeasuspectedtobesecondarytoendometriosisinayounggirl

Question15

Regardingthemedicaltreatmentofdysmenorrhoea,foreachcasescenariobelow(iviii)choosethe
mostsensiblechoicefromthelistgiven(AJ).Eachoptionmaybeusedonce,morethanonceornot
atall.

A) MirenaIUS

B) IbuprofenandOmeprazole

C) TENS

D) VitaminE

E) Ibuprofen

F) COCP

G) IbuprofenandGaviscon
 H) Acupuncture

I) Aspirin

J) Exercise

i) A14yearoldwhoissexuallyactivewithdysmenorrhoeaandnotcurrentlyusing
contraception

ii) A38yearoldwithincreasedBMIrequiringcontraceptionandtreatmentfordysmenorrhoea

iii) A27yearoldwithmildheartburnandhistoryofVTE
iv) A16yearoldwithdysmenorrhoea

v) A23yearoldwithvaginismusandvonWillebrandsdisease

vi) Awomankeenfornonpharmacologicalremedies

vii) A37yearoldwithdiabeticnephropathy

viii) A34yearoldwithmilddymenorrhoea,whosehusbandhashadavasectomy

Multiple Choice Questions

Question16

Answertrueorfalse

Thefollowingtherapiesaresuitableformanagingthesymptomsofawell,45yearold
perimenopausalwoman:

A) Tibolone
B) CyclicalHRT
C) Lowdosecontraceptivepill
D) Selectiveserotoninreuptakeinhibitor
E) OestrogenonlyHRT

Question17

Answertrueorfalse

Menopausalinducedurogenitalatrophymayresultin:

A) Vaginaldryness
B) Painfulsexualintercourse
C) Arousalfailure
D) Abnormalpapsmear
E) Lackofvaginallubrication

Question18

Considerthefollowingstatementsaboututerineassessmentasaninvestigationofabnormaluterine
bleedinginperimenopausalwomen.Answertrueorfalse

A) Hysteroscopyisthefirstlinetestforassessingtheuterus
B) Sonohysterographycanaccuratelyassessthepositionandsizeofsubmucousfibroids
C) IftheendometrialthicknessonTVUSSis2mmthenendometrialhyperplasiaisunlikely
D) AllpatientswithpostmenopausalbleedingshouldhaveaD&C
E) SonohysterographyisbetterthanTVUSSatdetectingsubserosalfibroids

Question19

Answertrueorfalse

Regardingmalesterilisation:

A) Thefailurerateforvasectomyis1in2000
B) Vasectomyneedstobedoneundergeneralanaesthetic
C) Vasectomyiseffectiveimmediately
D) Chronictesticularpainaffectingqualityoflifeisacommoncomplicationfollowing
vasectomy
E) Vasectomyisassociatedwithincreasedriskoftesticularandprostatecancer

Question20

Answertrueorfalse

Regardingfemalesterilisation:

A) Thevaginalapproachtothetubesisthepreferredchoice
B) Postpartumsterilisationisequallyeffectiveasintervalsterilisation
C) Hysteroscopicsterilisationislessinvasiveandaseffectiveaslaparoscopicsterilisation
D) WomenundergoingsterilisationneedtobecounselledonLARC
E) Thereisanincreasedriskofregretinpatientsunder30yearsofage.

Question21

Answertrueorfalse

ThefollowingriskissuesareontheNationalPatientSafetyAgency(NPSA)listofneverevents:

A) TransfusionofABOincompatibleblood
B) ThedeliveryofababywithanumbilicalarterialpHof<7.0
C) Removaloftheincorrectovary
D) Retainedswabfollowingperinealrepair
E) Unintentionalligationoftheureterathysterectomy

Question22
Answertrueorfalse

Dyspareuniais:

A) Aformofsexualdysfunctionassociatedwithgenitalpainexperiencedonlyduringsexual
intercourse
B) Ispresentonlyinwomen
C) Isusuallyconditionalwhenpsychosocialcausesareimplicated
D) Accountsforonlyasmallproportionofallcasesofsexualdysfunctionreachingmedical
attention
E) Hasbothphysicalandpsychologicalcomponents

Question23

Answertrueorfalse

Withregardstosexualintercourseafterchildbirth:

A) Themajorityofwomenaresexuallyactivewithin34monthsofdelivery
B) Sexualactivityduringearlypregnancyisassociatedwithincreasedsexualsatisfactionat3to
4monthsfollowingdelivery
C) Nearly25%ofprimiparouswomenwillexperiencelackofsexualsensationandorgasm6
monthsfollowingdelivery
D) Youngermaternalageisassociatedwithdelayedresumptionofsexualintercoursefollowing
delivery
E) Postnatalphysiologicalchangesmayleadtohypoactivesexualdesire

Question24

Answertrueorfalse

Inthetreatmentofdyspareunia:

A) Psychosexualcounsellinghasbeenshowntobeofvalueatanystageofmanagement
B) Androgenicdrugsareusefulduetotheireffectofimprovinglibido
C) Mostpatientsareeffectivelytreatedfollowingthefirstclinicvisit
D) Antibioticshavebeenshowntobeeffective
E) Vaginaloestrogensmaybeeffectiveinpremenopausalwomen

Question25

Answertrueorfalse

Progesteronereceptormodulators:

A) Areassociatedwithhypoestrogenism
B) Areagoodtreatmentforthosewhohavesymptomsrelatedtofibroidsizealone
C) Leadtoasignificantdecreaseinmenstrualbloodloss
D) Mayalsobeusedforemergencycontraception
E) Areassociatedwithanincreaseinhaemoglobin


Question26

Answertrueorfalse

UterineArteryEmbolisation:

A) Iscontraindicatedinthosedesiringpregnancy
B) Isausefultreatmentforfibroidassociatedheavymenstrualbleeding
C) Requiresangiographytodefinethebloodvessels
D) Isassociatedwithareinterventionrateofover30%
E) Isassociatedwithahigherrateofrecurrencethanaftermyomectomy

Question27

Answertrueorfalse

Riskfactorsforendometrialhyperplasiainclude:

A) Hormonereplacementtherapy
B) Thecombinedoralcontraceptivepill
C) Nulliparity
D) Obesity
E) TheMirenacoil

Question28

Answertrueorfalse

Patientssuspectedofhavingendometrialhyperplasiashouldhavethefollowinginitial
investigations:

A) Transvaginalultrasoundscan
B) MRIpelvis
C) Hysteroscopyandendometrialbiopsy
D) CA125
E) LHandFSH

Question29
Answertrueorfalse
Thefollowingactionswouldbeappropriatemidwaythroughahysteroscopicmyomectomywhenthe
surgeonnoticesthatthereisanelectrolytefluiddeficitof1200ml:

A) Informtheanaesthetist
B) Stoptheprocedure
C) Checktheelectrolytes
D) Considerfrusemide
E) Useglycineasthedistensionmediainstead

Question30
Answertrueorfalse
Whencounsellingpatientsaboutfirstandsecondgenerationendometrialablativetechniques:

A) Firstgenerationtechniquesareeasiertoperform
B) Secondgenerationtechniqueshavebetteroutcomesat5years
C) Firstgenerationtechniquestakelonger
D) Thechanceofequipmentfailureisgreaterwithsecondgenerationtechniques
E) Thereisagreaterriskofcomplicationswithsecondgenerationtechniques

Question31
Answertrueorfalse
Regardingheavymenstrualbleedinganditstreatments:

A) Levonorgestrelreleasingintrauterinesystemreleases24microgramsofthehormoneper24
hours
B) Routinepelvicexaminationisunnecessaryinwomenwithheavymenstrualbleeding
C) Thyroidfunctiontestsshouldnotbeperformedroutinelywhileinvestigatingwomenwith
heavymenstrualbleeding
D) 80%ormoreofwomenhavingsecondgenerationendometrialablationtechniquesachieve
amenorrhoea
E) Prophylacticbilateraloophorectomyatthetimeofhysterectomyeliminatestheriskof
developingovariancancer

Question32

Answertrueorfalse

Ulipristalacetate(UA):

A) Isaselectiveprogesteronereceptormodulator
B) Islicensedforlongtermuseinfibroids
C) Reducestheexpressionofmatrixmetalloproteinases
D) Downregulatesangiogenicgrowthfactors
E) Hasnoimpactonfibroidvolume

Question33

Answertrueorfalse

Whencomparedagainsttotalabdominalhysterectomy:

A) Subtotalhysterectomyisassociatedwithbetterlongtermbladder,bowelandsexual
outcomes
B) Theriskofthromboembolismfollowinglaparoscopichysterectomyisthesame
C) Vaginalhysterectomyismorecosteffective
D) Vaginalhysterectomyisassociatedwithmoreurinarytractinjuries
E) Hospitalstayisshorterwithlaparoscopicmethods


Question34

Answertrueorfalse
Regardingfemalegenitalsurgery:

A) Clitoralhoodreductionisaformoffemalegenitalmutilation
B) ThemajorityofwomenreferredtospecialistNHSclinicscomplainoffunctionalproblems
C) Hymenoplastyisperformedtoresectatighthymen
D) ThereisagoodevidencebasetosupportGspotaugmentation
E) Itcanonlybeperformedbyanaccreditedgynaecologist

Emergency Gynaecology

SBAs
Question35

WhichofthefollowingpiecesofinformationdoesNOTformpartofthestandardadvicegivento
womenreceivingmethotrexateformanagementofa2cmectopicwithanHCGlevelof1300IU/L?

A) Afurtherdoseofmethotrexatemayberequired
B) Onequarterwillultimatelyneedsurgicalintervention
C) Theyshouldavoidsexualintercourse
D) Theyshouldavoidgettingpregnantwithin3monthsfollowingthetreatment
E) Threequarterswillexperienceabdominalpainduringthetreatment

Question36

A38yearoldhasbeeninvestigatedforprimaryinfertilityandhasbeenfoundtohavebilateraltubal
disease.Shehasasomewhatirregularmenstrualcycle.WhilstonthewaitinglistforIVF,she
surprisinglyconceivesspontaneously.Shepresentstoanearlypregnancyunit,asymptomaticbut
veryanxious,56weeksfollowingherlastmenstrualperiod.Herobservationsarefine,sheisnon
tenderandascanshowsanemptyuterus,withnoadnexalmassesorfreefluid.HerHCGis1100
IU/L.Thisisrepeated48hourslater,andthevalueis1600IU/L.Sheremainswellandarepeat
transvaginalscanaddsnothingmore.Whichofthefollowingisyourbestcourseofaction?

A) Diagnosticlaparoscopyfollowedbysalpingectomyifanectopicisfound
B) Diagnosticlaparoscopyfollowedbysalpingostomyifanectopicisfound
C) Performaserumprogesteronemeasurement
D) RepeatanotherHCGvaluein2daystime
E) Treatmedicallywithmethotrexate

Question37
A34yearoldwomanisundergoingfollowupforacompletehydatidiformmole.Sheissexually
activeandawareoftheimportanceofnotgettingpregnantuntilherBHCGlevelshavebeennormal
for6months.WhichofthefollowingisNOTcorrectregardinghercontraceptiveadvice?

A) ThecombinedpilliscontraindicateduntilHCGlevelshavebeenundetectablefor3months
B) TheMirenaIUScanbeusedonlyonceHCGlevelsaredeclining
C) SterilisationshouldnotbeperformedwhileHCGlevelsarepersistentlyelevated
D) Theprogesteroneonlypillisnevercontraindicated
E) ThecopperIUCDiscontraindicatedwhilstHCGlevelsremainhigh

Question38

A19yearoldwomanhasbeenrapedandassaultedbyanunknownassailantwhilstwalkinghome.
Sheiscurrentlyintubatedandventilatedontheintensivecareunitwithsevereheadinjuries.Which
ofthefollowingstatementsiscorrectregardingforensicexaminationafterasexualassault?

A) Oralconsentissufficientfromacompetentadult
B) Itcanbeperformedwithoutconsentifthepatientdoesnothavecapacity
C) Thenecessarysitesforskinswabsaretheneckandlowerabdomen
D) Analsamplescanbetakenupto5daysfollowingtheassault
E) Vaginalsamplesmustbetakenwithin2days

Question39

Whichofthefollowingfeaturesonultrasoundscanconstitutesclearevidenceofanonviable
pregnancy?

A) Anemptygestationsacwithameandiameterof28mm
B) Afetalheartrateof80bpmat8weeksgestation
C) Anirregularshapedgestationsac
D) Anabsentheartbeatwithacrownrumplengthof6mm
E) Anabsentyolksacat6weeksgestation

Extended Matching Question

Question40

Belowisalistofpathologicaltermsforabnormaltrophoblast(AI).Fromthislist,choosethemost
appropriateoption(s)forthedescriptions,ivi,thatfollow.

A) Partialmole
B) Placentalnodule
C) Epithelioidtrophoblastictumour
D) Invasivemole
E) Choriocarcinoma
 F) Exaggeratedplacentalsite
G) Placentalmesenchymaldysplasia
H) Completemole
I) Placentalsitetrophoblastictumour

i) Atumourarisingfromintermediatetrophoblast,characterisedbyclustersorsheetsof
tumourcellswhichinvadeandinfiltratebetweenmyometrialsmoothmusclecells
ii) Thetermusedtodescribegrosslyhydropicvilliwithtrophoblasthyperplasia,intheabsence
offetalparts
iii) Fourformsofgestationaltrophoblasticneoplasia(GTN)
iv) Twotumoursthatarerelativelychemoresistant
v) Atumourarisingfromintermediatetrophoblastcharacterisedbynodularnestsorcordsof
tumourcellssurroundedbyextensivenecrosisandaneosinophilicmatrix
vi) Abnormaltrophoblastcharacterisedbytriploidcells

Multiple Choice Questions

Question41

Answertrueorfalse

HysterectomyshouldbeconsideredfortreatmentofGTNifthepatient:

A) Haschemoresistantdisease
B) Haschoriocarcinoma
C) Hasuncontrollablebleeding
D) Hascompletedherfamily
E) Hasplacentalsitetrophoblastictumour

Question42

Answertrueorfalse
ThefollowingagentsformpartoftheEMACOchemotherapeuticregimeforgestational
trophoblasticneoplasia:

A) Methotrexate
B) Cisplatin
C) Cyclophosphamide
D) 5FU
E) Etoposide

Question43

Answertrueorfalse

Regardingadvicefollowingsexualassault:
 A) 30mgUlipristalispreferredoverLevonelleforemergencycontraception
B) Beyond5days,thereisnoeffectiveformofemergencycontraception
C) PostexposureHIVprophylaxis(PEP)shouldbegivenwithin3days
D) PEPreducesseroconversionratesforHIVby80%
E) TheriskofHIVtransmissionwithvaginalintercourseis1in50ifthemanisseropositive

Oncology

SBAs
Question44

A77yearoldpatientpresentswithintensevulvalitchingandsoreness.Examinationrevealsa4cmx
4cmlesionontheleftlabiamajoraandapunchbiopsyiscarriedout.Thereportshowsevidenceof
necrosiswithinthespecimen.Whatisthebestnextcourseofaction?

A) Widelocalexcisionoftheprimarylesionwithipsilateralinguinofemorallymphadenectomy
B) Widelocalexcisionalbiopsy
C) Urgentwedgebiopsyfromtheedgeofthelesion
D) Widelocalexcisionofprimarylesionwithbilateralinguinofemorallymphadenectomy
E) Widelocalexcisionoftheprimarylesionwithoutinguinofemorallymphadenectomy

Question45

A70yearoldpatientpresentswitha3.5cmlesionontherightlabiamajora.Awedgebiopsyreports
asquamouscellcarcinomawithstromalinvasionof6mm.

Whatisthebestnextcourseofaction?

A) Widelocalexcisionoftheprimarylesionwithipsilateralinguinofemorallymphadenectomy
B) Widelocalexcisionalbiopsy
C) Urgentwedgebiopsyfromtheedgeofthelesion
D) Widelocalexcisionofprimarylesionwithbilateralinguinofemorallymphadenectomy
E) Widelocalexcisionoftheprimarylesionwithoutinguinofemorallymphadenectomy

Question46

AccordingtotheNHScervicalscreeningprogrammealgorithm,whereHPVtriageisincludedafter
thesmearhasbeenanalysedincertaingroupsofwomen,whichoneofthesituationsbelowwould
beavalidindicationforreferraltocolposcopy?

A) AborderlineendocervicalsmearwithnegativeHPVtesting
B) AborderlinesmearwithHPVpositivity
C) AborderlinesmearwithinadequateorunreliableHPVtesting
D) AborderlinesquamoussmearwithnegativeHPVtesting
E) AsmearwithlowgradedyskaryosiswithnegativeHPVtesting

Question47
A30yearoldwomanattendsthecancergeneticsclinicbecauseheroldersisterhasrecentlybeen
diagnosedwithovariancancer.Hermotherdiedofthesamedisease.Whichoneofthefollowingis
trueregardingfamilialovariancancer?

A) BRCA1andBRCA2carriersarerecommendedtohaveprophylacticriskreducingsurgery
afterthemenopause
B) HNPCCcarriersarerecommendedtohavebilateralsalpingooophorectomyat40yearsof
ageiftheyhavecompletedtheirfamilies
C) EvidencesupportsscreeningwithyearlyTVSandCA125measurementsasaneffective
alternativetoprophylacticsurgery
D) Moleculartestingcanruleoutafamilycancersyndromeinawomanwithafamilyhistory
E) Womenwithageneticpredispositionremainatresidualriskofepithelialcancerevenafter
bilateralsalpingooophorectomy

Question48
A72yearoldhasbeendiagnosedwithovariancancerandthemultidisciplinaryteammeetinghas
recommendedchemotherapyfollowedbyintervaldebulkingsurgery.
Whichoneofthefollowingoptionsistrueregardinghertreatment?
A) Shewouldbenefitfromasecondlooklaparotomyaftercompletionofchemotherapy
B) Sheshouldhaveeightcyclesofchemotherapy
C) Thereisnobenefitdemonstratedintrialsofintervaldebulking
D) Carboplatinistoleratedbetterthanpaclitaxel
E) Ifherdiseaserecurs,thenfurthercyclesofchemotherapywouldnotberecommended

Question49
WhichoneofthefollowingoptionsisNOTtrueconcerningHPV?

A) HPVisadoublestrandedDNAvirus
B) HPVcontainseightgenes
C) Approximately50%ofwomenwillspontaneouslyclearthevirusin2years
D) HPVE1andE2genescontrolviralreplication
E) HPVisnowemergingasacausativefactorinheadandneckcancers

Question50
A65yearoldwomanattendsherGPwithsymptomsofbloatingandnausea.Furtherquestioning
elicitssomeadditionalproblems.WhichoneofthefollowingisNOTareasontotestingofserum
CA125levelsaccordingtoguidancefromTheNationalInstituteofClinicalExcellence(NICE)?

A) Newpresentationofirritablebowelsyndromeinapostmenopausalwoman
B) Vaginaldischarge
C) Earlysatiety
D) Weightloss
E) Pelvicpain

Question51
A68yearoldwomanisdiagnosedwithanearlystageleiomyosarcomaafterinitialinvestigationfor
afibroiduterus.Whichoneofthefollowingfactorswillimproveher5yearsurvival?

A) Shewillreceiveadjuvantradiotherapy
B) Shehasahighgradetumourhistology
C) Shewillreceiveadjuvantchemoradiotherapy
D) Sheisolderatdiagnosis
E) Sheundergoescompletesurgicalclearance

Question52
AGPreceivesapelvicultrasoundreportfora40yearoldpatientwillchronicpelvicpain.She
contactsyouforadviceregardingthelikelihoodofmalignancyforanovariancystthathasbeen
reportedonthescan.Whichoneofthefollowingfeaturesincreasestheriskofmalignancy?

A) Maximumdiameterof80mm
B) Nobloodflow
C) Irregularshape
D) Presenceofacousticshadowing
E) Twopapillarystructures

Question53

A36yearoldwomanisreferredtothecolposcopyclinicwithconcernregardingtheappearanceof
thecervixonspeculumexamination.Whichoneofthefollowingfactorswouldincreaseherriskof
cervicalcancer?

A) UsingaMirenacoilforcontraception
B) Smoking
C) Useofhormonereplacementtherapy
D) Vulvalwartinfection
E) Nulliparity

Question54
A62yearoldwomanpresentswithadistendedabdomenandanelevatedCA125of
1244.Ultrasoundrevealedascites,acomplexovarianmassandanomentalcake.A
preliminarydiagnosisofstage3ovariancancerwasmadeandshereceivedthreecycles
ofchemotherapypriortoaplannedlaparotomy.Preoperatively,shehasbeenadmitted
complainingofnausea,breathlessness,andabdominaldiscomfort.Whichoneofthe
followingisnotalikelyexplanationforheradmission?

A) Bowelobstruction
B) Ascites
C) Pulmonaryembolism
D) Pancreatitis
E) Infection

Question55
A78yearoldwomanwithvulvalsorenessanda3cmwartylesionconfinedtothevulvaclosetothe
analmarginisreferredtoyourtertiarycentrewithadiagnosisofsquamouscellcarcinomaofthe
vulvaonwedgebiopsy.WhichoneofthefollowingproceduresisNOTlikelytoberequiredforthis
patient?

A) Examinationunderanaesthesia
B) Vulvalflapreconstructionperformedwithaplasticsurgeon
C) Bilateralgroinnodedissection
D) Stomaformation
E) Omentectomy

Question56

A56yearoldwomanwithavulvallumpapproximately2cmindiameterandbleedingisreferredto
atertiarygynaecologicaloncologycentrewithasuspicionofvulvalcancer.Whichofthefollowing
furtherinvestigationswouldNOTbeappropriateatthisstage?

A) Wedgebiopsy
B) MRIpelvis
C) Examinationunderanaesthesia
D) Bilateralgroinnodedissection
E) Ultrasoundpelvis

Extended Matching Question

Question57
Belowisalistofovariancancerhistologicaltypes(AN).Choosefromthelistthemostappropriate
optionstoanswerthequestionsi)tovi),whichfollow.

A) Endometrioid
B) Granulosacell
C) Mucinous
D) Yolksactumour
E) Clearcell
F) Fibroma
G) Choriocarcinoma
H) Transitionalcell(Brenner)
I) SertoliLeydigcell
J) Teratoma
K) Serous
L) Embryonal
M) Borderline
N) Dysgerminoma

i) Listthesixepithelialcelltumourtypes
ii) Listthethreesexcordstromaltumourtypes
iii) Listthefivegermcelltumourtypes
iv) Whichtumourtypecharacteristicallymayrecurafteralongperiodoftime?
 v) Whichtumourtypeisoftenassociatedwithendometrialhyperplasiaandcarcinoma?
vi) Whichisthemostcommongermcelltumour?

Multiple Choice Questions

Question58

Thefollowingstatementsregardinggynaecologicalmalignanciesarecorrect:

A) Endometrialcarcinomahasthehighestoverall5yearsurvivalrateofallthegynaecological
malignancies
B) Around50%ofpatientswithadvancedcervicalcarcinomaexperienceunrelievedcancerpain
thatunderminesfunction
C) Bowelobstructionisacommonterminaleventinovariancancer
D) TheincidenceofcervicalcancerintheUKisincreasing
E) Highlevelsofpsychologicaldistressareexperiencedbyapproximatelyonethirdofwomen
diagnosedwithgynaecologicalcancer

Question59

Answertrueorfalse

Inthepalliativemanagementofgynaecologicalmalignancies:

A) Pharmacologicaltreatmentshouldbethefirstlinemanagementforconstipation
B) Surgeryshouldbeconsideredasafirstlinemanagementinallpatientswithmalignant
bowelobstruction
C) Longtermsemipermanentcatheteruseisapotentiallyvaluablemodalityforthepalliation
ofmalignantascites
D) Arterialembolizationmayberegardedasaneffectiveprocedureforcontrolofmassive
bleedinginselectedcervicalcancerpatients
E) Theinsertionofanephrostomytubeisnotappropriateforthemanagementofuraemia
resultingfromuretericobstruction

Question60
WithregardtoHPVvaccination,answertrueorfalsetothefollowingstatements:

A) VaccinationisavailableofflicenceforboysintheUK
B) TherapeuticHPVvaccineshavebeenshowntoclearthevirusinestablishedinfection
C) ProphylacticHPVvaccinecomprisesanattenuatedlivevirus
D) Theadjuvantinthevaccinehelpsfurtherinboostingtheimmuneresponse
E) GardasilreplacedCervarixintheUKfromSeptember2013

Question61
Answertrueorfalse

Regardingcervicalcancer:

A) Adenocarcinomasaremorecommonthansquamouscelltumours
B) Adenocarcinomahasabetterprognosisthanthesquamoustype
C) Bloodbornespreadiscommon
D) Lymphaticspreadisprobablythemostimportantprognosticfactor
E) Morecancersarenowdiagnosedearlier

Question62

Answertrueorfalse

Whenchoosingatreatmentmethodforcervicalcancer:

A) WomenwithmicroinvasiveStageIa1diseaseshouldhavelymphnodedissection
B) SurgeryimprovessurvivalincomparisontoradiotherapyforstageIbIIadisease
C) Chemoradiationimprovessurvivalincomparisontoradiotherapyalone
D) StageIIbshouldbetreatedwithsurgery
E) Fertilitysparingsurgeryisavailablefortumours<2cm

Question63

Answertrueorfalse

Verrucouscarcinomaofvulva:

A) Isahistologicalvariantofsquamouscellcarcinoma
B) Ispoorlydifferentiated
C) Presentsasapatchyredandflatlesion
D) Showsextensivedistantmetastasis
E) Istreatedwithexcisionoftheprimarylesionandinguinofemorallymphadenectomyisnot
necessary

Question64

Answertrueorfalse

WhenchoosingatreatmentmethodforCIN:

A) Itdoesnotmatterwhetherthetransformationzoneisvisibleornot
B) Thesizeofthelesionisimportant
C) Lasershouldalwaysbepreferredifavailable
D) ThegradeoftheabnormalityshouldbeatleastCIN23
E) Fertilitywishesshouldbetakenintoconsideration

Question65
Answertrueorfalse

WithregardtoHPVDNAtestinginthepreventionofcervicalcancer:

A) ThereisnoevidencethatHPVDNAimprovestheaccuracyofprimaryscreening
B) WomenaftertreatmentshouldhaveanHPVDNAtestandcytologyannuallyfor10years
C) WomenwithborderlineandmilddyskaryosisthattestpositiveforHPVDNAtestare
referredtothecolposcopyclinic
D) MostcountrieshavealreadyimplementedHPVbasedcervicalscreeningprogrammes
E) Thetestassessesdirectlythepresenceoftheviralgenome

Question66

Answertrueorfalse

Vaccinesforcervicalcancer:

A) Aredescribedastrivalent
B) ProtectagainstalloncogenicHPVtypes
C) Avoidtheneedforscreeningforcervicalcancer
D) Areveryefficaciousandsafe
E) Areadministeredinthreedoses

Question67

Answertrueorfalse
Thefollowingregulardrugsshouldbeomittedpriortomajorgynaecologicalsurgery:

A) Combinedoralcontraceptivepill
B) Propanolol
C) Salbutamol
D) Warfarin
E) Shortactinginsulin

Question68

Answertrueorfalse
Concerningtheuseofradiotherapyingynaecologicalmalignancies:

A) FIGOstageIendometrialcancersaremanagedbysurgeryalone
B) ImageguidedradiotherapyrequiresrepeatedCTimagingofthepatienttoensureaccuracyof
treatment
C) Asignificantmajorityofpatientsgainpainrelieffrombonemetastasesfollowingasingle
radiotherapytreatment
D) Surgeryfollowedbychemotherapyandradiotherapyisthetreatmentofchoicefor
advancedcervicalcancer
E) Brachytherapytreatmentforendometrialandcervicalcancersistypicallygivenoverthe
 courseofseveralhours

Question69

Answertrueorfalse
Regardingtheuseofchemotherapyandbiologicalagentsinthetreatmentofgynaecological
cancers:

A) Cisplatinchemotherapyisusedasaradiosensitiserincervicalcancer
B) Patientsofperformancestatus2arerestrictedinphysicallystrenuousactivitybut
ambulatoryandareabletocarryoutworkofalightorsedentarynature
C) Anthracyclinesworkbyblockingmicrotubulesandinhibitingmitosis
D) Bevacizumabisamonoclonalantibodythatbindsvascularendothelialgrowthfactor
andisusedinthetreatmentofovariancancer
E) Patientswithneutropeniafollowingchemotherapyalwaysrequireantibiotictreatment

Infertility and Reproductive Medicine

SBAs
Question70

A35yearoldmarriedmultiparouspatientwithlongstandingtype1diabetesseeksadviceregarding
contraception.Sheisnotsureshehascompletedherfamily,althoughherendocrinephysicianhas
expressedtheirconcernsaboutanotherpregnancybecauseofherretinopathyandearlyrenal
disease.

Whatisthebestoption,fromthechoicesbelow,forcontraceptionforthiswoman?

A) Encouragesterilisation
B) Combinedoralcontraceptiveuse
C) CopperIUD
D) LNGIUS
E) DMPA

Question71

A15yearoldgirlpresentsinyourgynaeclinicwithprimaryamenorrhoea.Shehasevidenceof
developmentofsecondarysexualcharacteristics,butpubichairisscanty.Ultrasoundscanshowsan
absentuterus.

Whichdiagnosisfromthelistbelowismostlikelyfromtheseclinicalfeatures?

A) MayerRokitanskyKusterHausersyndrome(MRKH)
 B) Swyersyndrome
C) Completeandrogeninsensitivitysyndrome(CAIS)
D) Turnersyndrome
E) McKusickKaufmannsyndrome

Question72

Youhavebeenlookingafteracoupleinyourinfertilityclinic.Nofemalefactorshavebeen
identifiedandthemalepartneris32yearsold,fitandmuscularwithaBMIof26.Hehas
producedtwospermsamples,2monthsapart,bothshowingazoospermia.Onexamination,
hehasnormalsecondarysexualcharacteristics,normaltesticularvolumeandnoscrotal
abnormalities.HehasnormalserumFSH,LH,testosteroneandprolactinlevelsandhispost
ejaculatoryurinesampleshowsnospermatozoa.Atesticularultrasoundisnormal.
Howwouldyouproceedwithmanagement?Choosethesinglebestanswer.

A) Treathimwithgonadotrophins
B) Enquireaboutanabolicsteroidmisuse
C) Offergenetictesting
D) Adviseagainstsmokingandalcoholuse,toloseweight,andrepeatthesamplein3
monthstime
E) Offermicrosurgicalepididymalspermaspiration(MESA)

Question73

A34yearoldwomanattendsyourinfertilityclinic,alongwithher58yearoldhusband.Theyhave
beentryingtoconceivewithoutsuccessforover2years.Thefemalepartnerhashadarecentday3
FSHlevelof5.4mU/mlandhasaregular28daycycle.Herhusbandisconcernedthathisageisthe
causeoftheirfertilityissues.

WhichofthefollowingisNOTaproblemwithadvancedageinthemalepartner?

A) Asteadydecreaseinspermcount
B) Adeclineinmalefertility
C) Anincreaseintheriskofsinglegenedisordersinoffspring
D) Anincreaseintheirpartnersmiscarriagerisk
E) Anincreaseincertainmultifactorialcongenitalanomalies

Question74

A30yearoldwomanattendsthegynaecologyclinicforalongstandinghistoryofhirsutism.

WhichoneofthefollowingisNOTcorrectregardingherlikelydiagnosis?

A) Themostlikelycauseisanadrenaltumourproducingandrogens
B) Herethnicityisarelevantpartofthehistory
C) Hermainphysiologicalsourceofandrogenswillbetheovary
D) Herhirsutismwillbeaffectedmainlybyherlevelsoffreetestosterone
 E) Ifsheisobese,thiswillaffectherfreefractionoftestosterone

Question75

A36yearoldwomanwithaBMIof35andadiagnosisofPCOShasa3yearhistoryofanovulatory
infertility.Shehasundergoneayearoftreatmentwithclomiphenecitratewithoutsuccess.

Whichofthefollowingstatementsiscorrectregardinghermanagement?

A) Shecouldpotentiallyachievearegularcyclebyweightreductionalone
B) Sheshouldbeencouragedtohavefurthertreatmentwithclomiphenecitrate
C) Laparoscopicovariandrillingismoreeffectivethangonadotrophintherapyinwomenwho
areclomipheneresistant
D) Ifshechoosestohavelaparoscopicovariandrilling,thiswouldbeassociatedwithan
increasedriskofmultiplepregnancy
E) Metforminwouldimproveherchancesofalivebirth

Question76
A43yearoldpatientisconsideringaprivatecourseofIVFtreatment.Shehashadlongstanding
problemswithendometriosis,requiringseverallaparoscopicresectionsinthepast.Shewishesto
understandwhatheroptionsareandhowIVFtreatmentmightimpactonherandafuturechild.
Whichofthefollowingistrueregardinghermanagement?

A) IVFisfirstlineofmanagementforallendometriosisassociatedinfertility
B) DiminishedovarianreserveisacontraindicationtoIVFtreatment
C) Ectopicpregnancyoccursin2%ofIVFpregnancies
D) IVFbabieshaveahigherriskofepigeneticdisorders
E) IVFbabieshaveahigherriskofautism

Question77

A20yearoldwomanattendsthegynaecologyclinicwithprimaryamenorrhoea.

Whichofthefollowingstatementsistrueregardingherdifferentialdiagnosis?

A) IfshehasMllerianagenesisorRokitanskysyndromeherkaryotypewillbe46XY
B) Shemayhavehyperprolactinaemiaduetothetonicinhibitionofthepituitarybydopamine
C) Ifshehasandrogeninsensitivitysyndromethenshewillnothaveauterus
D) IfshehasTurnerssyndromethenshewillnothaveauterus
E) Shemayhavehypergonadotrophichypogonadismasaconsequenceofaneatingdisorder

Question78

AcoupleattendtheIVFclinicforpreimplantationgeneticdiagnosisduetoafamilyhistoryof
Huntingdonsdisease.Theyarekeentoknowifthereareanyadditionalriskstothepregnancy,
beyondtherisksofconventionalIVFtreatment.

Whichofthefollowingisanadditionalriskintheircase?
 A) Morecongenitalanomalies
B) Morepretermdeliveries
C) Moreneonatalmorbidity
D) Morestillbirths
E) Morepostnataldevelopmentaldelays

Question79

Whichoneofthefollowingstatementsaboutcongenitalreproductivetractanomaliesiscorrect?

A) MayerRokitanskyKusterHausersyndrome(MRKH)hasanincidenceof1:40,000births
B) VaginaldilationisthefirstlinetreatmentforvaginalaplasiainwomenwithMRKH
C) LaparoscopyisindicatedaspartofroutinemanagementforMRKH
D) Womenwithcompleteandrogeninsensitivitysyndrome(CAIS)oftenhaveamutationinthe
SRYgene
E) WomenwithSwyersyndromehaveanabsentuterus

Question80

A23yearoldnulliparouswomanpresentsforemergencycontraceptiveadvice.Shehasrecently
metanewpartnerandwouldliketoconsideranintrauterinecontraceptivedevice.Whichoneofthe
followingiscorrectregardinghermanagement?

A) Acoilisnotrecommendedassheisnulliparous
B) Sheshouldbeadvisedtohavescreeningforsexuallytransmittedinfection
C) TheIUDprimarilyexertsitscontraceptiveeffectbypreventingimplantation
D) ShecouldconsideraMirena(IUS)oracoppercoil(IUD)
E) Themostcommonreasonfordiscontinuationofintrauterinemethodsispain

Extended Matching Questions

Question81

Belowisalist(AK)ofpharmacologicaltreatmentsforhirsutism.Fromthislist,choosetheoption
whichbestsuitsthedescriptionsi)tovi)thatfollow.Eachoptionmaybeusedonce,morethanonce,
ornotatall.

A) Dianette
B) Spironolactone
C) Glucocorticoids
D) Vaniqua
E) Metformin
F) Danazol
G) Finasteride
H) Flutamide
I) Cilest
J) GnRHagonists
K) Sodiumvalproate

 i) Apotentandrogenreceptorantagonistwhichcarriesariskofhepatotoxicity
ii) A5reductaseinhibitor
iii) Anoralcontraceptivepillcontainingcyproteroneacetate
iv) Atreatmentforadultcongenitaladrenalhyperplasia
v) Anantiprotozoaldrugwhichalsohappenstoinhibithairgrowth
vi) Aninsulinsensitisingagent

Question82

Belowisalistofcauses(AJ)ofmaleinfertility.Fromthislist,pickthemostsuitablediagnosisthat
explainstheclinicalscenariodescribedincasesi)tov).Eachanswermaybeusedonce,morethan
once,ornotatall.

A) Retrogradeejaculation
B) Cryptorchidism
C) Prolactinoma
D) Congenitalbilateralabsenceofthevasdeferens
E) Klinefelterssyndrome
F) Useofanabolicsteroids
G) Previouschlamydiainfection
H) Androgenproducingtumour
I) Mildandrogeninsensitivitysyndrome
J) Mumpsorchitis

i) Threecausesthatwouldbeconsistentwithlowspermcounts,normalexaminationand
normalhormonelevels
ii) Atallmanwithgynaecomastia,scantypubichairandsmallfirmtestes
iii) Amanwithahistoryofhypospadiasrepair,normaltestes,elevatedlevelsofLHand
testosteroneandamutationintheandrogenreceptorgene
iv) ThreecausesofinfertilityassociatedwithhighFSHandLHlevels,andlowlevelsofandrogens
v) Amanwithatrophictestes,increasedlibido,normalerectilefunctionandlowlevelsofFSH,
LHandtestosterone
vi) Amanwithhighlevelsofandrogensandlowlevelsofgonadotrophins
vii) AmanfoundtohavemutationsintheCFTRgene

Question83
Belowisalistofmanagementoptions,AJ.Fromthislist,choosethesinglemostappropriate
answertothescenariosi)iv).
A) ICSI
B) Cabergoline
C) Folicacid5mg/day
D) Insulin
E) IValbumininfusion
F) LongGnRHaprotocol
 G) GnRHantagonistprotocol
H) IVF/PGD
I) Hysteroscopy
J) Hysterosonography

i)ApatientwiththreepreviousfailedIVFcyclesdespitesatisfactoryovarianresponseandgood
qualityembryos
ii) Apatientrecentlydiagnosedwithbreastcancerrequiringchemotherapywhohasbeen
referredforpreservationoffertility
iii) AdiabeticpatientwithBMIof35currentlyundergoingweightmanagementbefore
startingIVFtreatment
iv) ApatientwhohadOHSSinapreviousIVFcycleandhas30folliclesinhersecond
treatmentcycle

Question84

Belowarelistedtheriskcategories(AD)publishedbytheUKfacultyofsexualandreproductive
healthcarefortheuseofcontraceptivesincertainmedicalconditions.Fromthislist,pickthecorrect
categoryforthecontraceptionmedicalconditionpairingsdescribedinquestionstems(i)(xi).

(A) Category1
(B) Category2
(C) Category3
(D) Category4

(i) COCP(combinedoralcontraceptivepill)useinwellcontrolledhypertension
(ii) DMPA(Depotmedroxyprogesteroneacetate)useinaFactorVLeidenheterozygote
(iii) POP(Progesteroneonlypill)useinaninsulindependentdiabeticwithvasculardisease
(iv) UseoftheCuIUCDinsomeonebeingtreatedforaDVT
(v) UseoftheLNGIUD(Mirena)insomeonewithdiabeticretinopathy
(vi) DMPAusewithhypertensivevasculardisease
(vii) COCPuseinmildhypertension(150/94)
(viii) COCPuseinsomeonewithhistoryofgestationaldiabetesmellitus
(ix) COCPuseinsomeonewithvaricosevein
(x) DMPAuseinadequatelycontrolledhypertension
(xi) Implanonuseinseverehypertension

Question85
Belowisalist(AK)ofoptionsforinducingovulation.Fromthislist,choosethemostappropriate
optionfortheclinicalscenariosi)tovi),inwhichallthepatientsareanovulatoryandwantingto
becomepregnant.Eachanswercanbeusedonce,morethanonce,ornotatall.

A) Letrozole
B) Laparoscopicovariandrilling
C) Clomiphene50mgperday
D) Gonadotrophins
 E) Dietaryweightlossandexercise
F) Metformin
G) Clomipheneandbromocriptine
H) Bariatricsurgery
I) PulsatileGnRH
J) Clomiphene150mgperday
K) Noneoftheabove

i) ApatientwithaBMIof48,typeIIdiabetesandfailuretoloseweightwithdietarymeasures,
exerciseandOrlistat
ii) Awomanwithhyperprolactinaemiawhoisresistanttoclomiphene
iii) AwomanwithaBMIof36whoisresistanttoclomipheneandhasimpairedglucose
tolerance
iv) Awomanwithpersistentlyelevatedgonadotrophinlevels,andlowcirculatinglevelsof
oestrogen
v) AwomanwithaBMIof34,normallevelsofgonadotrophinsandanelevatedfreeandrogen
index
vi) AwomanwhohaslostweightandnowhasaBMIof25

Multiple Choice Questions

Question86

Answertrueorfalse

RegardingIVF:

A) ICSIisassociatedwithsignificantlylowerpregnancyratesthantraditionalIVF
B) Successratesarebetterwhenspermmotilityratesarehigher
C) Successisnotrelatedtospermcount
D) ThetechniqueofPESEextractsspermfromtesticularbiopsies
E) Themaleoffspringofinfertilemenarelikelytohaveahigherincidenceofinfertility
themselves

Question87

Regardingthetreatmentofhirsutism:

A) Antiandrogensareusuallythefirstlineoftreatment
B) About6monthsoftreatmentmaybenecessarybeforeaclinicaleffectcanbeseen
C) Combinedoralcontraceptivepillscontainingnorethisteronearepreferabletothose
containingotherprogestogens
D) Pharmacologicalagentsareeffectiveforthetreatmentofexistinghair
E) Eflornithineisunsuitableforwomenwithassociatedsevereacne

Question88

Answertrueorfalse

Thepolycysticovarysyndrome:
 A) Accountsfor20%ofcasesofanovulatoryinfertility
B) IsassociatedwithanincreasedriskofmiscarriagebecauseofLHhypersecretion
C) IsassociatedwithlowTSHlevels
D) IsassociatedwithincreasedFAI
E) Isassociatedwithmarkedlyelevatedserumprolactin

Question89
Answertrueorfalse
Withregardtoovarianhyperstimulationsyndrome:

A) Ittypicallypresentsatthepeakofoestrogenlevelsduringovarianstimulation
B) Themajorityofcasesrequireadmissiontohospitalandclosemonitoring
C) GnRHantagonistsaresaferthanagonistsinpatientswithpreviousOHSS
D) ItcanbepreventedcompletelybywithholdingtheHCGinjection
E) SingleblastocysttransferisadvisedforpatientsatriskofOHSS

Question90

Answertrueorfalse

A) Infertilityaffects1in6heterosexualcouplesintheUK
B) Sexhormonebindingglobulinlevelsareincreasedinpolycysticovariansyndrome
C) Highlevelsofleptinmayinhibitfolliculogenesis
D) Thereisnoevidencetosuggestweightlosswillimprovetheregularityofthemenstrualcycle
E) 40%ofpatientswithpolycysticovariansyndromeareobese

Question91

Answertrueorfalse

Regardingcontraceptiveuseinwomenwithbreastconditions:

A) Hormonalcontraceptioniscontraindicatedinwomenwithcurrentorrecentbreastcancer
(UKcategory4)
B) Hormonalcontraceptioniscontraindicatedinwomenwithapositivefamilyhistoryofbreast
cancer
C) TheWomensCAREstudyfoundincreasedriskofbreastcancertobeassociatedwithuseof
DMPA
D) OralhormonalcontraceptiveusereducesovariancancerriskinBRCA1andBRCA2carriers
E) (LNGIUS:Mirena)mayreducetheriskofendometrialabnormalitiesduringtamoxifen
therapy

Question92

Answertrueorfalse
A45yearoldwomanwithheavymenstrualbleedingrequestscontraceptionbutisnotkeenon
sterilisation.Afterexcludingapathologicalcauseforherbleedingyouadvisethat:

A) UseoftheCOCwillhaveabeneficialeffectonherriskofdevelopingovariancancer
B) TheCOCismoreeffectiveinreducingmenstruallossthantheIUS
C) Implanonisassociatedwithalossofbonemineraldensity
D) HRT/HTatthisageislikelytobecontraceptive
E) IfshehasanIUSfittedshecanretainituntilmenopause

Urogynaecology and the Pelvic Floor

SBAs
Question93
A38yearwomanattendstheurogynaecologyclinicwitha5yearhistoryofpainfulbladder
syndrome.ShehaspreviouslybeentreatedbyherGPwithmultiplecoursesofantibioticsfor
presumedurinarytractinfections.Sheisveryanxioustotryanylinesoftherapythatmightleadtoa
resolutionofhersymptoms.
WhichoneofthefollowingwouldNOTbeareasonableoptiontodiscusswithher?

A) Amitriptyline
B) Intravesicalhyaluronicacid
C) Alcoholavoidance
D) Dietarymodification
E) IntravesicalDMSO

Question94

A70yearoldwomanattendstheurogynaecologyclinicwithalongstandingmixedhistoryofstress
incontinenceandoveractivebladdersymptoms.Shewouldliketoproceedwithsurgicaltreatment
ofherstressincontinence,butherpreviousconsultanthasbeenreluctanttooperatethusfar.

WhichoneofthefollowingstatementsisNOTtrueregardinghermanagement?

A) Multichannelfillingandvoidingcystometryshouldbeperformedbeforesurgicaltreatment
B) Multichannelfillingandvoidingcystometryisnotrecommendedifsheoptsforongoing
conservativetreatment
C) Hertreatmentshouldfirstbedirectedtowardsheroveractivebladdersymptoms
D) Shewouldbenefitfromatrialofsupervisedpelvicfloormuscletrainingof6weeksduration
E) Duloxetinecouldbeofvalueinhermanagement

Question95
A45yearoldwomanattendsgynaecologyoutpatientswith8yearsofoveractivebladdersymptoms
sinceherlastdelivery.Shewouldliketoknowmoreaboutherconditionandwhatherfuture
optionsformanagementare.
Whichoneofthefollowingstatementswouldbeusefulincounsellingher?

A) Overactivebladderisverycommonandaffects40%ofwomen
B) Sheshouldundergofillingcystometrytoobtainaformaldiagnosisofhercondition
 C) Antimuscarinicsareausefulfirstlinetherapyformanagingsymptoms
D) Shecouldconsidertheuseofposteriortibialnervestimulation
E) Herconditioniscausedbyrecurrenturinarytractinfection

Question96
A68yearwomanhashada6monthcourseoftreatmentwithanantimuscarinicagentfor
idiopathicoveractivebladdersyndrome.Shehasattendedforaplanforfurthermanagement.
Whichoneofthefollowingistrueabouthermanagement?

A) Herchanceofsuccessfultreatmentwithantimuscarinicsisabout80%
B) Urinarydiversionshouldbeconsideredasasuitablenextstep
C) AtrialoftheanticholinergicdrugMirabegronisasuitablenextstep
D) Botulinumtoxinisasuitableoption,especiallyifsheisunabletodoselfcatheterisation
E) Ifsheproceedstoatrialofsacralnervestimulation,thenhercomplicationriskislow

Question97

A38yearoldwomanwithalongstandinghistoryofoveractivebladdersymptomsattendsa
urogynaecologyclinic.HerGPrecordsshowthatherthreemostrecentmidstreamurinesamples
havebothgrownStaphylococcusaureus.
Whichoneofthefollowingistrueregardingtherelevanceofthisresult?
A)Bacteriuria<105CFU/mlisnotconsideredrelevant
B)Asymptomaticbacteriuriamustalwaysbetreated
C)ThemostcommonuropathogenisStaphylococcusaureus
D)AllwomenwithrecurrentUTIshouldhaveacystoscopyperformed
E)Overactivebladdersymptomsareassociatedwithbacteriuria

Question98

A57yearoldwomanhasbeentroubledbyoccasionalurinarytractinfectionsassociatedwithsexual
intercoursesincegoingthroughthemenopauseaged55.Atherlastinfection,E.coliwerecultured
fromtheurine.

Whichoneofthefollowingistrueregardinghermanagement?

A) AshortcourseofantibioticswouldbelesseffectivethanalongcourseforsimpleUTIs
B) Trimethoprimisthepreferredantimicrobialtreatment
C) Escherichiacoliarerarelysusceptibletonitrofurantoin
D) LocaloestrogentherapywouldreduceherriskofrecurrentUTIs
E) Postcoitalnitrofurantoinisassociatedwithpulmonaryfibrosis

Question99

MrsGHisa50yearoldwomanwhocomplainsofincontinencewhenshecoughsorliftsher
grandchild.Shealsodescribessomeurinaryurgencyandvoidsabouttentimesaday.Shehashad
thesesymptomsfor2yearsandtheyareworsening.Shedeliveredbothherchildrenvaginally,andis
otherwiseingoodhealth.Shetakesstatins,butnoothermedication.

WhichofthefollowingstatementsisNOTtrueregardingherinitialmanagement?
 A) Sheshouldinitiallyhaveatrialofsupervisedpelvicfloorexercisesandbladderdrill
B) Shedoesnotrequireavaginalexaminationatthisstage
C) Shedoesnotrequireacystoscopyatthisstage
D) Shedoesnotrequirecystometryatthisstage
E) Sheshouldbeencouragedtomonitorherfluidintake,particularlyofcaffeinateddrinks

Extended Matching Questions

Question100

Foreachcasebelow(iiii),choosethesingletestmostsuitablefromthelistAK.

A. Standardcystometry
B. Flowstudies
C. Urethralfunctionstudies
D. Urinalysis
E. Ultrasoundofkidneys/ureters/bladder
F. Videocystometry
G. Neurophysiologicalbladderstudies
H. Bladderresidualscan
I. Ultrasoundofabdomenandpelvis
J. Midstreamurinesampleformicroscopy,cultureandsensitivities
K. Urethralswabformicroscopy,cultureandsensitivities

i) A45yearoldwomanwithtwochildrenbornbyvaginaldeliverypresentswithleakingwith
exercise,coughingandsneezingandoccasionalurgency.Shehastriedpelvicfloorexercises
withlittleimprovementinhersymptomsandseeksdefinitivetreatment.Onexamination
thereisminimalprolapseandurinalysisisclear.
ii) A76yearoldladypresentswithdenovosymptomsofurgencyandurgeincontinence.She
statesherabdomenfeelsmorebloatedandshecannotdothetopbuttonofhertrousersup
anymore.Urinalysisisclear.
iii) A54yearoldnulliparousladypresentswithrecurrentdysuriaandfrequencyworseningover
thepast4months.Shesmokes10cigarettesperday.RepeatedMSUsatherGPhavenever
demonstratedinfection.Urinalysisdemonstrates2+haematuria.Youhavesentarepeat
MSUformicroscopy,cultureandsensitivity.

Question101

Belowisalist(AP)ofmanagementoptionsforurinarydifficultiesexperiencedbywomen.Foreach
ofthecasesi)toiv)thatfollow,choosethemostappropriateoptionfromthelist.Eachoptionmay
beusedonce,morethanonceornotatall.

A) Midstreamurinesampleformicrobiology
B) Pelvicfloorexercises
C) Multichannelcystometry
D) Weightloss
E) Duloxetine
F) Oxybutynin
G) Tolterodine
H) Mirabegron
 I) Preoperativecounsellinginaclinicsetting
J) Casediscussioninmultidisciplinarysetting
K) JointmanagementwithUrology
L) Botulinumtoxin
M) Midurethralretropubictape
N) Midurethraltransobturatortape
O) Opencolposuspension
P) Laparoscopiccolposuspension

i) A40yearoldpresentswithleakingurine.Hersymptomsmainlyoccurwhilecoughing,
sneezingandgardening.Thereisalsosomedegreeofurgency.Thereisnoincontinence
demonstratedonexamination.Urodynamicssuggestevidenceofurodynamicstress
incontinence.
ii) A76yearoldwithaBMIof40presentswithsymptomsofincontinencewhichis
affectingherdailylife.Sheisontreatmentforheartfailure,unstableanginaandCOPD.
Pelvicexaminationrevealsasmallcystoceleandminimaluterinedescentwithleakage
oncoughing.Shehasalreadybeenreferredforphysiotherapywhichhasmadelittle
differencetohersymptoms.
iii) A35yearoldwomanpresentswithleakingonexercise.Sheisafitnessinstructorand
routinelydoestwosessionsaweek.Shedoesgiveahistoryofstrainingwhilevoiding.
Therearenosymptomsofurgencyorincreasedfrequency.Examinationisessentially
unremarkable.Shewantsadefinitivesolutiontoherprobleminordertoimproveher
qualityoflife.Shehasdone3monthsofpelvicfloorphysiotherapy.Uroflowmetryshows
max.flowrateof12ml/sandaverageflowrateof8ml/s.
iv) A45yearoldladypresentswithsymptomsofleakingurine.Sheleaksoncoughingbut
sherarelycoughs.Whenshewantstogotothetoiletshehassevereurgency.Shevoids
12timesadayandshewakestwiceatnighttopassurine.Shedoesnothaveanyvoiding
problems.Therearenoothermedicalcomorbidities.Bladderdiaryshowsadailyintake
ofaround1.5litres.Examinationisunremarkable.Shehasalreadytriedsupervisedpelvic
floorexercisesandbladderretraining.Shehasalsotriedoxybutyninanddarifenacin.

Gynaecology
Benign Gynaecology

SBAs
Question1

A36yearoldnulliparouswomanpresentswithabnormaluterinebleedingof2yearsduration.On
questioning,hercycleisregular,9/30days,andshedescribespassinglargeclotsandflooding
throughontoherclothes.

Answer1

C)Prolonged,heavymenstrualbleeding

Assessmentoffrequency,duration,regularityandheavinessisrequiredinthiswomanto
appropriatelydefinehersymptoms.Thefrequencyandregularityofbleedingisnormal.Normal
durationis4.58daysandthereforehermenstrualbleedingisprolonged.Theclotsandflooding
suggestbleedingthatsheisunabletocopewithandshehassubjectiveheavymenstrualbleeding.
Menorrhagiaisaredundantterm.Overall,thesesymptomsaresummarisedasprolonged,heavy
menstrualbleeding.

Question2

A47yearold,recentlyremarried,womanpresentswitha2yearhistoryofmenstrualirregularity
andhotflushes.Shebleedsevery14to40days,andthebleedingcansometimeslastaslongas2
weeks.Sheisotherwisewell,takesnomedicationandisasmoker.Arecentcervicalsmearwas
normal.Atransvaginalultrasoundscanshowsa10cmuteruswithtwosmallintramuralfibroidsand
anendometriumof18mmthickness.Apipellebiopsyshowsnoatypiaormalignantchange.

Answer2

D) LevonorgestrelIUSwithtransdermaloestrogen

Thekeyissuesarehersymptomsofirregularandprolongedmenstrualbleeding,herhotflushesand
herneedforcontraception.AlthoughtheCOCPwouldaddressalltheseconcerns,sheisasmoker
andthisisnotthemostappropriateoptiontherefore.CyclicalHRTmightnotregulatehercycle
successfullyandendometrialablationwouldonlytreatthebleeding.Tranexamicacidandcyclical
progestogenswouldnotprovidecontraceptionandarelesslikelytobesuccessfulortoleratedas
wellastheIUSwithsupplementaloestrogen.


Question3

A48yearoldwomanwithaBMIof24andnopersonalorfamilyhistoryofnotecomestoseeyouto
seekouttreatmentforseverehotflusheswhichareseriouslyinterferingwithhersleep.Shehas
heavyandirregularperiodsandalsocomplainsofsomediscomfortduringsexualintercourse.

Answer3

C) Mirenaintrauterinesystemandsystemicoestrogen

Thiswomanisexperiencingthemenopausaltransition.Althoughthereareanumberofmorelikely
reasonswhyshemaybeexperiencingdyspareuniaotherthanurogenitalatrophyfromoestrogen
deficiency,herhotsweatswillbeasaresultoftheimpendingmenopauseandthemosteffective
treatmentwillbesystemicoestrogenreplacement.Tiboloneandacontinuouscombinedregimeof
HRTarenotappropriatebecausesheisstillmenstruatingandtheseoptionsarelikelytofurther
complicatehervaginalbleeding.TheMirenawillprovideherwithcontraceptionandprotecther
endometriumfromthesystemicoestrogensheneedsforhersymptoms.Venlafaxinehasbeen
showntobeeffectiveinamelioratingvasomotorsymptoms,butlesssothanHRT.Shehasno
contraindicationstoHRTanditshouldbeofferedasfirstlineprovidedsheisalsocounselledabout
theotherprosandcons.

Question4

WhichoneofthefollowingstatementsabouttheconsequencesofHRTusewouldbeincorrectand
inappropriatetosharewiththepatientinquestion3,duringyourcounselling?

Answer4

D) Herriskofdementiawillbereducedinthelongterm

ThereisnogoodevidencethattheuseofHRTreducesthechanceofdevelopingdementia.
Osteoporoticfracturesarereducedinincidence,andtheriskofvenousthromboembolismand
breastcancerisincreased,toadegree.Althoughthe2002WomensHealthInitiativeinitially
reportedthatmortalityandmorbidityfromcardiovasculardiseasewasincreasedinHRTusers,
closerexaminationofthedatashowedthatthiseffectwasconfinedtoolderwomenwhohadgone
throughthemenopausemanyyearsbefore.Indeed,forwomenlikethispatientwhoarein
transition,oronlyrecentlymenopausal,theuseofHRTreducescardiovascularriskandallcause
mortality.

Extended Matching Questions

Question5

Belowisalistofevidencebasedtreatmentoptions(AK)commonlyavailabletopatientswith
vulvodynia.Fromthislist,selectthemostappropriateoptionsforthestatementsgivenafterwards
(iv).

i) Listfourfirstlinetreatmentsusedforprovokedvulvodynia(vestibulodynia)
ii) Listthreefirstlinetreatmentsusedforunprovokedvulvodynia
iii) Listtwotreatmentsthatdealwiththecentralsensitisationofpain
iv) Listfivetreatmentsthathelpovercomelevatormusclehypertonicity
v) Listthreesecondlinetreatments

Answer5

i) A,E,F,G(biofeedback,lignocaine,vaginaltrainersandvaginalmassage)
ii) B,C,D(nortryptiline,acupuncture,gabapentin)
iii) B,D(nortryptilineandgabapentin)
iv) A,F,G,H,J(biofeedback,vaginaltrainers,vaginalmassage,Botox,triggerpointtherapy)
v) D,H,K(gabapentin,Botoxandvestibulectomy)

Question6

Thefollowing(AL)havebeendemonstratedtobeeffectivetreatmentsinthenonpsychosexual
managementofsomeoftheelementsofdyspareunia.Pleaseselectthemostappropriateoptionfor
eachclinicalscenario(ivi).

i) A29yearoldwomanwithchronicpelvicpain.Examinationandpreliminaryinvestigations
includingpelvicultrasoundandvaginalswabshavesofarbeennormal

ii) A23yearoldwomaninanewrelationshipwithalongstandinghistoryofvaginismus
withoutanyclearprecipitatingfactors

iii) A65yearoldwomanwithsuperficialdyspareuniaandpostcoitalbleedinginwhomvaginal
ultrasoundandbiopsyarenormal

iv) A35yearoldwomanwithwidespread,laparoscopicallyproven,endometriosis

v) A32yearoldwomanwhohashadsuperficialdyspareuniasincethebirthofherlastchild,
whichwasbyforceps.Onexaminationshehasasmalldegreeofintroitalnarrowing
wheretheepisiotomywassited

vi) A38yearoldwomanwithvulvodyniainwhomsimpleanalgesiahasbeenfoundtobe
ineffective

Answer6
 i) K.AnalgesicsandNSAIDmedications
ii) F.Vaginaltrainers
iii) C.Vaginaloestrogens
iv) H.GnRHanalogueswithaddbackHRT
v) F.Vaginaltrainers
vi) J.Amitriptyline

Question7

Belowisalistofimagingmodalities(AF)thatmightbeusedintheinvestigationofgynaecological
pathology.Fromthislist,pickthemostappropriateinvestigationforthesituationsdescribed
thereafter(iviii).

i) Theprimaryimagingmodalityforsuspectedgynaecologicalpathologyinanobesewoman
ii) Theimagingmodalityofchoiceforcongenitalanomalies
iii) Aninvestigationthatisusefulinthedetectionofdistantmetastasesfromgynaecological
cancers
iv) Theinvestigationofchoiceforstagingcervicalcancer
v) Theimagingmodalityofchoicewhenultrasoundfindingsareindeterminate
vi) Afunctionaltechniquewhichmaybeemployedtodetectcancerrecurrences
vii) Theimagingmodalityofchoiceforstagingovariancancer
viii) Theinitialinvestigationforsuspectedbowelobstructionindisseminatedovariancancer

Answer7

i) F.Transvaginalultrasoundscan
ii) E.MRI
iii) C.CTscan
iv) E.MRI
v) E.MRI
vi) B.PET/CT
vii) C.CTscan
viii) D.AbdominalXray

Question8

Belowisalistofcausesofvulvalpruritus(AJ).Fromthislist,choosethemostappropriateanswers
tothequestionslistedafterwards(iv).

A) Vulvovaginalcandidiasis
B) Lichensclerosus
 C) Vulvarfolliculitis
D) Vulvalintraepithelialneoplasia
E) Psoriasis
F) Tineacruris
G) Eczema
H) Lichensimplexchronicus
I) Allergicdermatitis
J) Lichenplanus

i) Twovulvalconditionstreatedwithfluconazoleorclotrimazole
ii)Fourconditionstreatedwithtopicalsteroids
iii)
Aconditionsometimestreatedbysurgicalexcision
iv)Threeconditionswhereenvironmentalfactorsortriggersareparticularlyimportantto
consider
v) Aconditionthatshouldrespondwelltoantibiotics

Answer8

i) AandF(VulvovaginalcandidiasisandTineacruris).Thesearebothfungalconditions
affectingthevulva
ii) AnyfourofB,E,G,H,IandJ(Lichensclerosus,Psoriasis,Eczema,Lichensimplex
chronicus,Allergicdermatitis,Lichenplanus).
iii) D(Vulvalintraepithelialneoplasia).VINshouldbekeptundersurveillance.Highgrade
VINmayneedtobetreatedwithlaserablationorsurgicalexcision
iv) E,GandI(Psoriasis,Eczema,Allergicdermatitis).Asearchforenvironmentalcausesor
triggersisimportantinpsoriasis,eczemaandallergicdermatitistolimitflaresandthe
needfortopicalsteroids
v) C(Vulvarfolliculitis).FolliculitisisnormallycausedbyStaphylococcusaureusand
antibacterialwashesandtopicalantibioticsareusuallyeffective

Question9

Foreachoftheultrasoundscanreportsgivenbelow(ivi),choosethesinglebestchoicefromthelist
ofleiomyomaclassifications(AK).

i) A5cmfibroidisseenontheouteraspectoftheanterioruterinewallextendingintothe
myometriumby10%
ii) Thereisasubmucosalfibroidontheposterioruterinewall,whichis2cmindiameter.It
extendsintotheendometrialcavityanddoesnotinvolvemuchofthemyometrium
iii) Thereisa7cmmassintheabdominalcavity;itappearstobeseparatefromtheovariesand
maybeattachedtotheuterusbyastalk.
iv) Thecervixcontainsa3cmfibroid,distortingthecervicalcavity
v) Alargeanteriorfibroidisdistendingtheuterinecavityandextendsthroughoutthe
myometriumtobecomesubserosalinnature
vi) Thereisa3cmintramuralfibroidthatcontactstheendometriumbutdoesnotdistendthe
cavity

Answer9

i) G. AUBLO6
ii) B. AUBLSM1
iii)H. AUBLO7
iv) I. AUBLO8
v) J. AUBL25
vi) D. AUBLO3

(seeRedefinitionandreclassificationofmenstrualdisordersFigure2foranexplanation:in
Obstetrics:PreparefortheMRCOGonwww.ExpertConsult.com)

Question10

Belowisalist(AK)ofprobabilities/proportions.Fromthislist,choosethenearestvalueappropriate
forthequestionsgivenafterwards(ivii).

i) Theriskofdeathwithin6weeksfollowingahysterectomy
ii) Theriskofurinarytractdamageatthetimeofhysterectomy
iii) Thereductioninmenstrualbloodlosswithmefenamicacid
iv) Theriskofovariancancerfollowingtotalabdominalhysterectomywithovarianconservation
v) Theriskofbloodtransfusionassociatedwithhysterectomy
vi) Theriskofcyclicalbleedingfromthecervixfollowingsubtotalhysterectomy
vii) Theproportionofwomenbecomingamenorrhoeicfollowingasecondgeneration
endometrialablation

Answer10

i) L.32inevery100,000women
ii) H.7inevery1000
iii) B.Overalla25%reductioninthevolumeofmenstrualbloodloss
iv) G.Alifetimeriskof1in72
v) F.23per1000
vi) C.A15%chance
vii) A.4050%chanceofamenorrhoea

Question11

Foreachcasesummarybelow(iv),choosethemostsuitableinvestigation(s)fromthelistbelow(A
J).

i) A29yearoldnulliparahasirregularperiodswhichoccurapproximatelyevery6months.She
alsogivesahistoryofgalactorrhoeaandheadaches.Sheisnotsexuallyactive.Whichkey
 singleinvestigationshouldbeperformed?
ii) A14yearoldisadmittedwithveryheavybleedingduringherfirstperiod.Whichtwokey
investigationswouldyoudotofindacause?
iii) A30yearoldnulliparahasahistoryofirregularbleedingoccurringapproximatelyevery3
months.Shegivesahistoryofrecentweightgainandworseningacne.Whichtwo
investigationswouldyouchoosefromthelistabove?
iv) A51yearoldpresentswithahistoryoferraticbleedingwithnopattern.Herperiodswere
previouslyfairlyregular.
v) A42yearoldpara3withalonghistoryofheavyregularperiodsovermanyyearshashadan
ultrasoundscanwhichconfirmsmultipleuterinefibroids.Shewishestohaveuterineartery
embolisationandhasbeensterilisedinthepast.Whichinvestigationshouldbeperformed
beforeschedulingherforthistreatment?

Answer11

i) G(Serumprolactin).Thispatientprobablyhasoligomenorrhoeaduetoanovulation.Her
historyofgalactorrhoeasuggestshyperprolactinaemiaasthecause.
ii) A,I(VonWillebrand'sfactor,Plateletcount).Heavyperiodsfrommenarcheissuggestiveof
apossiblecoagulationdisorder.Themostcommontopresentatmenarchearevon
Willebrandsdiseaseandplateletdisorders.
iii) C,F(Pelvicultrasoundscan,Serumandrogenmeasurement).Thehistoryofacneandweight
gaininapatientwitholigomenorrhoeasuggestsanovulationsecondarytopolycysticovarian
syndrome.Serumandrogensandapelvicultrasoundscanwillaidinthediagnosis.
iv) C,E(Pelvicultrasoundscan,Outpatienthysteroscopywithendometrialbiopsy).Thispatient
hasasignificantriskofprecancerousorcancerouslesionoftheendometriumandthus
shouldbeassessedthoroughlywithatransvaginalultrasoundscan,hysteroscopyand
endometrialbiopsytoruleoutseriouspathology.
v) J(MagneticResonanceImagingoftheabdomenandpelvis).UAEisanappropriate
treatmentmodalityformenorrhagiainapatientwithuterinefibroidswhohascompleted
herfamily.AnabdominalandpelvicMRscanispartofthepreproceduralworkup.

Question12

Foreachcasesummarybelow(iv),choosethemostsuitablemanagementoption(s)fromthelist
below(AJ).

i) A19yearoldnulliparapresentswithahistoryofheavyregularperiodswithanormalpelvic
ultrasoundscan.Sheisnotsexuallyactiveatthemoment,buthasbeeninthepast.Which
fourmanagementoptionswouldyouoffer?
ii) A28yearoldpara1describesahistoryofheavyregularperiodsthathaveresultedin
significantanaemiarequiringbloodtransfusion.Abdominalexaminationrevealsa28week
sizeduterinemassandultrasoundscanconfirmsmultipleuterinefibroidsintheintramural
andsubserosallayersoftheuterus.Sheiskeenonhavinganotherbabyinthefuture,butis
notactivelytryingatthemoment.
iii) A32yearoldpara3,whohasbeensterilisedpreviously,attendsforheavyperiods.Clinical
examinationrevealsanormalsizeduterus.Listfiveoptionsopentoher.
iv) A17yearoldwithahistoryofvonWillebrandsdiseaseisreferredbyherhaematologistfor
controlofherperiods.Whichthreeoptionswouldyoudiscusswithher?
 v) A50yearoldpara2presentswithahistoryofirregularbleeding.Shehashada
hysteroscopyandendometrialbiopsy,revealingcomplexhyperplasiaoftheendometrium
withatypia.Sheisfitandotherwisewell.

Answer12

i) C,E,F,G(MirenaIUS,Combinedoralcontraceptivepill,Mefenamicacid,Tranexamicacid).
Anyoftheseoptionswouldbeappropriateastheywillnotimpairfertility,butarelikelyto
reducemenstrualloss.
ii) J(Myomectomy).Amyomectomyisthemostappropriatetreatmentforthispatientwhose
heavybleedingduetofibroidsiscausingsignificantanaemia.UAEandhysterectomyarenot
appropriateoptionsasshewishesapregnancyinthefuture
iii) A,C,E,F,G(Endometrialablation,MirenaIUS,Combinedoralcontraceptivepill,Mefenamic
acid,Tranexamicacid).Thesearealloptionsasthepatienthascompletedherfamilyandhas
beensterilised.Hysterectomyshouldbeconsideredalastresortinsuchapatient.
iv) E,F,I(Combinedoralcontraceptivepill,Mefenamicacid,Desmopressin).Mefenamicacid
andthecombinedoralcontraceptivepillarefirstlineoptionsincasesofclottingdisorder.
DesmopressinisaspecificmanagementoptionforsometypesofvonWillebrandsdisease.
v) B(Hysterectomy).Thispatienthasasignificantriskofcoexistentendometrialcarcinoma
andasignificantriskofprogressiontocarcinoma,thereforehysterectomyisthebest
managementoption.

Question13

Fromthelistbelow(AL)ofvulvaldisorders,choosethemostlikelydiagnosisfortheclinical
scenariosdescribedafterwards(iv).

i) Aconditionwheregenitalulcerationisoftenfoundwithocularinflammation,suchasuveitis
ii) Aninfectiouscondition,causingvulvalerythematousplaques,whereskinscrapingsmay
showTrichophyton
iii) Anoninfectiousautoimmuneconditioncausingsevereitchingandshinywhitepatcheson
thevulva
iv) AvulvalinfectioncharacterisedbyacoralpinkfluorescenceunderaWoodslight
v) Avulvalconditionofunknowncausethatoftenpresentswithpurplepapulesand
abnormalitiesoftheskin,hairandoralmucosa

Answer13

i) H.Behetsdisease
ii) L.Tineacruris
iii) G.Lichensclerosus
iv) I.Erythrasma
v) C.Lichenplanus

Question14

Withregardstothemedicaltreatmentofdysmenorrhoea,foreachstatementbelow(iviii)choose
themostsensiblechoicefromthelistgiven(AK).

i) Firstlinetreatmentina15yearoldgirlwithdysmenorrhoea

ii) Idealtreatmentfora40yearoldsmokerwithconcomitantmenorrhagia

iii) Aconservativedietarysupplementthatcanreducepainandbloodflow

iv) Adietarysupplementwhichmaycausenausea,vomitingandworsenacne

v) Couldbeusedastrialofbenefitofoophorectomywheresymptomsarerefractorytomore
conservativetreatments

vi) Secondlinetreatmentforprimarydysmenorrhoea

vii) Atreatmentfordysmenorrhoeasuspectedtobesecondarytoendometriosisinayounggirl

Answer14

i) A.Ibuprofen.NSAIDsarefirstlinetreatmentfordysmenorrhoea.Thereisnoevidencethat
ibuprofenandparacetamolismoreeffective.BecautiousofGIsideeffects.

ii) G.MirenaIUS.Itisnotlicensedfordysmenhorrhoeaalonebutislicensedandrecommended
astreatmentformenorrhagia.

iii) E.VitaminE.Alargerandomisedtrialhasshownbenefitinadolescents.

iv) J.Omega3oil.

v) D.GnRHanalogues.Thesecausecompleteovariansuppressionandwouldreplicate
medicallytheeffectanoophorectomywouldhave.Theyareforrefractorysymptomsin
someoneusuallywithsecondarydysmenorrhoeaconsideringhysterectomyplusorminus
removalofovariesasatreatment.

vi) C.COCP.Suppressionofovulationwillinhibittheincreaseandwithdrawalofprogesterone
inthelutealphaseofmenstrualcyclethatstimulatesprostaglandinproduction.

vii) H.TricycleCOCP.Theextendeddurationoftakingthreepillpacketsconsecutivelyis
associatedwithlesspainthanwithamonthlywithdrawalbleed.

Question15

Regardingthemedicaltreatmentofdysmenorrhoea,foreachcasescenariobelow(iviii)choosethe
mostsensiblechoicefromthelistgiven(AJ).

 i) A14yearoldwhoissexuallyactivewithdysmenorrhoeaandnotcurrentlyusing
contraception

ii) A38yearoldwithincreasedBMIrequiringcontraceptionandtreatmentfordysmenorrhoea

iii) A27yearoldwithmildheartburnandhistoryofVTE
iv) A16yearoldwithdysmenorrhoea

v) A23yearoldwithvaginismusandvonWillebrandsdisease

vi) Awomankeenfornonpharmacologicalremedies

vii) A37yearoldwithdiabeticnephropathy

viii) A34yearoldwithmilddymenorrhoea,whosehusbandhashadavasectomy

Answer15

i) F.COCP.Anonsteroidalantiinflammatoryanalgesicwouldbefirstlinebutinayoungage
grouponeaimstoincreasecompliancewithleastamountofmedicationandprovide
effectivecontraception.

ii) A.Mirena.Thecombinedoralcontraceptivepilliscontraindicatedinanobesesmokerover
35years.TheMirenawillprovidecontraceptionandrelievedysmenorrhoeaforher.One
couldconsiderlaparoscopytoinvestigatethecauseofdysmenorrhoeainawomaninher
thirddecade.However,itisrecommendedtotryconservativetreatmentsasafirstlinegiven
theriskofnegativelaparoscopyandtheincreasedsurgicalriskinawomanwithincreased
BMI.

iii) B.Ibuprofenandomeprazole.TheCOCPiscontraindicatedwithpreviousVTEandsomeform
ofgastricprotectionwouldberecommendedinviewofherhistoryofheartburn,ratherthan
givinganNSAIDalone.

iv) E.Ibuprofen.Firstlinetherapyfordysmenorrhoea.

v) F.COCP.OnewouldavoidNSAIDsinthisladyduetotheriskofincreasingvaginalbleeding.

vi) H.Acupuncture.Thereisevidencethatacupunctureisbeneficialwhereasthereisno
evidencetorecommendTENSfordysmenorrhoeaandanywayonewouldbelikelytohave
towearitforseveraldays.

vii) A.Mirena.COCPandNSAIDsarecontraindicatedindiabeticnephropathy.

viii) E.Ibuprofen.Firstlinetreatmentfordysmenorrhoea.

Multiple Choice Questions

Question16

Thefollowingtherapiesaresuitableformanagingthesymptomsofawell,45yearold
perimenopausalwoman:
 A) Tibolone
B) CyclicalHRT
C) Lowdosecontraceptivepill
D) Selectiveserotoninreuptakeinhibitor
E) OestrogenonlyHRT

Answer16

A) False
B) True
C) True
D) True
E) False

Ifthewomanstillhasauterus,thenshemustnotreceiveunopposedoestrogen.Tiboloneis
commonlyassociatedwithirregularbleedinginperimenopausalwomen,whichmaybe
inconvenient,andalsogiveunnecessaryconcernregardingunderlyingpossiblepathology.Thelow
dosecombinedpillisnotcontraindicatedbyageperse.SSRIsmaybehelpfulintreatinghotflushes.

Question17

Menopausalinducedurogenitalatrophymayresultin:

A) Vaginaldryness
B) Painfulsexualintercourse
C) Arousalfailure
D) Abnormalpapsmear
E) Lackofvaginallubrication

Answer17

A) True
B) True
C) True
D) False
E) True

Question18

Considerthefollowingstatementsaboututerineassessmentasaninvestigationofabnormaluterine
bleedinginperimenopausalwomen.

A) Hysteroscopyisthefirstlinetestforassessingtheuterus
B) Sonohysterographycanaccuratelyassessthepositionandsizeofsubmucousfibroids
C) IftheendometrialthicknessonTVUSSis2mmthenendometrialhyperplasiaisunlikely
D) AllpatientswithpostmenopausalbleedingshouldhaveaD&C
E) SonohysterographyisbetterthanTVUSSatdetectingsubserosalfibroids


Answer18

A) False
B) True
C) True
D) False
E) False

Theusualfirstlinetestforassessingtheuterusistransvaginalultrasound.D&Cisnolongerthebest
testforinvestigatingpostmenopausalbleeding.Hysteroscopycanhelpdelineatefocallesions.
Sonohysterographyisgoodatassessingsubmucousfibroidsandotherintracavitylesionssuchas
polyps.IftheETis4mmorlessthenendometrialhyperplasiaisunlikely.IftheETis5mmormore
thenhysteroscopyandbiopsyshouldbeperformed.

Question19

Regardingmalesterilisation:

A) Thefailurerateforvasectomyis1in2000
B) Vasectomyneedstobedoneundergeneralanaesthetic
C) Vasectomyiseffectiveimmediately
D) Chronictesticularpainaffectingqualityoflifeisacommoncomplicationfollowing
vasectomy
E) Vasectomyisassociatedwithincreasedriskoftesticularandprostatecancer

Answer19

A) True
B) False
C) False
D) False
E) False

Vasectomyisaveryeffectivemethodofsterilisation.Itismoreeffectivethanfemalesterilisation
andlongactingreversiblemethodsofcontraception.Thetechniqueisverysimpleandisusually
doneunderlocalanaestheticinanofficesetting.Theprocedureisassociatedwithlowmorbidityand
extremelylowmortalityrate.Vasectomyisnoteffectiveimmediately.Itmaytake12weeksormore
orsomewherebetween12and20ejaculationsbeforetheejaculateisspermfree.Itisimportantto
counselpatientsandeffectivecontraceptionmustbeusedintheinterveningperiod.Theincidence
ofchronicorchalgiaisquitehigh(1252%).Theproportionofpatients,however,whosequalityof
lifewasaffected,orthosewhosoughttreatmentwasmuchlower(2.215%).Vasectomydoesnot
seemtobeassociatedwithanysignificantlongtermphysicalormentalhealthproblems.Well
designedepidemiologicalstudieshaveshownnoassociationwithtesticularorprostatecancer.

Question20
Regardingfemalesterilisation:

A) Thevaginalapproachtothetubesisthepreferredchoice
B) Postpartumsterilisationisequallyeffectiveasintervalsterilisation
C) Hysteroscopicsterilisationislessinvasiveandaseffectiveaslaparoscopicsterilisation
D) WomenundergoingsterilisationneedtobecounselledonLARC
E) Thereisanincreasedriskofregretinpatientsunder30yearsofage.

Answer20

A) False
B) False
C) True
D) True
E) True

Thevaginalapproachtothetubesisassociatedwithincreasedinfectionratesandistechnically
moredifficult.ThereforethisapproachisnotrecommendedbytheRoyalCollegeofObstetricians
andGynaecologists.Postpartumsterilisationisassociatedwithincreasedriskoffailureandregret
comparedtointervalsterilisation.Clientsshouldbemadeawareofthisfactbeforetheyundergothe
procedure.Hysteroscopicsterilisationmethodshavebeendevelopedtoavoidtherisksof
laparoscopyandforthosewomeninwhomlaparoscopyiscontraindicated.Initialstudieshave
showntheproceduretobeaseffectiveaslaparoscopicsterilisation.Clientsrequestingsterilisation
shouldbemadeawareoflongactingreversiblemethodofcontraceptionandthatthe
Levonorgestrelintrauterinesystemandhormoneonlyimplantsaremoreeffectivethanfemale
sterilisation.Ina2yearfollowupanalysisoftheCRESTdata,womenlessthan30yearsofagewere
fourtosixtimesmorelikelytoexperienceregretthanwerewomenagedmorethan30years(a4.3%
incidenceofregretinwomenaged2024yearsversusa2.4%incidenceforwomenaged3034
years,at5yearfollowup).

Question21

ThefollowingriskissuesareontheNationalPatientSafetyAgency(NPSA)listofneverevents:

A) TransfusionofABOincompatibleblood
B) ThedeliveryofababywithanumbilicalarterialpHof<7.0
C) Removaloftheincorrectovary
D) Retainedswabfollowingperinealrepair
E) Unintentionalligationoftheureterathysterectomy

Answer21

A) True
B) False
C) True
 D) True
E) False

Nevereventsaredefinedasserious,largelypreventablepatientsafetyincidentsthatshouldnot
occuriftheavailablepreventativemeasureshavebeenimplementedbyhealthcareproviders.The
NationalPatientSafetyAgency(NPSA)hascompiledalistofnevereventswiththeaimofraising
awarenessofsuchincidents,andwrongsitesurgery,retainedforeignobjectsaftersurgeryandthe
transfusionofABOincompatiblebloodcomponentsareallonit.Withsystemsinplace,allthese
eventsshouldbepreventable.Evenwithgoodstandardsofcare,andexcellentsurgicalskills,babies
willcontinuetobeborninpoorconditionandureterswillbedamagedduringdifficultpelvicsurgery.
Itisnotpossibletoputguidelinesandsafetymeasuresinplacetoalwaysstoptheseunfortunate
eventshappening.

Question22

Dyspareuniais:

A) Aformofsexualdysfunctionassociatedwithgenitalpainexperiencedonlyduringsexual
intercourse
B) Ispresentonlyinwomen
C) Isusuallyconditionalwhenpsychosocialcausesareimplicated
D) Accountsforonlyasmallproportionofallcasesofsexualdysfunctionreachingmedical
attention
E) Hasbothphysicalandpsychologicalcomponents

Answer22

A) False
B) False
C) False
D) True
E) True

Dyspareuniaisgenitalpainexperiencedjustbefore,during,oraftersexualintercourse,andcan
affectbothmenandwomen.Althoughitsprevalence,andcontributiontoallsexualdysfunction,
variesdependingonthepopulationstudied,itisalesscommonpresentationofsexualdysfunction
thanproblemsofdesire,arousalandorgasm.Itismultifactorial,butwhenpsychosocialcausesare
implicateditismorelikelytobeconditional.

Question23

Withregardstosexualintercourseafterchildbirth:

A) Themajorityofwomenaresexuallyactivewithin34monthsofdelivery
 B) Sexualactivityduringearlypregnancyisassociatedwithincreasedsexualsatisfactionat3to
4monthsfollowingdelivery
C) Nearly25%ofprimiparouswomenwillexperiencelackofsexualsensationandorgasm6
monthsfollowingdelivery
D) Youngermaternalageisassociatedwithdelayedresumptionofsexualintercoursefollowing
delivery
E) Postnatalphysiologicalchangesmayleadtohypoactivesexualdesire

Answer23

A) True
B) True
C) True
D) False
E) True

Althoughnearly90%ofwomenresumesexualactivitywithin34monthsofchildbirth,4outof5
willexperiencedifficultiesofonesort,oranother.Satisfactionwithsexafterchildbirthdependson
manyfactorsbutyoungerwomen,andthosewhoremainedsexuallyactiveduringtheearlierpartof
thepregnancy,arelesslikelytobedissatisfied.

Question24

Inthetreatmentofdyspareunia:

A) Psychosexualcounsellinghasbeenshowntobeofvalueatanystageofmanagement
B) Androgenicdrugsareusefulduetotheireffectofimprovinglibido
C) Mostpatientsareeffectivelytreatedfollowingthefirstclinicvisit
D) Antibioticshavebeenshowntobeeffective
E) Vaginaloestrogensmaybeeffectiveinpremenopausalwomen

Answer24

A) True
B) False
C) False
D) False
E) False

Question25

Progesteronereceptormodulators:

A) Areassociatedwithhypoestrogenism
B) Areagoodtreatmentforthosewhohavesymptomsrelatedtofibroidsizealone
C) Leadtoasignificantdecreaseinmenstrualbloodloss
 D) Mayalsobeusedforemergencycontraception
E) Areassociatedwithanincreaseinhaemoglobin

Answer25

A) False
B) False
C) True
D) True
E) True

Progesteronereceptormodulatorsdonotaffectovarianfunctionandthereforefollicularphase
levelsofoestrogenoccur,unlikewiththeGnRHagonists.Theyproducemodestfibroidshrinkage,
possiblyonly20%,andarethereforeunlikelytobesuitableforthosewishingtohavetreatment
becauseofsizealone.Theyareextremelyeffectiveatdecreasingmenstrualbloodloss,whichoccurs
veryquickly,andthushaemoglobinlevelsincrease.Theyarealsolicensedforuseasanemergency
contraceptivebecauseoftheireffectonthecorpusluteumandtheendometrium.

Question26

UterineArteryEmbolisation:

A) Iscontraindicatedinthosedesiringpregnancy
B) Isausefultreatmentforfibroidassociatedheavymenstrualbleeding
C) Requiresangiographytodefinethebloodvessels
D) Isassociatedwithareinterventionrateofover30%
E) Isassociatedwithahigherrateofrecurrencethanaftermyomectomy

Answer26

A) False
B) True
C) True
D) False
E) False

UterineArteryEmbolisation(UAE)isauterussparingtechniquethatrequiresangiographyaspartof
thestandardproceduretooutlinethebloodvessels.Itissuitableforthosedesiringpregnancy
althoughcarefulcounsellingregardingpotentialsideeffectsisrequiredaspregnancycomplications
havebeenshowntobeincreasedinsomesmallstudies.Itisaveryeffectivetreatmentforheavy
menstrualbleedingalthoughthebenefitmaynotbeimmediatelyapparent.Reinterventionoccurs
inupto25%at5years,usuallyduetosymptomrecurrencebuttherateofregrowthanddenovo
reappearanceoffibroidsisverysmallandmuchlessthanaftermyomectomy.

Question27

Riskfactorsforendometrialhyperplasiainclude:

A) Hormonereplacementtherapy
B) Thecombinedoralcontraceptivepill
C) Nulliparity
D) Obesity
E) TheMirenacoil

Answer27

A) True
B) False
C) True
D) True
E) False

Theriskfactorsforendometrialhyperplasiaarethesameasthoseforendometrialcarcinoma.
Endometrialhyperplasiaresultsfromexposureoftheendometriumtooestrogenunopposedbya
progestogen.Unopposedoestrogencanbeofanendogenousorexogenoussource.Endogenous
sourcesofoestrogenincludechronicanovulation,obesity,diabetes,PCOSandhormonesecreting
tumours.ExogenoussourcesofoestrogenexposureincludeHRTandtamoxifen.TheCOCPand
Mirenacoilarenotriskfactorsforendometrialhyperplasiaandcanbeusedinthetreatmentofthis
condition.

Question28

Patientssuspectedofhavingendometrialhyperplasiashouldhavethefollowinginitial
investigations:

A) Transvaginalultrasoundscan
B) MRIpelvis
C) Hysteroscopyandendometrialbiopsy
D) CA125
E) LHandFSH

Answer28

A) True
B) False
C) True
D) False
E) False

Investigationofwomenpresentingwithabnormaluterinebleedingwouldnormallyincludea
transvaginalultrasoundscanandendometrialsampling.Thegoldstandardfordiagnosisof
endometrialhyperplasiaishysteroscopyandendometrialbiopsy.MRIpelvisisnotcurrently
recommendedfortheinvestigationofwomenwithsuspectedendometrialhyperplasia.Thereisno
roleforCA125,LHorFSHintheinvestigationofendometrialhyperplasia.

Question29
Thefollowingactionswouldbeappropriatemidwaythroughahysteroscopicmyomectomywhenthe
surgeonnoticesthatthereisanelectrolytefluiddeficitof1200ml:

A) Informtheanaesthetist
B) Stoptheprocedure
C) Checktheelectrolytes
D) Considerfrusemide
E) Useglycineasthedistensionmediainstead

Answer29
A) True
B) False
C) True
D) True
E) False

Therearerecommendationsfortheactionsthatsurgeonsandanaesthetistsshouldtakewhena
fluiddeficitdevelopsduringhysteroscopicsurgerywithagradedresponsedependingonthevolume
andthetypeofdistensionmediaused.Nonelectrolytemediaarehypotonicandgivegreatercause
forconcernatlowervolumedeficits,thandoelectrolytebasedmedia.Withadeficitof1200ml,itis
reasonabletocontinuetheprocedure,butbringittoacloseassoonaspossible.Electrolytesshould
becheckedandfrusemidegivenifthereisanyconcernregardingpulmonaryorcerebraloedema.
Changingtoanonelectrolytedistensionmediawouldnotbesensibleasthiswouldincreasetherisk
ofoedemadeveloping.

Question30
Whencounsellingpatientsaboutfirstandsecondgenerationendometrialablativetechniques:
A) Firstgenerationtechniquesareeasiertoperform
B) Secondgenerationtechniqueshavebetteroutcomesat5years
C) Firstgenerationtechniquestakelonger
D) Thechanceofequipmentfailureisgreaterwithsecondgenerationtechniques
E) Thereisagreaterriskofcomplicationswithsecondgenerationtechniques

Answer30
A) False
B) False
C) True
D) True
E) False

Althoughsatisfactionratesat2yearsmaybegreaterwithsecondgenerationtechniquesof
endometrialablation,thereisnodifferenceinoutcomesat5years.Firstgenerationtechniquestake
longerandcarryagreaterriskofcomplicationsthandosecondgenerationtechniques.Thelatterare
morelikelytobehamperedbyequipmentfailure.

Question31
Regardingheavymenstrualbleedinganditstreatments:
A) Levonorgestrelreleasingintrauterinesystemreleases24microgramsofthehormoneper24
hours
B) Routinepelvicexaminationisunnecessaryinwomenwithheavymenstrualbleeding
C) Thyroidfunctiontestsshouldnotbeperformedroutinelywhileinvestigatingwomenwith
heavymenstrualbleeding
D) 80%ormoreofwomenhavingsecondgenerationendometrialablationtechniquesachieve
amenorrhoea
E) Prophylacticbilateraloophorectomyatthetimeofhysterectomyeliminatestheriskof
developingovariancancer

Answer31

A) False
B) False
C) True
D) False
E) False

TheMirenaIUSreleases20microgramsovera24hourtimeframe.Internalexaminationisonly
requiredforheavymenstrualbleedingifastructuralabnormalityormassissuspected.Routine
testingforthyroiddisordersisnotrecommendedintheworkupofforheavymenstrualbleeding.
Mostfollowupstudieshavereportedanamenorrhoearateof4050%followingsecondgeneration
endometrialablativetechniques.Mostwomentendtohavereducedbloodloss,butasmanyas15
20%ofwomendonotnoticeanychangeinmenstrualloss.Thereisaresidualriskofovarian
peritonealcancerinwomenwhohavehadabilateraloophorectomypreviously.

Question32

Ulipristalacetate(UA):

A) Isaselectiveprogesteronereceptormodulator
B) Islicensedforlongtermuseinfibroids
C) Reducestheexpressionofmatrixmetalloproteinases
D) Downregulatesangiogenicgrowthfactors
E) Hasnoimpactonfibroidvolume

Answer32
 A) True
B) False
C) False
D) True
E) False

Ullipristalisaselectiveprogesteronereceptormodulatorthatcausesanincreaseintheexpression
ofmatrixmetalloproteinasesandareductionintheinhibitoroftheseenzymes,meaningthattheir
overallactivityisincreased.This,alongwiththedownregulationofangiogenicgrowthfactors
resultsinreducedvascularisation,reducedcellproliferation,increaseinapoptosisandanoverall
reductioninfibroidvolume.Itisnotyetlicensedforuselongtermformanagementoffibroids,but
isusedpreoperativelytoreducefibroidsizeasanalternativetoGnRHanalogues,whichare
toleratedlesswell.

Question33

Whencomparedagainsttotalabdominalhysterectomy:

A) Subtotalhysterectomyisassociatedwithbetterlongtermbladder,bowelandsexual
outcomes
B) Theriskofthromboembolismfollowinglaparoscopichysterectomyisthesame
C) Vaginalhysterectomyismorecosteffective
D) Vaginalhysterectomyisassociatedwithmoreurinarytractinjuries
E) Hospitalstayisshorterwithlaparoscopicmethods

Answer33

A) False
B) True
C) True
D) False
E) True

Contrarytopopularbelief,theevidenceviewedinitstotalitydoesnotsupportbetterlongterm
bladder,bowelandsexualoutcomeswithsubtotalhysterectomy.Althoughlaparoscopic
hysterectomiesareassociatedwithmoreurinarytractinjuriesthantheabdominalprocedure,
overallcomplicationratesarelower.Bothvaginalandlaparoscopicmethodsreducethelengthof
stayandtherecoverytimecomparedwithanopenprocedure,andthisimprovestheircost
effectiveness.However,laparoscopicmethodsusemoreexpensiveandspecialisedequipment;one
reasonwhythevaginalrouteismostcosteffectiveofthemall.

Question34

Regardingfemalegenitalsurgery:
A) Clitoralhoodreductionisaformoffemalegenitalmutilation
B) ThemajorityofwomenreferredtospecialistNHSclinicscomplainoffunctionalproblems
 C) Hymenoplastyisperformedtoresectatighthymen
D) ThereisagoodevidencebasetosupportGspotaugmentation
E) Itcanonlybeperformedbyanaccreditedgynaecologist

Answer34

A) False
B) True
C) False
D) False
E) False

AlthoughmanywouldarguethatthereisaveryfinelinedividingFemaleGenitalCosmetic
Surgery(FGCS)andfemalegenitalmutilation(FGM),clitoralhoodreductionisclassedwithin
theformergroup.However,surgeonsperformingtheseproceduresshouldexplainthatthe
evidencebasesupportingsuchtherapyispoor,andrecognisethataproportionofwomen
seekingsuchsurgerieshavepsychologicalratherthanfunctionalproblems.Workingwithina
multidisciplinaryteammaximisesthechancesofthewomanreceivingthetreatmentshereally
needs,andhelpstoprotectthesurgeonfromcriticism.Functionalproblemswithexternal
genitalia(e.g.interferencewithsportorsexualintercourse)arethemostcommonindications
forreferraltoNHSclinics,whereastruecosmesismaybemorecommonintheprivatesector.
Hymenoplastyusuallyreferstoaprocedurethatreconstructsthehymen,tocreatethe
impressionofvirginity.FGCSispractisedbyawidevarietyofsurgeonsfromvariousspecialties.
Noformalaccreditationexistspersefortheseskills.

Emergency Gynaecology

SBAs
Question35

WhichofthefollowingpiecesofinformationdoesNOTformpartofthestandardadvicegivento
womenreceivingmethotrexateformanagementofa2cmectopicwithanHCGlevelof1300IU/L?

Answer35

B) Onequarterwillultimatelyneedsurgicalintervention

WhentheHCGlevelisbelow3000IU/Landtheadnexalmassissmall(<3.5cm),8090%ofwomen
willbeeffectivelytreatedwithouttheneedforfurthersurgeryormoremethotrexate.However,the
RCOGguidelinerecommendsadvisinga7%chanceoftubalruptureduringmedicaltreatmentofan
ectopic.


Question36

A38yearoldhasbeeninvestigatedforprimaryinfertilityandhasbeenfoundtohavebilateraltubal
disease.Shehasasomewhatirregularmenstrualcycle.WhilstonthewaitinglistforIVF,she
surprisinglyconceivesspontaneously.Shepresentstoanearlypregnancyunit,asymptomaticbut
veryanxious,56weeksfollowingherlastmenstrualperiod.Herobservationsarefine,sheisnon
tenderandascanshowsanemptyuterus,withnoadnexalmassesorfreefluid.HerHCGis1100
IU/L.Thisisrepeated48hourslater,andthevalueis1600IU/L.Sheremainswellandarepeat
transvaginalscanaddsnothingmore.Whichofthefollowingisyourbestcourseofaction?

Answer36

A) Diagnosticlaparoscopyfollowedbysalpingectomyifanectopicisfound

Thiswomanisknowntohavebilateraltubaldamagealready.TheHCGvaluesalonedonotallowa
confidentdiagnosistobemade,butanongoingintrauterinepregnancydoesnotseemverylikely.
SheisathighriskofhavinganectopicpregnancyandoptionsCandDserveonlytodelaytreatment
andputheratelevatedriskofrupture.Sheissuitableformedicalmanagement,butshemaynot
wishtodeferherIVFtreatmentfollowingthemedicalmanagement,andanactualdiagnosisof
ectopichasnotyetbeenestablished.Furthermore,theevidencebasesupportsbilateral
salpingectomiespriortoIVFforwomenwithtubaldiseaseandhydrosalpinges.Conservativesurgery
(salpingostomy)tothetubewiththeectopicwillleaveheratelevatedriskofanotherectopic.An
argumentcouldbemadeforrecommendingbilateralsalpingectomiesatthetimeofthetreatment
fortheectopicifbothtubesareseverelydamaged.Consentforthiswouldneedtobetakenvery
carefully.

Question37

A34yearoldwomanisundergoingfollowupforacompletehydatidiformmole.Sheissexually
activeandawareoftheimportanceofnotgettingpregnantuntilherBHCGlevelshavebeennormal
for6months.WhichofthefollowingisNOTcorrectregardinghercontraceptiveadvice?

Answer37

A) ThecombinedpilliscontraindicateduntilHCGlevelshavebeenundetectablefor3months

AlthoughhormonalmethodsareusuallyavoideduntilthehCGlevelshavereturnedtonormal,the
UKMECrecommendationisthatthecombinedpillisnotcontraindicated,evenwhilsthCGlevelsare
persistentlyraised,orindeedinthepresenceofchoriocarcinoma.Intrauterinedevicesshouldonly
beconsideredoncehCGlevelsarefalling.SterilisationisnotappropriatewhilsthCGlevelsremain
highandshouldbedelayeduntilhCGlevelshavereturnedtonormal.


Question38

A19yearoldwomanhasbeenrapedandassaultedbyanunknownassailantwhilstwalkinghome.
Sheiscurrentlyintubatedandventilatedontheintensivecareunitwithsevereheadinjuries.Which
ofthefollowingstatementsiscorrectregardingforensicexaminationafterasexualassault?

Answer38

B) Itcanbeperformedwithoutconsentifthepatientdoesnothavecapacity

Acompetentadultshouldbeaskedtogivewrittenconsentforaforensicexamination.However,if
theyhavelimitedcapacity(e.g.unconscious)anditisfeltthatcapacitywillnotberegainedona
shorttimeframe(e.g.iftheyweredrunk),thentheDNAsamplesandforensicassessmentcanbe
performedwithoutconsent.Twoskinswabs(onewet,onedry)shouldbetakenfromunderneath
thefingernails,thehands,theperioralarea,theneckandthelowerabdomen.Analsamplescanbe
takenupto3daysaftertheassault,butvaginalsamplescanbetakenupto7daysafterit.

Question39

Whichofthefollowingfeaturesonultrasoundscanconstitutesclearevidenceofanonviable
pregnancy?

Answer39

A) Anemptygestationsacwithameandiameterof28mm

NewrecommendationsfromtheRCOGnowstatethatthemeansacdiametermustbe25mm
beforeananembryonicpregnancycanbediagnosed.Thefetusmustbe7mminlength,beforea
missedmiscarriagecanbedeclaredbythefindingofanabsentheartbeat.Theotherfeaturesareall
negativepredictorsforanongoingviableearlypregnancybuttakeninisolation,orcombined,they
provideinsufficientevidencetoconfidentlystatethatthepregnancyisnonviable.

Extended Matching Question

Question40

Belowisalistofpathologicaltermsforabnormaltrophoblast(AI).Fromthislist,choosethemost
appropriateoption(s)forthedescriptions,ivi,thatfollow.

 i) Atumourarisingfromintermediatetrophoblast,characterisedbyclustersorsheetsof
tumourcellswhichinvadeandinfiltratebetweenmyometrialsmoothmusclecells
ii) Thetermusedtodescribegrosslyhydropicvilliwithtrophoblasthyperplasia,intheabsence
offetalparts
iii) Fourformsofgestationaltrophoblasticneoplasia(GTN)
iv) Twotumoursthatarerelativelychemoresistant
v) Atumourarisingfromintermediatetrophoblastcharacterisedbynodularnestsorcordsof
tumourcellssurroundedbyextensivenecrosisandaneosinophilicmatrix
vi) Abnormaltrophoblastcharacterisedbytriploidcells

Answer40

i) I.Placentalsitetrophoblastictumour
ii) H.Completemole
iii) D,E,IandC.Invasivemole,choriocarcinoma,PSTTandETT
iv) CandI.ETTandPSTT
v) C.Epithelioidtrophoblastictumour
vi) A.Partialmole

Multiple Choice Questions

Question41

HysterectomyshouldbeconsideredfortreatmentofGTNifthepatient:

A) Haschemoresistantdisease
B) Haschoriocarcinoma
C) Hasuncontrollablebleeding
D) Hascompletedherfamily
E) Hasplacentalsitetrophoblastictumour

Answer41

A) True
B) False
C) True
D) False
E) True

SinceGTN,includingchoriocarcinoma,isaverychemosensitivedisease,chemotherapyisnowthe
standardfirstlinetreatment.However,ifchemotherapyfails,hysterectomywouldbeapossible
optiontoremoveresidualdiseaseintheuterus.Placentalsitetrophoblastictumourtendstobe
localisedintheuterusandismorechemoresistantandhysterectomywouldplayanimportantrole.
Intheeventofheavybleeding,hysterectomymaybealifesavingoptionwhenothermeasuressuch
asarterialembolisationfail.GTNhasapotentialtometastasisetherefore,regardlessofthewomans
childbearingdesireorage,chemotherapywouldgiveabetterchanceofcurethanahysterectomy
alone,whichonlydealswiththelocaldisease.Priortotheavailabilityofeffectivechemotherapy,
hysterectomywasadvocatedinthetreatmentofmolarpregnancies.Althoughhysterectomymay
reducetheriskofsubsequentdevelopmentofGTN,itdoesnotcompletelypreventinvasivedisease
oreliminatetheneedforchemotherapy.

Question42

ThefollowingagentsformpartoftheEMACOchemotherapeuticregimeforgestational
trophoblasticneoplasia:

A) Methotrexate
B) Cisplatin
C) Cyclophosphamide
D) 5FU
E) Etoposide

Answer42

A) True
B) False
C) True
D) False
E) True

TheEMACOregimecompromisesetoposide,methotrexate,actinomycinD,cyclophosphamideand
vincristinewithfolinicacidrescue.

Question43

Regardingadvicefollowingsexualassault:

A) 30mgUlipristalispreferredoverLevonelleforemergencycontraception
B) Beyond5days,thereisnoeffectiveformofemergencycontraception
C) PostexposureHIVprophylaxis(PEP)shouldbegivenwithin3days
D) PEPreducesseroconversionratesforHIVby80%
E) TheriskofHIVtransmissionwithvaginalintercourseis1in50ifthemanisseropositive

Answer43

A) True
B) False
C) True
D) True
E) False

Levonelleisthepreferredformofemergencycontraceptionatlessthan3days.Afterthat,Ulipristal
ismoreeffectivebutiscontraindicatedifthewomanistakingPEP.AnIUCDcanbefittedupto5
daysbeyondtheexpecteddayofovulationhowever.TheriskoftransmissionfromanHIVinfected
mantoawomanthroughunprotectedvaginalintercourseis1in500andthiscanbefurtherreduced
bytakingPEPprophylaxiswithin3days.

Oncology

SBAs
Question44

A77yearoldpatientpresentswithintensevulvalitchingandsoreness.Examinationrevealsa4cmx
4cmlesionontheleftlabiamajoraandapunchbiopsyiscarriedout.Thereportshowsevidenceof
necrosiswithinthespecimen.Whatisthebestnextcourseofaction?

Answer44

C)Urgentwedgebiopsyfromtheedgeofthelesion

Thecentralpartofatumouroftenundergoesnecrosisandthereforepunchbiopsyfromthecentre
oflesionmightonlyshownecrosiswithnoviabletissueforanalysis.Secondly,itdoesnotincludethe
normaltissueforcomparison.Thereforethebestwaytoobtainabiopsyisanincisionalwedge
biopsyfromthejunctionofthetumourwithnormalvulvalskin.Abiopsyspecimenlikethisshould
bereferredtoarecognisedspecialistgynaecologicalpathologistforassessment.

Question45

A70yearoldpatientpresentswitha3.5cmlesionontherightlabiamajora.Awedgebiopsyreports
asquamouscellcarcinomawithstromalinvasionof6mm.

Whatisthebestnextcourseofaction?

Answer45

D)Widelocalexcisionofprimarylesionwithbilateralinguinofemorallymphadenectomy

Inguinofemorallymphadenectomyshouldbecarriedoutinsquamouscellcarcinomaofvulvawhen
depthofinvasionexceeds1mm.Bilateralinguinofemorallymphadenectomyisrequiredinmedial
tumoursorlargelaterallesionsof>2cm.Ipsilateralinguinofemorallymphadenectomyshouldbe
performedforlateraltumours<2cmdiameter.Ifthenodesarepositive,contralateral
Inguinofemorallymphadenectomyshouldbeperformed.


Question46

AccordingtotheNHScervicalscreeningprogrammealgorithm,whereHPVtriageisincludedafter
thesmearhasbeenanalysedincertaingroupsofwomen,whichoneofthesituationsbelowwould
beavalidindicationforreferraltocolposcopy?

Answer46

B)AborderlinesmearwithHPVpositivity

Asingleborderlinesquamousorendocervicalsmear,oroneshowinglowgradedyskaryosisshould
promptreferralonlyifHPVtestsarepositive.IfthewomanisHPVnegative,thenshecanberecalled
routinely.IftheHPVtestisinadequateorunreliable,thencolposcopyshouldbeperformedifthe
originalsmearshowedlowgradedyskaryosis.Ifitshowedborderlinechanges,thenthesmearand
HPVtestshouldberepeatedin6months.Ifthisrepeattestshowseitherhighgradecytological
changes,orHPVpositivity,thenareferralshouldbemadetocolposcopyatthatpoint.

Question47
A30yearoldwomanattendsthecancergeneticsclinicbecauseheroldersisterhasrecentlybeen
diagnosedwithovariancancer.Hermotherdiedofthesamedisease.Whichoneofthefollowingis
trueregardingfamilialovariancancer?

Answer47
E) Womenwithageneticpredispositionremainatresidualriskofepithelialcancerevenafter
bilateralsalpingooophorectomy
Thereisnogoodevidence,asyet,thatyearlyscreeningforwomenathighriskofovariancancerisas
effectiveasprophylacticsurgeryandalthoughitisrecommendedforthesewomenwhilstthey
completetheirfamilies,orwhilsttheyarestillyoung,thisisnotthecasewhentheyhavehadtheir
childrenandreachedtheageof35.Evenfollowingthesurgery,however,thesewomenremainat
riskofprimaryperitonealmalignancy.HNPCCcarriersarealsoatriskofendometrialcancer,sothey
arerecommendedtohaveahysterectomyandbilateralsalpingooophorectomy,oncetheyreach35
andhavecompletedtheirfamilies.Unfortunately,notallcancerpredisposinggenesandtheir
sequencesareknown.Failuretofindamutationinoneofthewellcharacterisedgenesdoesnotrule
outthepossibilityofaninheritedmutationinanotherrelevantgene.

Question48
A72yearoldhasbeendiagnosedwithovariancancerandthemultidisciplinaryteammeetinghas
recommendedchemotherapyfollowedbyintervaldebulkingsurgery.
Whichoneofthefollowingoptionsistrueregardinghertreatment?

Answer48
D) Carboplatinistoleratedbetterthanpaclitaxel
Althoughasecondlooklaparotomyforfurtherdebulkinghasnotbeenfoundtoimprovesurvival,
intervaldebulkingafterthreecyclesofchemotherapyhasbeenassociatedwithfewersurgical
complicationsandisbecomingincreasinglypopular.Sixcyclesofchemotherapyareusually
recommendedformostovariancancertypesandthisisusuallycarboplatin,withorwithout
paclitaxel.Thecarboplatiniswelltolerated,whereaspaclitaxelhasbeenassociatedwithneuropathy
andallergicreactions.Avarietyofotherchemotherapeuticagentshavebeenusedeffectivelyfor
recurrentdisease.

Question49
WhichoneofthefollowingoptionsisNOTtrueconcerningHPV?

Answer49
C) Approximately50%ofwomenwillspontaneouslyclearthevirusin2years
HPVisasmalldoublestrandedDNAviruscontainingeightgenes.Morethan80%ofsexually
activewomenwillhaveanHPVinfectionduringtheirlifetimebutitisclearedinalmost90%by
thebodysimmunesystemwithin2years.E1andE2arerequiredfor,andcontrolviral
replicationandalsomaintainthecircularviralgenome.E4interactswiththehostcellproteins
causinginstability,allowingthereleaseofviralparticles.E6andE7arethediseaseforming
genes,oroncogenesthatmaycauseaneoplasticchangewithinanormalcell.Therecent
emergenceofHPVasacausativefactorinheadandneckcancershasbeenanotherargument
forvaccinatingboys.

Question50
A65yearoldwomanattendsherGPwithsymptomsofbloatingandnausea.Furtherquestioning
elicitssomeadditionalproblems.WhichoneofthefollowingisNOTareasontotestingofserum
CA125levelsaccordingtoguidancefromTheNationalInstituteofClinicalExcellence(NICE)?

Answer50
B) Vaginaldischarge
TheNationalInstituteofClinicalExcellence(NICE)recommendedintheir2011ovariancancer
guidelinethatgeneralpractitionersshouldbeawareofsymptomsandsignsofovariancancerand,
whensuspected,serumCA125leveltestingshouldbeperformed.Thisshouldbeperformedifa
woman,especiallyover50years,reportsanyofthefollowingonapersistentorfrequentbasis:
abdominaldistensionorbloating,feelingfullorlossofappetite,pelvicorabdominalpain,
increasedurinaryurgencyorfrequency.Anewdiagnosisofirritablebowelsyndromeinapost
menopausalwoman,isabnormal,andshouldpromptinvestigation.

Question51
A68yearoldwomanisdiagnosedwithanearlystageleiomyosarcomaafterinitialinvestigationfor
afibroiduterus.Whichoneofthefollowingfactorswillimproveher5yearsurvival?

Answer51
E) Sheundergoescompletesurgicalclearance
Adjuvantradiotherapyhasbeenshowntoreducelocalrecurrencerates,buthasnolongterm
benefitonsurvival.Chemotherapyhasbeenshowntoreducebothlocalrecurrenceandlongterm
survivalinadvancedstagedisease(IIIandIV);however,itisnotoftenrecommendedforearlystage
(IandII)duetotoxicityandperceivedlimitedbenefit.Chemoradiotherapyhasbeenshowntobe
detrimental.Otherpoorprognosticfactorsincludehightumourgrade,increasingage,requirement
foradjuvanttherapy,andincompletesurgicalclearance.

Question52
AGPreceivesapelvicultrasoundreportfora40yearoldpatientwillchronicpelvicpain.She
contactsyouforadviceregardingthelikelihoodofmalignancyforanovariancystthathasbeen
reportedonthescan.Whichoneofthefollowingfeaturesincreasestheriskofmalignancy?

Answer52
C)Irregularshape
AccordingtotheIOTAMrules,thefollowingaresuspiciousformalignancy:irregularsolid
tumours,ascites,atleastfourpapillarystructures,irregularmultilocularsolidtumourswitha
largestdiameterof100mm,andverystrongbloodflow.Brules,suggestinglowlikelihoodof
malignancy,includeunilocularcysts,solidcomponentswhenthelargestsolidcomponentisless
than7mm,acousticshadowing,smoothmultiloculartumourswithalargestdiameterofless
than100mm,andnobloodflow.

Question53

A36yearoldwomanisreferredtothecolposcopyclinicwithconcernregardingtheappearanceof
thecervixonspeculumexamination.Whichoneofthefollowingfactorswouldincreaseherriskof
cervicalcancer?

Answer53

B)Smoking

Therearemanyriskfactorsassociatedwithcancerofthecervix.However,manyoftheseare
surrogatesforsexualactivity.UseofHRTisassociatedwithahigherriskofbreastcancerbutnot
cervicalcancer.VulvalwartsareusuallyduetolowriskHPVtypes6and11andarenotdirectly
associatedwithanincreasedcervicalcancerrisk.

Question54
A62yearoldwomanpresentswithadistendedabdomenandanelevatedCA125of
1244.Ultrasoundrevealedascites,acomplexovarianmassandanomentalcake.A
preliminarydiagnosisofstage3ovariancancerwasmadeandshereceivedthreecycles
ofchemotherapypriortoaplannedlaparotomy.Preoperatively,shehasbeenadmitted
complainingofnausea,breathlessness,andabdominaldiscomfort.Whichoneofthe
followingisnotalikelyexplanationforheradmission?

Answer54
D)Pancreatitis
Therearemanypossiblecausesforthispatientssymptoms.Multiplepathologyis
commonandmustbeconsidered.Afullhistoryandexaminationismandatorytohelp
determinethedifferentialdiagnosis.Themostobviouscauseispressurefromascetic
fluidwithintheabdomenalthoughothertumoureffects,suchasbowelobstruction,
shouldalsobeconsidered.Anothercommoneventispulmonaryembolism.Electrolyte
imbalancecouldexplainsomeofhersymptoms.Otherdrugsshemaybetakingcould
beresponsible.Forexample,opiatescausenauseaandconstipation.Finally,infectionis
apossibility.Thiscouldbealowerrespiratorytractinfection,aurinarytractinfection
orinfectionintraabdominally.

Question55

A78yearoldwomanwithvulvalsorenessanda3cmwartylesionconfinedtothevulvaclosetothe
analmarginisreferredtoyourtertiarycentrewithadiagnosisofsquamouscellcarcinomaofthe
vulvaonwedgebiopsy.WhichoneofthefollowingproceduresisNOTlikelytoberequiredforthis
patient?

A) Examinationunderanaesthesia
B) Vulvalflapreconstructionperformedwithaplasticsurgeon
C) Bilateralgroinnodedissection
D) Stomaformation
E) Omentectomy

Answer55

E)Omentectomy

Theprinciplesofsurgeryarethesameasinearlydisease,i.e.wideexcisionofthediseasewithat
least1cmexcisionalmarginsandmanagementofthegroinnodes.Consideringthesizeofthelesion
andcloseapproximationtotheanalsphincter,thispatientislikelytorequireexenterativesurgery
withadefunctioningstomaandplasticreconstructionofthevulva.Thispatientshouldhavean
examinationunderanaesthesiabyamultidisciplinaryteaminvolvingagynaecologicaloncologist,
plasticsurgeon,colorectalsurgeonandoncologist.Somestudiessuggestthatpreoperativechemo
radiationcanreducetheneedfordefunctioningstoma.

Question56

A56yearoldwomanwithavulvallumpapproximately2cmindiameterandbleedingisreferredto
atertiarygynaecologicaloncologycentrewithasuspicionofvulvalcancer.Whichofthefollowing
furtherinvestigationswouldNOTbeappropriateatthisstage?

Answer56

D) Bilateralgroinnodedissection

Furthermanagementofthispatientwoulddependonthemeasuredsizeofthelesionandthedepth
ofinvasionofcancerinthewedgebiopsyspecimen.Ifthedepthofinvasionis<1mmandsizeof
lesionis<2cm,withoutinvolvementofadjacentstructuressuchasurethraoranus,theriskofgroin
nodemetastasisisverysmall(<1%).Therefore,thepatientcanbemanagedwithawidelocal
excision,withoutlymphadenectomy.Thewidelocalexcisionshouldbewithatleast1to1.5cm
clearancemarginsothatthe8mmhistologicalclearancemarginisobtainedinthespecimen.Ifthe
depthofinvasionismorethan1mm,orthesizeofthetumour>2cm,orthetumourencroaches
upontheadjacentstructures,thenthepatientwillrequiregroinnodedissectionsalongwithwide
localexcisionofprimarylesion.Iftheedgeofthewidelocalexcisionmargin(1cmfromvisible
tumouredge)involvesmidlinestructuressuchasclitoris,urethra,vagina,perinealbodyoranus;
bilateralgroinnodedissectionisrequired.Thepatientwouldalsorequireappropriateimagingto
assessextentofdiseaseandnodalstatus.ThismayincludemodalitiessuchasUltrasonography,CT
orMRIscanning.Imagingofpelvicnodesisindicatedifthegroinisclinicallysuspicious.

Extended Matching Question

Question57
Belowisalistofovariancancerhistologicaltypes(AN).Choosefromthelistthemostappropriate
optionstoanswerthequestionsi)tovi),whichfollow.

A) Endometrioid
B) Granulosacell
C) Mucinous
D) Yolksactumour
E) Clearcell
F) Fibroma
G) Choriocarcinoma
H) Transitionalcell(Brenner)
I) SertoliLeydigcell
J) Teratoma
K) Serous
L) Embryonal
M) Borderline
N) Dysgerminoma

i) Listthesixepithelialcelltumourtypes
ii) Listthethreesexcordstromaltumourtypes
iii) Listthefivegermcelltumourtypes
iv) Whichtumourtypecharacteristicallymayrecurafteralongperiodoftime?
v) Whichtumourtypeisoftenassociatedwithendometrialhyperplasiaandcarcinoma?
vi) Whichisthemostcommongermcelltumour?

Answer57
i) A,C,E,H,KandM(Endometrioid,Mucinous,Clearcell,Transitionalcell(Brenner),Serous,
Borderline)
ii) B,FandI(Granulosacell,Fibroma,SertoliLeydigcell)
iii) D,G,J,LandN(Yolksactumour,Choriocarcinoma,Teratoma,Embryonal,Dysgerminoma)
iv) M(Borderline).Borderlineepithelialtumoursmayrecurmanyyearsfollowingtheiroriginal
resection.
 v) B(Granulosacell).Granulosacelltumoursfrequentlysecreteoestrogenwhichcauses
hyperplasiaoftheendometrium,andevencarcinoma.
vi) N(Dysgerminoma).Dysgerminomasarethemostcommongermcelltumoursandare
commonlyfoundinyoungerwomen.

Multiple Choice Questions

Question58

Thefollowingstatementsregardinggynaecologicalmalignanciesarecorrect:

A) Endometrialcarcinomahasthehighestoverall5yearsurvivalrateofallthegynaecological
malignancies
B) Around50%ofpatientswithadvancedcervicalcarcinomaexperienceunrelievedcancerpain
thatunderminesfunction
C) Bowelobstructionisacommonterminaleventinovariancancer
D) TheincidenceofcervicalcancerintheUKisincreasing
E) Highlevelsofpsychologicaldistressareexperiencedbyapproximatelyonethirdofwomen
diagnosedwithgynaecologicalcancer

Answer58

A) True
B) False
C) True
D) False
E) True

Endometrialcarcinomahasa>75%5yearsurvivalrate,whichishigherthananyoftheother
gynaecologicalmalignancies.Ovariancancerstillretainsthehighestmortalityrateswith5year
survivalofapproximately30%.Painisacommonsymptomofadvancedcervicalcancer.7075%of
patientsexperienceunrelievedcancerpainthatsubstantiallyunderminesfunction.Bowel
obstructionisarelativelyfrequentcomplicationofadvancedgynaecologicalmalignancy.Inovarian
canceritisoftenasignofprogression,andpoorprognosis,andamajorcauseofdeath.Cervical
cancerrateshaveshownadownwardtrendsince1990,andhavedonesosincetheintroductionof
thecervicalscreeningprogramme.Approximately33%ofwomendiagnosedwithgynaecological
malignanciessufferhighlevelsofpsychologicaldistress.

Question59

Inthepalliativemanagementofgynaecologicalmalignancies:

A) Pharmacologicaltreatmentshouldbethefirstlinemanagementforconstipation
 B) Surgeryshouldbeconsideredasafirstlinemanagementinallpatientswithmalignant
bowelobstruction
C) Longtermsemipermanentcatheteruseisapotentiallyvaluablemodalityforthepalliation
ofmalignantascites
D) Arterialembolizationmayberegardedasaneffectiveprocedureforcontrolofmassive
bleedinginselectedcervicalcancerpatients
E) Theinsertionofanephrostomytubeisnotappropriateforthemanagementofuraemia
resultingfromuretericobstruction

Answer59

A) False
B) False
C) True
D) True
E) False

Generallyacceptedfirstlinemanagementforconstipationinvolvesrehydration,increasedmobility,
andanincreaseindietarybulk.Althoughpharmacologicaltreatmentisoftennecessaryitisnot
regardedasafirstlineintervention.Theroleofsurgeryformalignantbowelobstructionremains
controversial.Surgerymustbejustifiedonthebasisofachievingasignificantbenefittothepatient.
Longtermsemipermanentcatheteruseisapotentiallyvaluablemodalityforthepalliationof
malignantascites.Itsusemayhelptominimiseintervention,reducehospitalvisits,limitadverse
events,andimprovepatientqualityoflife.Theliteraturesupportsaroleforarterialembolisationas
aneffectiveprocedurewhichcanbeusedtocontrolmassivebleedinginselectedcervicalcancer
patients.Incasesinvolvinguretericobstruction,whichmayresultinuraemia,managementoptions
indeedincludetheinsertionofanephrostomytube,theformationofilealconduitsorthecreation
ofcutaneousureterostomies.

Question60
WithregardtoHPVvaccination,tothefollowingstatements:
A) VaccinationisavailableofflicenceforboysintheUK
B) TherapeuticHPVvaccineshavebeenshowntoclearthevirusinestablishedinfection
C) ProphylacticHPVvaccinecomprisesanattenuatedlivevirus
D) Theadjuvantinthevaccinehelpsfurtherinboostingtheimmuneresponse
E) GardasilreplacedCervarixintheUKfromSeptember2013

Answer60
A) True
B) True
C) False
D) True
E) False

AlthoughvaccinationofboyshasnotbeenimplementedintheUK,itisavailableofflicence.
AustraliaisthefirstcountrytohavestartedHPVvaccinationofboysinFebruary2013.Studies
undertakeninbothanimalsandhumanshavedemonstratedclearanceofthevirusfollowing
therapeuticvaccination.AsHPVcannotbeculturedinvitro,thevaccineisnotalivevaccinebut
containsVLP(VirusLikeParticles).BothCervarixandGardasilcontainanadjuvantthathelpsin
boostingtheimmuneresponse.GardasilreplacedCervarixintheUKvaccinationprogramme
fromSeptember2012.

Question61

Regardingcervicalcancer:

A) Adenocarcinomasaremorecommonthansquamouscelltumours
B) Adenocarcinomahasabetterprognosisthanthesquamoustype
C) Bloodbornespreadiscommon
D) Lymphaticspreadisprobablythemostimportantprognosticfactor
E) Morecancersarenowdiagnosedearlier

Answer61

A) False
B) False
C) False
D) True
E) True

Themajorityofcervicalcancersaresquamousinorigin,butadenocarcinomasappeartobe
increasinglycommon,accountingforapproximately2030%ofallprimarycervicalcancers.
Adenocarcinomaismorelikelytobediagnosedinyoungerwomenandhaslargelypoorerprognosis
incomparisontocervicalsquamouscarcinoma;thispartlyreflectsthedelayindiagnosis.Cervical
cancersspreadbydirectextensionintothecervicalstroma,parametriumandbeyondandby
lymphaticmetastasisintoparametrial,pelvicsidewallandparaaorticnodes.Bloodbornespreadis
unusual.Lymphaticspreadisprobablythemostimportantprognosticsign.Thepresenceofpositive
nodessignificantlyreducesoverallsurvivalandlymphovascularspaceinvasionisanadditional
prognosticfactor.Screeningprogrammeshaveledtobothreducedincidenceanddownstagingof
thediseasewitharoundathirdofcancersbeingdiagnosedasStageI.

Question62

Whenchoosingatreatmentmethodforcervicalcancer:

A) WomenwithmicroinvasiveStageIa1diseaseshouldhavelymphnodedissection
B) SurgeryimprovessurvivalincomparisontoradiotherapyforstageIbIIadisease
C) Chemoradiationimprovessurvivalincomparisontoradiotherapyalone
D) StageIIbshouldbetreatedwithsurgery
 E) Fertilitysparingsurgeryisavailablefortumours<2cm

Answer62

A) False
B) False
C) True
D) False
E) True

Treatmentoptionsvaryforeachstage.Conebiopsyissufficientformicroinvasivedisease(Ia1)
providedthemarginsareclear.ThemanagementofstageIa2diseaseismorecontroversial.Surgery
andradiationhavesimilarsurvivalratesforstageIbIIadisease,whilethecombinationincreases
morbidity.Laterstagetumours(aboveIIb)shouldbetreatedwithchemoradiationasthisappearsto
improvesurvivalincomparisontoradiotherapyalone,butalsoincreasestoxicity.Newerfertility
sparingsurgicaltechniquessuchasradicaltrachelectomymaybeappropriateinselectedcases.

Question63

Verrucouscarcinomaofvulva:

A) Isahistologicalvariantofsquamouscellcarcinoma
B) Ispoorlydifferentiated
C) Presentsasapatchyredandflatlesion
D) Showsextensivedistantmetastasis
E) Istreatedwithexcisionoftheprimarylesionandinguinofemorallymphadenectomyisnot
necessary

Answer63

A) True
B) False
C) False
D) False
E) True

VerrucouscarcinomaisahistologicalvariantofinvasiveSCCandtypicallyoccursinpostmenopausal
women.Itshowsawelldifferentiatedsquamousepitheliumwithminimalcellularatypiaandusually
presentsasacondylomatousfungatingtumourwithexophyticcauliflowerlikelesions.Itrarely
showslymphovascularspaceinvasionandmetastasesfromthesetumoursisuncommon.Treatment
isbyradicalsurgicalexcision;however,formallymphadenectomyistypicallyomitted.

Question64
WhenchoosingatreatmentmethodforCIN:

A) Itdoesnotmatterwhetherthetransformationzoneisvisibleornot
B) Thesizeofthelesionisimportant
C) Lasershouldalwaysbepreferredifavailable
D) ThegradeoftheabnormalityshouldbeatleastCIN23
E) Fertilitywishesshouldbetakenintoconsideration

Answer64

A) False
B) True
C) False
D) False
E) True

Theaimoftreatment,whetherablativeorexcisional,shouldbetoremovetheentiretransformation
zone(TZ).IfablativetherapiesaretobeusedthentheTZshouldbefullyvisualised,whereas,
excisionalmethodscanremovelesionswheretheTZmayextendintothecervicalcanal.Excisional
methodsareappropriatewherethereiscervicalstenosis,apreviouslytreatedcervixorifthereisa
suspicionofinvasiveorglandulardisease.Ifusingcryotherapy,thelesionshouldideallybesmalland
lowgrade.LLETZisthepreferredmethodoftreatmentinmostcasesasthistechniqueisquick,easy
andrelativelyeasytolearn.Lasermaybechoseninsomecasesbutitisexpensive,takeslongerto
performandhasalongerlearningcurve.Fertilityissuesshouldalwaysbetakenintoconsideration
andappropriatecounsellingshouldbegiveninviewoftreatmentmorbidities.However,therisksof
treatmentonfuturepregnanciesareoutweighedbythebenefitsofremovingtheCIN.

Question65

WithregardtoHPVDNAtestinginthepreventionofcervicalcancer:

A) ThereisnoevidencethatHPVDNAimprovestheaccuracyofprimaryscreening
B) WomenaftertreatmentshouldhaveanHPVDNAtestandcytologyannuallyfor10years
C) WomenwithborderlineandmilddyskaryosisthattestpositiveforHPVDNAtestare
referredtothecolposcopyclinic
D) MostcountrieshavealreadyimplementedHPVbasedcervicalscreeningprogrammes
E) Thetestassessesdirectlythepresenceoftheviralgenome

Answer65

A) False
B) False
C) True
D) False
E) True


HPVDNAtestinghasbeenintroducedintheUKasatestofcureaftertreatmentforCIN.Ifthisand
cytologyarenegativeat6monthsposttreatment,womenmayreturnbacktoroutinerecall.
Womenwithminorfindingsatcytologyareonlyreferredtocolposcopywhentheytestpositivefor
highriskHPV.TheuseofanHPVDNAtestinprimaryscreeningmayimprovetheprotectionagainst
cervicalcancer.Thishasnotyetbeenintroducedinmostcountries,asthiswillrequireachangein
infrastructure.MoreevidenceonhowtobestmanagewomenthattestpositiveforHPVatscreening
isrequired.

Question66

Vaccinesforcervicalcancer:

A) Aredescribedastrivalent
B) ProtectagainstalloncogenicHPVtypes
C) Avoidtheneedforscreeningforcervicalcancer
D) Areveryefficaciousandsafe
E) Areadministeredinthreedoses

Answer66

A) False
B) False
C) False
D) True
E) True

Thetwoavailablevaccinesarethebivalent(16,18)andthequadrivalent(16,18,6,11)vaccine.The
latteralsoprotectsagainstanogenitalwarts.Theyarehighlyeffectiveandsafe.Astheydonotcover
forallhighrisktypesandcoverageisnotexpectedtobe100%,screeningisstillrequiredfor
vaccinatedcohorts.

Question67

Thefollowingregulardrugsshouldbeomittedpriortomajorgynaecologicalsurgery:

A) Combinedoralcontraceptivepill
B) Propanolol
C) Salbutamol
D) Warfarin
E) Shortactinginsulin

Answer67
 A) True
B) False
C) False
D) True
E) True

Thecombinedoralcontraceptivepillshouldbestopped46weekspriortomajorsurgerytolimit
theriskofpostoperativevenousthromboembolism.Cardiacdrugsandantihypertensivesshould
usuallybecontinued,asshouldmedicationsforcontrolofasthma.Warfarinshouldbestoppedwith
sufficienttimetobringtheprothrombintimebacktonormal.Anticoagulationwithheparinmaybe
neededasanalternativeduringtheperioperativeperiod.Normalsubcutaneousinsulinsareusually
omittedonthemorningofmajorsurgeryandaslidingscaleinstituted.However,itisincreasingly
thecasethatthelongactingbackgroundinsulinisgiveninthemorningandaslidingscaleonly
commencedifthebloodsugarsexceedaparticularlevel.

Question68

Concerningtheuseofradiotherapyingynaecologicalmalignancies:
A) FIGOstageIendometrialcancersaremanagedbysurgeryalone
B) ImageguidedradiotherapyrequiresrepeatedCTimagingofthepatienttoensureaccuracyof
treatment
C) Asignificantmajorityofpatientsgainpainrelieffrombonemetastasesfollowingasingle
radiotherapytreatment
D) Surgeryfollowedbychemotherapyandradiotherapyisthetreatmentofchoicefor
advancedcervicalcancer
E) Brachytherapytreatmentforendometrialandcervicalcancersistypicallygivenoverthe
courseofseveralhours

Answer68
A) False
B) True
C) True
D) False
E) False

Surgeryaloneisadequateforlow gradestageIaendometrialcancer.Forthosewithhigher
riskfeaturese.g.stageIband/orgrade3consideradjuvantradiotherapy.Chemoradiotherapy
(externalbeamradiotherapyfollowedbybrachytherapy)istheprimarytreatmentofchoice
forstage2bto4asquamouscellcarcinomaofcervix.Lowdoseratebrachytherapytreatment,
e.g.caesiumcouldtakemanyhours.Nowcentresaremovingtohighdoseratebrachytherapy
andtreatmentcanbeadministeredinafewminutes.

Question69
Regardingtheuseofchemotherapyandbiologicalagentsinthetreatmentofgynaecological
cancers:

A) Cisplatinchemotherapyisusedasaradiosensitiserincervicalcancer
B) Patientsofperformancestatus2arerestrictedinphysicallystrenuousactivitybut
ambulatoryandareabletocarryoutworkofalightorsedentarynature
C) Anthracyclinesworkbyblockingmicrotubulesandinhibitingmitosis
D) Bevacizumabisamonoclonalantibodythatbindsvascularendothelialgrowthfactor
andisusedinthetreatmentofovariancancer
E) Patientswithneutropeniafollowingchemotherapyalwaysrequireantibiotictreatment

Answer69
A) True
B) False
C) False
D) True
E) False

Patientswithperformancestatus2areambulatoryandcapableofallselfcarebutunableto
carryoutanyworkactivities.Theyareupandaboutmorethan50%ofwakinghours.
Taxanesworkbyblockingmicrotubules;anthracyclinesinhibitDNAsynthesis.Patientswith
neutropeniarequireantibioticsifthereisevidenceofinfectionsuchastemperatureorsignsof
sepsis.Antibioticsmaybeconsideredasprophylaxisifthepatienthastoundergoaprocedure
thatcannotbedelayed.

Infertility and Reproductive Medicine

SBAs
Question70

A35yearoldmarriedmultiparouspatientwithlongstandingtype1diabetesseeksadviceregarding
contraception.Sheisnotsureshehascompletedherfamily,althoughherendocrinephysicianhas
expressedtheirconcernsaboutanotherpregnancybecauseofherretinopathyandearlyrenal
disease.

Whatisthebestoption,fromthechoicesbelow,forcontraceptionforthiswoman?

Answer70

C)CopperIUD

Althoughthiswomanshouldreceivecarefulprepregnancycounselling,itwouldbeunreasonableto
encouragesterilisationwhenshehasexpressedadesireforanotherpregnancy.Copperintrauterine
devicesshouldbeconsideredthefirstchoiceforcontraceptionindiabeticwomenwithunderlying
vascularorrenalcomplications,andinthisgroupofwomen,theCOCPandDMPAshouldbeavoided
(UKcategory3).TheLNGIUSisconsideredcategory2andwouldbeanalternativeoptionifthe
copperIUDwasassociatedwithheavierbleedingorpainfulperiods.

Question71

A15yearoldgirlpresentsinyourgynaeclinicwithprimaryamenorrhoea.Shehasevidenceof
developmentofsecondarysexualcharacteristics,butpubichairisscanty.Ultrasoundscanshowsan
absentuterus.

Whichdiagnosisfromthelistbelowismostlikelyfromtheseclinicalfeatures?

Answer71

C) Completeandrogeninsensitivitysyndrome(CAIS)

Allfivediagnosesmaypresentwithprimaryamenorrhoea,butsecondarysexualcharacteristicsand
pubertaldevelopmentwillbenormalinMcKusickKaufmannsyndrome(transversevaginal
septum/imperforatehymen,associatedwithpolydactylyandcongenitalheartdisease)andMRKH
syndrome.ThedevelopmentofsecondarysexualcharacteristicsisdelayedinTurnersyndromeand
womenwithSwyersyndromewillhaveauterus.GirlswithCAISpresentwithprimaryamenorrhoea,
secondarysexualcharacteristics,scantypubicandaxillaryhair,absenceofauterusand46XY
karyotype.Thisrareconditioniscausedbyamutationintheandrogenreceptorgene;hencethe
poorpubichairdevelopment.

Question72

Youhavebeenlookingafteracoupleinyourinfertilityclinic.Nofemalefactorshavebeen
identifiedandthemalepartneris32yearsold,fitandmuscularwithaBMIof26.Hehas
producedtwospermsamples,2monthsapart,bothshowingazoospermia.Onexamination,
hehasnormalsecondarysexualcharacteristics,normaltesticularvolumeandnoscrotal
abnormalities.HehasnormalserumFSH,LH,testosteroneandprolactinlevelsandhispost
ejaculatoryurinesampleshowsnospermatozoa.Atesticularultrasoundisnormal.
Howwouldyouproceedwithmanagement?Choosethesinglebestanswer.

Answer72
C) Offergenetictesting
Theazoospermiaisunlikelytocorrectwithlifestylechanges.AlthoughhisBMIis26,ifheis
muscularthisisunlikelytobebecauseheisoverweight.Hehasproducedtwosamples
already.Itisnotlikelythatathirdwillshowanythingsignificantlydifferent.Hisbloodtests
ruleoutahypogonadotrophiccauseandsuggestobstructiveazoospermiaoraprofound
problemwithspermatogenesis.Thepostejaculatoryurinesamplerulesoutretrograde
ejaculation.Althoughhehasamuscularbuild,thenormallevelsofFSHandLHdonot
supportanabolicsteroidmisuse.Nodiagnosishasyetbeenreached,andtreatingwith
gonadotrophinsisnotappropriateuntilithas.
Ultimatelyhemayneedtobeofferedsomeformofsurgicalspermretrieval,butfirsthe
shouldbeofferedgenetictestingtolookforchromosomalrearrangements,Ychromosome
microdeletions,andcysticfibrosismutations.

Question73

A34yearoldwomanattendsyourinfertilityclinic,alongwithher58yearoldhusband.Theyhave
beentryingtoconceivewithoutsuccessforover2years.Thefemalepartnerhashadarecentday3
FSHlevelof5.4mU/mlandhasaregular28daycycle.Herhusbandisconcernedthathisageisthe
causeoftheirfertilityissues.

WhichofthefollowingisNOTaproblemwithadvancedageinthemalepartner?

Answer73

A) Asteadydecreaseinspermcount

Severalstudieshaveshownthatincreasingpaternalageabove40islinkedwithafailuretofather
children,boththroughadeclineinmalefertilityandanincreaseinmiscarriagerisk.Thereislittle
evidencethoughofdecreasingspermcountswithage.Theriskofcertainsinglegeneand
multifactorialconditions(e.g.achondroplasiaandschizophrenia)doesincreaseintheoffspringof
olderfathers.

Question74

A30yearoldwomanattendsthegynaecologyclinicforalongstandinghistoryofhirsutism.

WhichoneofthefollowingisNOTcorrectregardingherlikelydiagnosis?

Answer74

A) Themostlikelycauseisanadrenaltumourproducingandrogens

Inclinicalpractice,PCOSisthemostcommonlyencounteredunderlyingcauseofhirsutism.The
incidenceofhirsutismisinfluencedbygeneticandracialfactors.Testosteroneisproducedbyboth
theovaryandadrenalglandsandonlytheunbound(free)fractionismetabolicallyactive.Obesity
canleadtoadecreaseinSHBGleadingtoanincreaseinthefreefractionoftestosterone.Inaddition
associatedinsulinresistancecanleadtoanincreaseinthereleaseofovarianandrogens.


Question75

A36yearoldwomanwithaBMIof35andadiagnosisofPCOShasa3yearhistoryofanovulatory
infertility.Shehasundergoneayearoftreatmentwithclomiphenecitratewithoutsuccess.

Whichofthefollowingstatementsiscorrectregardinghermanagement?

Answer75
A) Shecouldpotentiallyachievearegularcyclebyweightreductionalone
Lifestylemanagementaimedatnormalisingbodyweightisthefirstlineoftherapyforwomenwith
PCOS.Weightlossofjust510%isoftensufficienttoshiftmetabolicallyactivevisceralfatand
restorenormalmenstrualregularity.Therecommendedfirstlinetreatmentforovulationinduction
remainsclomiphenecitrate(ortamoxifen)forupto12months.Thecumulativeconceptionratewith
CCcontinuestoincreaseuntil12cycles,thenplateaus.Prolongingclomiphenetreatmentbeyond12
cycleshasbeenlinkedwithanincreasedriskofborderlineorinvasiveovariantumoursandshould
thereforebediscouraged.
LODisaseffectiveasgonadotrophintherapyforovulationinductioninwomenwithclomiphene
resistantPCOS.Itusuallyleadstomonofolliculardevelopmentandhastheadvantageofbeing
associatedwithlowerriskofmultiplepregnanciesandovarianhyperstimulationsyndrome,
comparedwithgonadotrophinovulationinduction.
ArecentCochranereviewshowedthatmetforminuseinPCOSwasassociatedwithimproved
ovulationandimprovedclinicalpregnancyratesbutthereisnoevidencethatmetforminimproves
livebirthrates,whetheritisusedaloneorincombinationwithclomiphene.Alsothereisno
evidencethatmetformintreatmentbeforeorduringassistedreproductivetechniquesimproveslive
birthrates.

Question76
A43yearoldpatientisconsideringaprivatecourseofIVFtreatment.Shehashadlongstanding
problemswithendometriosis,requiringseverallaparoscopicresectionsinthepast.Shewishesto
understandwhatheroptionsareandhowIVFtreatmentmightimpactonherandafuturechild.
Whichofthefollowingistrueregardinghermanagement?

Answer76
D) IVFbabieshaveahigherriskofepigeneticdisorders
IVFtreatmentwouldusuallyberecommendedafterfailureofablative/excisionalsurgery+/
intrauterineinseminationwithorwithoutovarianstimulation.Diminishedovarianreserveis
associatedwithlowerIVFsuccessratesbutthisdoesnotmakeitacontraindication.Diminished
ovarianreserveisactuallyviewedbysomeasanindicationforexpedientreferralforIVF
treatment.Ectopicpregnanciesoccurinapproximately5%ofIVFpregnancies.IVFbabieshavea
higherriskofgenomicimprintingdisorderssuchasBeckwithWiedemannsyndrome,Silver
Russellsyndromeandretinoblastomas.Thereisnoevidenceofanincreasedriskof
psychomotordisordersinIVFbabies.

Question77
A20yearoldwomanattendsthegynaecologyclinicwithprimaryamenorrhoea.

Whichofthefollowingstatementsistrueregardingherdifferentialdiagnosis?

Answer77

C) Ifshehasandrogeninsensitivitysyndromethenshewillnothaveauterus

Mllerianagenesisisfoundinindividualswithanormalfemalekaryotype(46XX)butanabsentor
underdevelopedMlleriansystem.Hyperprolactinaemiaresultsfromtheremovalofdopamine
inducedtonicinhibitionofpituitary.Patientswithandrogeninsensitivitysyndromehaveamale
karyotype,andduetothenormalMllerianinhibitionassociatedwiththeYchromosome,theydo
nothaveanyMllerianstructuressuchasauterusorfallopiantubes.Turnerssyndromeiscaused
bymonosomyX(45XO),buttheMlleriansystemispresentandtheydohaveauterus.Girlswith
eatingdisorderscanpresentwithamenorrhoeaduetolowlevelsofFSHandLH(hypogonadism)
leadingtoahypoestrogenicstatecausingamenorrhoea.

Question78

AcoupleattendtheIVFclinicforpreimplantationgeneticdiagnosisduetoafamilyhistoryof
Huntingdonsdisease.Theyarekeentoknowifthereareanyadditionalriskstothepregnancy,
beyondtherisksofconventionalIVFtreatment.

Whichofthefollowingisanadditionalriskintheircase?

Answer78

D) Morestillbirths

Thereisnosignificantincreaseinrateofpregnancycomplications,congenitalanomaliesorpostnatal
developmentproblemscomparedtoregularIVFcycles.TherateofpretermbirthissimilarinPGD
andIVFcycles,mainlyduetomultiplepregnancies.Onereportshowedanincreasedrateof
stillbirthsinmultiplepregnanciesfollowingPGDinacentrewhichbiopsiedtwocells.Childrenborn
followingPGS(notPGD)havebeenshowntohavelowerneurologicoptimalityscoresat2years
comparedwithroutineIVFoffspring.

Question79

Whichoneofthefollowingstatementsaboutcongenitalreproductivetractanomaliesiscorrect?

Answer79

B) VaginaldilationisthefirstlinetreatmentforvaginalaplasiainwomenwithMRKH
MRKHhasanincidenceofonein5000asopposedtoCAISthathasasimilarinitialpresentationand
israrerwithanincidenceofonein40,000.

Forwomenwithuterovaginalaplasia,suchasinMRKHandCAIS,vaginaldilationshouldbethefirst
linetreatmentforcreatingavagina.Approximately1to2in10,however,willrequiresomeformof
surgicalvaginoplasty,suchasthelaparoscopicVecchiettiprocedure.

LaparoscopyisnotpartofroutineinvestigationormanagementforMRKH,exceptforthecases
wheremagneticimaginghasidentifiedarudimentarycavitythatleadstoobstructedmenstruation
andcyclicalpain.

CAISiscausedbyamutationintheandrogenreceptorgene,whichresidesontheXchromosomes,
andnottheSRYgene,whichshouldfunctionnormally.Amutationinthelatterdoesnotallowfor
thegonadtobecomedifferentiatedintoatestisandleadstoSwyersyndrome.InSwyersyndrome,
unlikeCAIS,Mllerianstructuresformnormally,asthegonadswillnotproduceAMH.

Question80

A23yearoldnulliparouswomanpresentsforemergencycontraceptiveadvice.Shehasrecently
metanewpartnerandwouldliketoconsideranintrauterinecontraceptivedevice.Whichoneofthe
followingiscorrectregardinghermanagement?

Answer80

B) Sheshouldbeadvisedtohavescreeningforsexuallytransmittedinfection

Nulliparityisnotacontraindicationtointrauterinecontraception.Youngnulliparouswomenshould
havethechoiceofthismethodforitsconvenience,highefficacyandnonsystemicnature.Screening
forsexualinfections,inwomenatrisk,isrecommended.Thereisincreasingevidencetosuggestthat
theactionofIUDsispreventionoffertilisationthroughtheinhibitoryroleofcopperonspermand
cervicalmucus.OnlytheIUDcanbeusedforemergencycontraception.BoththeIUDandtheIUSare
mostcommonlydiscontinuedbecauseofheavyorirregularbleeding.

Extended Matching Questions

Question81

Belowisalist(AK)ofpharmacologicaltreatmentsforhirsutism.Fromthislist,choosetheoption
whichbestsuitsthedescriptionsi)tovi)thatfollow.

i) Apotentandrogenreceptorantagonistwhichcarriesariskofhepatotoxicity
ii) A5reductaseinhibitor
iii) Anoralcontraceptivepillcontainingcyproteroneacetate
 iv) Atreatmentforadultcongenitaladrenalhyperplasia
v) Anantiprotozoaldrugwhichalsohappenstoinhibithairgrowth
vi) Aninsulinsensitisingagent

Answer81

i) H.Flutamide
ii) G.Finasteride
iii) A.Dianette
iv) C.Glucocorticoids
v) D.Vaniqua
vi) E.Metformin

Question82

Belowisalistofcauses(AJ)ofmaleinfertility.Fromthislist,pickthemostsuitablediagnosisthat
explainstheclinicalscenariodescribedincasesi)tov).

i) Threecausesthatwouldbeconsistentwithlowspermcounts,normalexaminationand
normalhormonelevels
ii) Atallmanwithgynaecomastia,scantypubichairandsmallfirmtestes
iii) Amanwithahistoryofhypospadiasrepair,normaltestes,elevatedlevelsofLHand
testosteroneandamutationintheandrogenreceptorgene
iv) ThreecausesofinfertilityassociatedwithhighFSHandLHlevels,andlowlevelsofandrogens
v) Amanwithatrophictestes,increasedlibido,normalerectilefunctionandlowlevelsofFSH,
LHandtestosterone
vi) Amanwithhighlevelsofandrogensandlowlevelsofgonadotrophins
vii) AmanfoundtohavemutationsintheCFTRgene

Answer82

i) A,DandG(Retrogradeejaculation,Congenitalbilateralabsenceofthevasdeferens,
Previouschlamydiainfection).Retrogradeejaculation,previouschlamydiainfectionand
CBAVD.Theseareallcausesofposttesticularazoospermia.
ii) E.Klinefelterssyndrome(usually47XXY).
iii) I.Mildandrogeninsensitivitysyndrome.
iv) E,BandJ.Klinefelterssyndrome,cryptorchidismandorchitisareallcausesof
hypergonadotrophichypogonadismwherepituitarygonadotrophinsareelevatedin
responsetopoorlyresponsivegonads.
v) F.AnabolicsteroidusesuppressesFSH,LHandtestosteronelevels,butisassociatedwitha
normalphysicalexaminationandoftenincreasedlibido.
vi) H.Anandrogenproducingtumourcausesmarkedelevationofandrogens,butsuppression
ofFSHandLHlevels.
 vii) D(Congenitalbilateralabsenceofthevasdeferens).MutationsintheCFTRgene(usually
responsibleforcysticfibrosis)arecommonlyfoundinmenwithCBAVD.

Question83
Belowisalistofmanagementoptions,AJ.Fromthislist,choosethesinglemostappropriate
answertothescenariosi)iv).

i) ApatientwiththreepreviousfailedIVFcyclesdespitesatisfactoryovarianresponseandgood
qualityembryos
ii) Apatientrecentlydiagnosedwithbreastcancerrequiringchemotherapywhohasbeen
referredforpreservationoffertility
iii) AdiabeticpatientwithBMIof35currentlyundergoingweightmanagementbefore
startingIVFtreatment
iv) ApatientwhohadOHSSinapreviousIVFcycleandhas30folliclesinhersecond
treatmentcycle

Answer83
i) I.Hysteroscopy.Thismayhelpidentifyandtreatintrauterinesynchiae,septaeor
polypsthatcouldimpairimplantation.
ii) G.GnRHantagonist.Ashorterdurationcycle,whichcarrieslessrisk.
iii) C.Highdosefolicacid.Thisshouldberecommendedinthispatientbecauseofthe
increasedriskofcongenitalmalformationsincludingneuraltubedefectsinthe
offspringofobeseanddiabeticpatients.
iv) B.Cabergoline.ThishasbeenshowntobeeffectiveinpreventingmoderateOHSS
andinaheadtoheadcomparisonwithIValbuminfusionthenumberneededto
treatwaslesstopreventOHSS.Moreoveritcarrieslessriskofallergicreactionsand
infections

Question84

Belowarelistedtheriskcategories(AD)publishedbytheUKfacultyofsexualandreproductive
healthcarefortheuseofcontraceptivesincertainmedicalconditions.Fromthislist,pickthecorrect
categoryforthecontraceptionmedicalconditionpairingsdescribedinquestionstems(i)(xi).

(i) COCP(combinedoralcontraceptivepill)useinwellcontrolledhypertension
(ii) DMPA(Depotmedroxyprogesteroneacetate)useinaFactorVLeidenheterozygote
(iii) POP(Progesteroneonlypill)useinaninsulindependentdiabeticwithvasculardisease
(iv) UseoftheCuIUCDinsomeonebeingtreatedforaDVT
(v) UseoftheLNGIUD(Mirena)insomeonewithdiabeticretinopathy
(vi) DMPAusewithhypertensivevasculardisease
(vii) COCPuseinmildhypertension(150/94)
(viii) COCPuseinsomeonewithhistoryofgestationaldiabetesmellitus
(ix) COCPuseinsomeonewithvaricosevein
 (x) DMPAuseinadequatelycontrolledhypertension
(xi) Implanonuseinseverehypertension

Answer84

i) C(cat3)
ii) B(cat2)
iii) B(cat2)
iv) A(cat1)
v) B(cat2)
vi) C(cat3)
vii) C(cat3)
viii) A(cat1)
ix) A(cat1)
x) B(cat2)
xi) A(cat1)

Question85

Belowisalist(AK)ofoptionsforinducingovulation.Fromthislist,choosethemostappropriate
optionfortheclinicalscenariosi)tovi),inwhichallthepatientsareanovulatoryandwantingto
becomepregnant.

i) ApatientwithaBMIof48,typeIIdiabetesandfailuretoloseweightwithdietarymeasures,
exerciseandOrlistat
ii) Awomanwithhyperprolactinaemiawhoisresistanttoclomiphene
iii) AwomanwithaBMIof36whoisresistanttoclomipheneandhasimpairedglucose
tolerance
iv) Awomanwithpersistentlyelevatedgonadotrophinlevels,andlowcirculatinglevelsof
oestrogen
v) AwomanwithaBMIof34,normallevelsofgonadotrophinsandanelevatedfreeandrogen
index
vi) AwomanwhohaslostweightandnowhasaBMIof25

Answer85

i) H.Bariatricsurgery.Thiswomanshouldnotbehelpedtogetpregnantwithherco
morbiditiesofobesityandtypeIIdiabetesuntilshehaslostweight.Asdietaryanddrug
measureshavefailed,shewouldbeacandidateforbariatricsurgery.
ii) G.Clomipheneandbromocriptine.Womenwithhighprolactinlevelsmayfindtheir
clomipheneusemoreeffectiveifitisaccompaniedbybromocriptineasanadjunctive
agent.
iii) F.Metformin.Thisisasecondlineagent,andforawomanwithanelevatedBMIand
impairedglucosetoleranceitwouldbeabetterchoicethanLetrozoleorlaparoscopic
ovariandrilling.
iv) K.Noneofthese.Thisendocrineprofileissuggestiveofprematureovarianfailure,andthisis
unlikelytorespondtoovulationinduction.Donoroocyteswillbeneeded.
 v) I.PulsatileGnRH.ThiswomanhasKallmanssyndrome(anosmiaassociatedwith
hypogonadotrophichypogonadism).PulsatileGnRHanaloguesareusuallythetreatment
ofchoicetoinduceovulation.
vi) C.Clomiphene50mgperday.Thisisthestartingdoseforclomiphene.Thispatienthaslost
weightandherBMIisalmostinthenormalrange.Thisdoseofclomipheneisusually
firstlinechoice.Thedosecanbeincreasedto150mgperdayifthereisadegreeof
resistancetotheeffectsofthedrug.

Multiple Choice Questions

Question86

RegardingIVF:

A) ICSIisassociatedwithsignificantlylowerpregnancyratesthantraditionalIVF
B) Successratesarebetterwhenspermmotilityratesarehigher
C) Successisnotrelatedtospermcount
D) ThetechniqueofPESEextractsspermfromtesticularbiopsies
E) Themaleoffspringofinfertilemenarelikelytohaveahigherincidenceofinfertility
themselves

Answer86

A) False
B) False
C) True
D) False
E) True

DatafromESHREshowthatclinicalpregnancyratesareverysimilarwithICSIandtraditionalIVF,and
thattheyarenotrelatedtospermcount,motilityormorphology.PESErecoversspermfromthe
epididymis.ItisTESEthatextractsspermfromtesticularbiopsies.Aproportionofcasesofmale
infertilityarecausedbyYchromosomalmicrodeletionsthatwill,ofcourse,behandedontomale
offspring.ItisreasonabletoexpectthattheincidenceofmaleinfertilityintheoffspringofIVF
(particularlyICSI)willbeabovethebackgroundrate.

Question87

Regardingthetreatmentofhirsutism:

A) Antiandrogensareusuallythefirstlineoftreatment
B) About6monthsoftreatmentmaybenecessarybeforeaclinicaleffectcanbeseen
C) Combinedoralcontraceptivepillscontainingnorethisteronearepreferabletothose
containingotherprogestogens
D) Pharmacologicalagentsareeffectiveforthetreatmentofexistinghair
E) Eflornithineisunsuitableforwomenwithassociatedsevereacne

Answer87

A) False
B) True
C) False
D) False
E) True

Thecombinedoralcontraceptivepillisusuallyusedasfirstlinetreatmentduetoitseffectiveness,
favourablesafetyprofile,addedcontraceptivebenefitsandcycleregulation.Sinceitisnecessaryto
targetthegrowthphaseofthehaircycle(anagen),andsincethiscanbeparticularlylongforfacial
hair,prolongedtreatmentisnecessary.Norethisteronecontainingpillsshouldbeavoidedsinceit
hasanandrogeniceffect.Pharmacologicalagentswillonlyslowthenewhairgrowthbutwillnot
treatexistinghair.Eflornithinemayleadtoaggravationofexistingacneduetoocclusionofthe
sebaceousglands.

Question88

Thepolycysticovarysyndrome:

A) Accountsfor20%ofcasesofanovulatoryinfertility
B) IsassociatedwithanincreasedriskofmiscarriagebecauseofLHhypersecretion
C) IsassociatedwithlowTSHlevels
D) IsassociatedwithincreasedFAI
E) Isassociatedwithmarkedlyelevatedserumprolactin

Answer88

A) False
B) True
C) False
D) True
E) False

PCOSaccountsforapproximately75%womenwithanovulatoryinfertility.LHhypersecretionis
foundin40%ofwomenwithPCOSandisassociatedwithreducedchanceofconceptionandan
increasedriskofmiscarriageinbothnaturalandassistedconception.TSHlevelsareunaffectedand
hyperprolactinaemiaisusuallymildandpresentinonly~30%ofwomen.PCOSisassociatedwith
decreasedSHBG(~50%)levelsandincreasedFAI(>5inapproximately75%).FAIismoresensitivein
detectinghyperandrogenismthantotaltestosterone.

Question89
Withregardtoovarianhyperstimulationsyndrome:
A) Ittypicallypresentsatthepeakofoestrogenlevelsduringovarianstimulation
B) Themajorityofcasesrequireadmissiontohospitalandclosemonitoring
 C) GnRHantagonistsaresaferthanagonistsinpatientswithpreviousOHSS
D) ItcanbepreventedcompletelybywithholdingtheHCGinjection
E) SingleblastocysttransferisadvisedforpatientsatriskofOHSS

Answer89
A) False
B) False
C)True
D) False
E) True

Earlyovarianhyperstimulationsyndromepresentswithin10daysofHCGinjection,i.e.afteroocyte
retrieval.LateOHSSoccursaftermorethan10daysfollowingHCGinjection,i.e.afterembryo
transfer.ThemajorityofcasesofOHSSaremildormoderateandcanbemanagedonanoutpatient
basis.GnRHantagonistprotocolshavebeenshowntobeassociatedwithalowerriskofOHSS.
WithdrawaloftheHCGtriggercannotpreventearlyOHSSinGnRHantagonistprotocolswhere
theendogenousLHsurgemayoccurshortlyafterstoppingtheGnRHantagonist.Single
blastocyst(embryo)transferwillreducetheriskofmultiplepregnancy(whichisassociatedwith
ahigherriskoftheseverelatetypeofOHSS).

Question90

A) Infertilityaffects1in6heterosexualcouplesintheUK
B) Sexhormonebindingglobulinlevelsareincreasedinpolycysticovariansyndrome
C) Highlevelsofleptinmayinhibitfolliculogenesis
D) Thereisnoevidencetosuggestweightlosswillimprovetheregularityofthemenstrualcycle
E) 40%ofpatientswithpolycysticovariansyndromeareobese

Answer90

A) False
B) False
C) True
D) False
E) True

Infertilityaffectsapproximately1in7couples,andPCOSisamajorcontributorycause.Lowlevelsof
SHBGincreasetheamountoffreeandrogenandthese,combinedwithhigherleptinlevels
inhibit/arrestfolliculogenesis.40%ofpatientswithPCOSareobeseandthereisgoodevidenceto
showthatweightreductionimprovesovulation,andthesensitivitytoovulationinducingagentsin
thesewomen.

Question91

Regardingcontraceptiveuseinwomenwithbreastconditions:
 A) Hormonalcontraceptioniscontraindicatedinwomenwithcurrentorrecentbreastcancer
(UKcategory4)
B) Hormonalcontraceptioniscontraindicatedinwomenwithapositivefamilyhistoryofbreast
cancer
C) TheWomensCAREstudyfoundincreasedriskofbreastcancertobeassociatedwithuseof
DMPA
D) OralhormonalcontraceptiveusereducesovariancancerriskinBRCA1andBRCA2carriers
E) (LNGIUS:Mirena)mayreducetheriskofendometrialabnormalitiesduringtamoxifen
therapy

Answer91

A) True
B) False
C) False
D) True
E) True

TheWomensContraceptiveandReproductiveExperiences(CARE)studyrecentlyfoundnoincrease
intheriskofbreastcancerinusersoforalhormonalcontraception,orthosereceivingDMPA.These
optionsarenotcontraindicatedforwomenwithafamilyhistoryofbreastcancer,orevenBRCA1
and2mutationcarrierswheretheCOCPactuallyreducestheriskofovarianmalignancy.TheLNG
IUSmayreducetheriskofendometrialabnormalitiesinwomenreceivingtamoxifenforbreast
cancertreatment;however,itremainssomewhatunclearwhetherthiscarriesahigherrecurrence
riskforthebreastcanceritself.

Question92

A45yearoldwomanwithheavymenstrualbleedingrequestscontraceptionbutisnotkeenon
sterilisation.Afterexcludingapathologicalcauseforherbleedingyouadvisethat:

A) UseoftheCOCwillhaveabeneficialeffectonherriskofdevelopingovariancancer
B) TheCOCismoreeffectiveinreducingmenstruallossthantheIUS
C) Implanonisassociatedwithalossofbonemineraldensity
D) HRT/HTatthisageislikelytobecontraceptive
E) IfshehasanIUSfittedshecanretainituntilmenopause

Answer92

A) True
B) False
C) False
D) False
 E) True

UseoftheCOCpillreducesthechanceofovariancancer,aneffectthatisgreaterwithlongeruse.
TheCOCproducesapproximately50%reductioninbloodlosswhereastheIUS,by12months,
reducesbleedingbyover90%.ImplanonsuppressesovulationthroughLHinhibitionbutdoesnot
haveanimpactonbonedensityasfollicularactivityandoestradiolproductionaremaintained.

HRT,whethersequentialorcontinuouscombined,doesnotprovidecontraceptionashigherdoses
arerequiredtosuppressovulation.TheIUScanbeleftinsituuntilthemenopause,iffittedin
womenaged45orover.ThisisanofflicenceusesupportedbyguidancefromtheFSRH.

Urogynaecology and the Pelvic Floor

SBAs
Question93
A38yearwomanattendstheurogynaecologyclinicwitha5yearhistoryofpainfulbladder
syndrome.ShehaspreviouslybeentreatedbyherGPwithmultiplecoursesofantibioticsfor
presumedurinarytractinfections.Sheisveryanxioustotryanylinesoftherapythatmightleadtoa
resolutionofhersymptoms.
WhichoneofthefollowingwouldNOTbeareasonableoptiontodiscusswithher?

Answer93
B) Intravesicalhyaluronicacid
Thereisgoodevidencefortheuseoftricyclicantidepressantsformanagingmanydifferentpain
syndromes,includingpelvicpain.Dietarymodificationshouldbetriedbecauseitissimpleandsafe,
althoughtheeffectsarevariable.Avoidingcaffeine,alcoholandacidicandspicyfoodsisworth
trying.SmallstudieshaveshownbenefitwithintravesicalDMSOtherapyanditislicensedforthis
use.Theuseofantibioticsisnotsupportedbytheevidence,norisintravesicalhyaluronicacid.

Question94

A70yearoldwomanattendstheurogynaecologyclinicwithalongstandingmixedhistoryofstress
incontinenceandoveractivebladdersymptoms.Shewouldliketoproceedwithsurgicaltreatment
ofherstressincontinence,butherpreviousconsultanthasbeenreluctanttooperatethusfar.

WhichoneofthefollowingstatementsisNOTtrueregardinghermanagement?

Answer94

D) Shewouldbenefitfromatrialofsupervisedpelvicfloormuscletrainingof6weeks
duration
Theuseofmultichannelcystometry,ambulatoryurodynamicsorvideourodynamicsisnot
recommendedbeforestartingconservativetreatment.Forthesmallgroupofwomenwithaclearly
definedclinicaldiagnosisofpurestressurinaryincontinence,theuseofmultichannelcystometryis
notroutinelyrecommended.Multichannelfillingandvoidingcystometryisrecommendedin
womenbeforesurgeryforUIifthereisclinicalsuspicionofdetrusoroveractivity,therehasbeen
previoussurgeryforstressincontinenceoranteriorcompartmentprolapseortherearesymptoms
suggestiveofvoidingdysfunction.

InmixedUI,conservativeormedicaltreatmentshouldideallybethefirstlinebeforesurgery.

Atrialofsupervisedpelvicfloormuscletrainingofatleast3monthsdurationshouldbeofferedas
firstlinetreatmenttowomenwithstressormixedUI.Thereisgoodevidencethatdailypelvicfloor
muscletrainingcontinuedfor3monthsisasafeandeffectivetreatmentforstressandmixedUI.A
minimumof6weeksisusedasacutoffforbladdertrainingasfirstlinetreatmenttowomenwith
urgeormixedUI.

DuloxetineshouldnotbeusedasafirstlinetreatmentforstressUI.Itshouldnotroutinelybeused
asasecondlinetreatmentforstressUI.Itmaybeofferedasanalternativetosurgicaltreatment;
andwomenneedtobecounselledaboutadverseeffects.

Question95
A45yearoldwomanattendsgynaecologyoutpatientswith8yearsofoveractivebladdersymptoms
sinceherlastdelivery.Shewouldliketoknowmoreaboutherconditionandwhatherfuture
optionsformanagementare.
Whichoneofthefollowingstatementswouldbeusefulincounsellingher?

Answer95
D) Shecouldconsidertheuseofposteriortibialnervestimulation
OABisreportedinapproximately17%ofwomen.Itisasymptomcomplexofurinaryurgency
withorwithoutincontinenceusuallyfoundwithfrequencyandnocturia,intheabsenceof
otherpathologysuchasurinarytractinfection,calculusorneoplasm.Thefirststepin
managementisconservativebehaviouralchanges,suchasbladderretraining,with
antimuscarinicsreservedforcasesinwhichthesestepsfail.Inwomenwhofaildrugtherapy,
PTNS,BotoxorSNSmaybeconsidered.

Question96
A68yearwomanhashada6monthcourseoftreatmentwithanantimuscarinicagentfor
idiopathicoveractivebladdersyndrome.Shehasattendedforaplanforfurthermanagement.
Whichoneofthefollowingistrueabouthermanagement?

Answer96
A) Herchanceofsuccessfultreatmentwithantimuscarinicsisabout80%
Symptomswillremainrefractorytoantimuscarinicdrugsin20%ofwomenwithidiopathic
OAB.Urinarydiversionshouldonlybeconsideredinwomenwhohavefaileddrugtherapy,
andwhohavefailedorarenotsuitablefortreatmentwithBotulinumtoxinA,SNSand
augmentationcystoplasty.Asaresultofthesenewertreatmentmodalities,thenumberof
urinarydiversionsfordetrusoroveractivityhasreducedinrecentyears.Theriskofrequiring
selfcatheterisationfollowingtreatmentwithBotulinumtoxinAisatleast1in6andhenceNICE
guidancerecommendsallwomenshouldbewillingandabletoundertakecatheterisationprior
totreatment.Mirabegronisabeta3agonistusedtotreatdetrusoroveractivity.Sacralnerve
stimulationisasuccessfultreatmentfordetrusoroveractivity;however,thereported
complicationrateishigh,ataround30%.

Question97

A38yearoldwomanwithalongstandinghistoryofoveractivebladdersymptomsattendsa
urogynaecologyclinic.HerGPrecordsshowthatherthreemostrecentmidstreamurinesamples
havebothgrownStaphylococcusaureus.
Whichoneofthefollowingistrueregardingtherelevanceofthisresult?

Answer97
E) Overactivebladdersymptomsareassociatedwith
bacteriuria
TheEuropeanUrologyAssociationhasrecentlychangedtheirguidelinesonthecriterionfor
bacteriuriaandtheynowrecommendathresholdof>103CFU/ml.Thepreviouslyusedcriterion
(>105CFU/ml)doesnotdiagnoselowgradebacteriuria,whichisparticularlyrelevantto
urogynaecologypatientswithoveractivebladdersymptoms,asanassociationhasbeenproven.
Asymptomaticbacteriuriainpregnancyrequirestreatment,duetotheassociationwithneonatal
complications.RCOGguidelinesstilluseathresholdof>105CFU/ml.Themostcommonly
cultureduropathogenisE.coli.WomenwithrecurrentUTIsshouldhaveacystoscopyifbasic
measures(i.e.oestrogentherapy,cranberryproducts,hygiene)donotimprovesymptoms,orif
haematuriaispresent.

Question98

A57yearoldwomanhasbeentroubledbyoccasionalurinarytractinfectionsassociatedwithsexual
intercoursesincegoingthroughthemenopauseaged55.Atherlastinfection,E.coliwerecultured
fromtheurine.

Whichoneofthefollowingistrueregardinghermanagement?

Answer98
D) LocaloestrogentherapywouldreduceherriskofrecurrentUTIs
Ashortcourseofantimicrobialtreatmenthasbeenproventobeaseffectiveasalongcourse
whentreatingsimpleUTI.Nitrofurantoinisthefirstchoiceantibioticasresistanceislow(4%)and
sideeffectsfew.Localoestrogentherapystimulatesthegrowthofvaginallactobacilli,whichlowers
thepH,inhibitinguropathogengrowth.ThisinturnreducestheriskofUTI.Postcoital
Nitrofurantoin(Macrodantin)issafetouse.Consistentdailyprophylacticuseformorethan12
monthsisassociatedwithpulmonaryfibrosis,althoughtheriskissmall.

Question99

MrsGHisa50yearoldwomanwhocomplainsofincontinencewhenshecoughsorliftsher
grandchild.Shealsodescribessomeurinaryurgencyandvoidsabouttentimesaday.Shehashad
thesesymptomsfor2yearsandtheyareworsening.Shedeliveredbothherchildrenvaginally,andis
otherwiseingoodhealth.Shetakesstatins,butnoothermedication.

WhichofthefollowingstatementsisNOTtrueregardingherinitialmanagement?

Answer99

B) Shedoesnotrequireavaginalexaminationatthisstage

GHisaperimenopausalwomanwhogivesahistorysuggestiveofmixedstressincontinenceand
urgency.Adetailedhistoryshouldbeundertakentoestablishwhichishermoretroublesomeurinary
symptom.Sheshouldhaveavaginalexaminationtocheckforatrophyorcoexistingprolapse.Initial
investigationswillincludeurinedipsticktoexcludeurinarytractinfectionorotherpathology,and
completionofafrequency/volumechart.Thiswillgiveamoredetailedaccountofhervoiding
frequencyandvoidedvolumestoaiddiagnosis.Initialtreatmentwillbeconservativeandinclude
adviceaboutfluidintakeandthetypeoffluidsthataredrunk(avoidanceofcaffeine).Ifshehassigns
ofvaginalatrophyatopicaloestrogencreamcouldbeused.Sheshouldbereferredforsupervised
pelvicfloorexercisesandinstructioninbladderdrill.Ifurgencypersistsinspiteoftheseconservative
measuresthensheshouldbegivenatrialofantimuscarinics.

Iftheseconservativeandmedicalmeasuresfail,andifstressincontinenceishermainsymptom,she
shouldbereferredforurodynamicinvestigationinviewofhercoexistingurgency.Standard
cystometryistheinvestigationofchoice.Ifcystometryconfirmsurodynamicstressincontinence
thensurgerycouldbeconsidered.Additionalurodynamicfindingsofdetrusoroveractivityorvoiding
dysfunctionshouldbetakenintoaccountwhensurgeryisdiscussed.

Extended Matching Questions

Question100

Foreachcasebelow(iiii),choosethesingletestmostsuitablefromthelistAK.

i) A45yearoldwomanwithtwochildrenbornbyvaginaldeliverypresentswithleakingwith
exercise,coughingandsneezingandoccasionalurgency.Shehastriedpelvicfloorexercises
withlittleimprovementinhersymptomsandseeksdefinitivetreatment.Onexamination
thereisminimalprolapseandurinalysisisclear.
ii) A76yearoldladypresentswithdenovosymptomsofurgencyandurgeincontinence.She
statesherabdomenfeelsmorebloatedandshecannotdothetopbuttonofhertrousersup
anymore.Urinalysisisclear.
iii) A54yearoldnulliparousladypresentswithrecurrentdysuriaandfrequencyworseningover
thepast4months.Shesmokes10cigarettesperday.RepeatedMSUsatherGPhavenever
demonstratedinfection.Urinalysisdemonstrates2+haematuria.Youhavesentarepeat
MSUformicroscopy,cultureandsensitivity.

Answer100

i) A(Standardcystometry).Thiswomanhastriedconservativemeasuresforherpresumed
stressincontinenceandseeksdefinitivetreatment.Shehasstressincontinencecomplicated
byurgency,sostandardcystometrywouldbetheinvestigationofchoicepriortosurgery.
ii) I(Ultrasoundofabdomenandpelvis).Althoughthepresentationcouldbeconsistentwith
detrusoroveractivity,thesesymptomscouldalsoindicateanovarianmass.Anultrasound
examinationofabdomenandpelvisisindicatedbeforefurtherinvestigationofherurinary
symptoms.
 iii) E(Ultrasoundofkidneys/ureters/bladder).Carcinomainsituofthebladdercanpresentwith
urinarysymptoms.Haematuriashouldalwaysbeinvestigatedbeforetreatingurinary
symptomsasbenign.Cystoscopyandcytologyareotherinvestigationsthatcouldbe
performed.

Question101

Belowisalist(AP)ofmanagementoptionsforurinarydifficultiesexperiencedbywomen.Foreach
ofthecasesi)toiv)thatfollow,choosethemostappropriateoptionfromthelist.

i) A40yearoldpresentswithleakingurine.Hersymptomsmainlyoccurwhilecoughing,
sneezingandgardening.Thereisalsosomedegreeofurgency.Thereisnoincontinence
demonstratedonexamination.Urodynamicssuggestevidenceofurodynamicstress
incontinence.
ii) A76yearoldwithaBMIof40presentswithsymptomsofincontinencewhichis
affectingherdailylife.Sheisontreatmentforheartfailure,unstableanginaandCOPD.
Pelvicexaminationrevealsasmallcystoceleandminimaluterinedescentwithleakage
oncoughing.Shehasalreadybeenreferredforphysiotherapywhichhasmadelittle
differencetohersymptoms.
iii) A35yearoldwomanpresentswithleakingonexercise.Sheisafitnessinstructorand
routinelydoestwosessionsaweek.Shedoesgiveahistoryofstrainingwhilevoiding.
Therearenosymptomsofurgencyorincreasedfrequency.Examinationisessentially
unremarkable.Shewantsadefinitivesolutiontoherprobleminordertoimproveher
qualityoflife.Shehasdone3monthsofpelvicfloorphysiotherapy.Uroflowmetryshows
max.flowrateof12ml/sandaverageflowrateof8ml/s.
iv) A45yearoldladypresentswithsymptomsofleakingurine.Sheleaksoncoughingbut
sherarelycoughs.Whenshewantstogotothetoiletshehassevereurgency.Shevoids
12timesadayandshewakestwiceatnighttopassurine.Shedoesnothaveanyvoiding
problems.Therearenoothermedicalcomorbidities.Bladderdiaryshowsadailyintake
ofaround1.5litres.Examinationisunremarkable.Shehasalreadytriedsupervisedpelvic
floorexercisesandbladderretraining.Shehasalsotriedoxybutyninanddarifenacin.

Answer101

i) B)Pelvicfloorexercises.Firstlinetreatmentforstressormixedurinaryincontinenceshould
bepelvicfloormuscletraining(PFMT)lastingatleast3months.PFMTshouldconsistofat
leasteightcontractions,threetimesaday.IfPFMTisbeneficial,continueanexercise
programme.
ii) D)Weightloss.Thisladyregardlessofthepictureofincontinenceisnotanidealcandidate
formedicationaswellassurgerygivenhercomorbiditiesandlargeBMI.Themost
appropriateoptioninhercasewouldbeweightlossinthefirstinstance.
iii) I)Preoperativecounsellinginaclinicsetting.Thisladyhasstressincontinenceonlyonhigh
impactexercise.Herpoorvoidingputsherathighriskoflongtermintermittentself
catheterisationwithadefinitivetreatmentoptionsuchasretropubictape.Thisriskistobe
balancedwithoverallqualityoflifegiventhathersymptomsmainlyaffectherduringhigh
impactexercise.Hencesheneedsadetailedpreoperativecounsellinginaclinicsetting.
iv) H)Mirabegron.Thisladyhasmixedincontinencebutoveractivebladderisherpredominant
symptom.NICErecommendsmirabegronasapossibletreatmentforthesymptomsof
 overactivebladderinwomenwhohavenotrespondedtoanticholinergics.Mirabegronisa
beta3agonist.

Obstetrics
General Obstetrics
SBAs
Question102

Youreviewapatientinclinicwhodeliveredheronlychild5yearsagoat28weeksgestation
followingaspontaneouspretermlabour.

Whichofthecounsellingpointsgivenbelowwouldbeappropriateadviceforher?

A) Herriskofarepeatpretermdeliveryisthesameasthatofawomanwhodelivered
herlastbabyat32weeks

B) Antenatalcervicalultrasoundscansareofnobenefit

C) Sheshouldberecommendedtoundergoacervicalsuture

D) Sheshouldberecommendedtoreceiveprophylacticcorticosteroidsat27weeks

E) Fetalfibronectinswabat22weeksmayhelpdeterminetheriskinthiscase

Question103

Youarecalledtolabourwardtoseeapatientwhohasbeenadmittedwithregularcontractionsand
intactmembranesat28weeksgestation.Hercervixisclosedandisfoundtobe1cmlongon
speculumexamination.

Whichoneofthefollowingstatementsistrue?

A) Shehasa50%chanceofdeliveringprematurelyinthenext4days

B) Acervicalsuturemaybeofbenefit

C) AdministrationofAtosibanhasbeenshowntoimproveneonataloutcomes

D) Oralerythromycinisofbenefit

E) Magnesiumsulphatemaybeofbenefit

Question104
A30yearoldprimigravidaat41weeksgestationhadaspontaneousvaginaldelivery.Duringthe
secondstageoflabour,itwasnotedthatherliquorwasstainedwiththickmeconium.Thebaby
wasborningoodconditionwitha5minuteApgarscoreof9.
Whichofthefollowingisthemostappropriatemanagementstep:

A) Neonatalantibioticsfor7days
 B) Twohourlyobservationsinaneonatalintensivecareunitfor24hours
C) Oropharyngealandnasopharyngealsuctioningattheperineumpriortodeliveryofthe
shoulders
D) Endotrachealintubationandsuctioning
E) Closemonitoringat1and2hourspostdelivery,followedby2hourlyobservationsfor12
hours

Question105
Whichoneofthefollowingstatementswithregardstothereductioninriskofmeconium
aspirationsyndrome(MAS)istrue:

A) AmnioinfusionreducestheriskofMASincaseswherethereareCTGabnormalities
suggestiveoffetalcompromise
B) Inductionoflabourat41weeksdoesnothelptoreduceMAS
C) MaternalnarcoticsreducetheincidenceoffetalgaspingandthereforepreventMAS
D) Avoidinginductionoflabourwithvaginalmisoprostolisadvisable
E) Deliveryshouldbeexpeditedifmeconiumstainedliquorisnotedduringlabour

Question106

Aprimipisinducedforsuspectedfetalgrowthrestrictionwithprostaglandins.Thesymphysiofundal
heightisonly33cmat38weeksgestationandaseriesofscanssuggestcrossingoftheabdominal
circumferencecentiles,althoughliquorvolumeandumbilicalarteryDopplerrecordingsareinthe
normalrange.Hermembranesarerupturedartificiallyat2cmdilatationandSyntocinonstarted.
Withinanhoursheiscontractingregularly34every10minutesandafurtherexamination3hours
afterthisshowssheis3cmdilated.Afurther3hourslateryouareaskedtoreviewthesituation
becausethemidwifehasconcernsabouttheCTG.Youfindabaselinerateof155bpm(previously
135bpm),variabilityof<5bpmfor50minutesandtypicalvariabledecelerationsforthelast2hours,
occurringwiththemajorityofthecontractions.Onexamination,youfindhertobe4cmdilatedwith
a1cmthickcervixandmeconiumstainedliquor.Shehasketonuriaandisrequestingmorepain
relief,havingsofarreceivedcodeine.

Whichofthefollowingoptionswouldbethemostappropriatecourseofaction?

A) Turntoleftlateral,rehydrate,givefacialoxygenandreassessin1hour
B) Proceedtocategory2caesareansection
C) Performafetalbloodsampling
D) Proceedtocategory1caesareansectionundergeneralanaesthesia
E) TurnofftheSyntocinon,giveterbutalineandrecommendanepidural

Question107
Amultiparouspatientpresentswithsevereabdominalpainat36weeksgestation,precededbymild
uterinetighteningfollowingacleargushoffluidpassedpervaginam2daysbefore,whichshe
thoughtwasurine.Shehasntvomited,butfeelssickandhasnoticedshouldertippain.Shehasa
historyofbiliarycolic,apreviouscaesareansectionandmoderateasthma.Sheisapyrexialbut
tachycardiconexamination,withabloodpressureof85/45.Shehasreboundtenderness,guarding
andrigidityandabsentbowelsounds.Speculumexaminationrevealsaclosedcervix,butblood
stainedliquor.TheCTGshowsafetaltachycardiawithpoorvariabilityandunprovoked
decelerations.HerHbis87g/landherwhitecellcountis13.7109/l.
Whichisthemostlikelydiagnosis?

A) Chorioamnionitis
B) Placentalabruption
C) Appendicitis
D) Cholecystitis
E) Uterinerupture

Question108

Whichofthefollowingfeaturesofamnioticfluidembolismisunlikelytobethepresentingproblem?

A) Acutehypotension
B) Cardiacarrest
C) Haemorrhage
D) Suddenfetalcompromise
E) Respiratorycompromise

Question109

Whichofthefollowingproposedriskfactorshasthestrongestassociationwithamnioticfluid
embolism?

A) Advancedmaternalage
B) Caesareansection
C) Inductionoflabour
D) Uterinehyperstimulation
E) Placentapraevia

Question110

Whichoneofthefollowingistrue:maternityclaimstopatientsarepaidby:

A) TheCrownIndemnityforTrusts
B) TheNationalHealthServiceLitigationAuthority(NHSLA)
C) ClinicalNegligenceSchemeforTrusts(CNST)
D) Obstetricdepartmentsfromtheirannualbudget
E) Theindividualtrustsfromtheirannualbudget

Question111
A28yearoldwomanisdeliveringhersecondbabyafterinductionoflabourforpostmaturityat42
weeksgestation.ThereisthickmeconiumandapathologicalCTGinthesecondstage,soaventouse
deliveryisperformed.

Whichoneofthefollowingstatementsiscorrectregardingdeliverymanagement?

A) Nasopharyngealsuctionshouldbeperformedwiththeheadontheperineum,beforethe
bodyhasdelivered
B) Thenasopharynxshouldbesuctionedimmediatelyafterdelivery
C) Thenewbornshouldbeelectivelyintubatedatbirth
D) Thenewbornheadshouldbekeptinanextendedposition
E) Positivepressureventilationbymaskisnotcontraindicated

Question112

A39yearoldwomanisinpretermlabourwithherfirstbabyat27+2weeks.Shewishestoknow
whatwillbedoneforthebabyatbirth.

Whichoneofthefollowingstatementsiscorrectregardingmanagementinthissituation?

A) Thebabywillbeelectivelyintubated
B) Thebabywillbegivensurfactant
C) Thebabywillbethoroughlydriedtopreventhypothermia
D) Cordclampingwillbedelayedifthebabyisvigorous
E) Thebabywillbeathighriskofmetabolicalkalosis

Question113

Whichoneofthefollowingoptionsiscorrectregardinginfectioninpregnancy?

A) Malariaisresponsibleforlessthan20%ofstillbirthsinAfrica
B) Screeningforsyphilisindevelopedcountrieshasreducedstillbirthsattributedtothis
infection
C) MaternalCMVinfectionisassociatedwithafetallossrateofover50%
D) ToxoplasmosisisacommoncauseofstillbirthintheUK
E) E.coliinfectionofthemotherisararecauseofstillbirth

Question114

A40yearoldwomaninherfirstpregnancypresentsat34weekswithaheadacheandreducedfetal
movements.Herbloodpressureonadmissionis170/110,with4+proteinintheurine.Immediate
stepsaretakentostabilisethematernalcondition.

Whichoneofthefollowingistrueregardinghermanagement?

A) Sublingualnifedipinemaybeadministered
B) Methyldopaisaverywelltoleratedandwouldhaveminimaladversesideeffectsinthiscase
C) Aprotein:creatinineratioof30mg/mmolisequivalenttoa24hourproteinexcretionof300
mg
D) Signsandsymptomsofmagnesiumsulphateoverloadincludetachycardiaandblurredvision
 E) Theantidotetomagnesiumsulphateoverdoseis10ml1%calciumgluconategivenslowly
intravenously

Question115

A20yearoldwomaninherfirstlabourhasbeenpushingforover1hourwhenthemidwifeasksfor
areview.Subsequentexaminationrevealsthatthebabyisinanoccipitoposteriorposition.

WhichoneofthefollowingfactorsisNOTassociatedwithapersistentoccipitoposteriorposition?

A) Deflexionofthefetalhead
B) Prolongedlabour
C) Increaseduseofoxytocin
D) Epiduralanalgesia
E) Youngmaternalage

Question116

A20yearoldwomaninherfirstlabourhasbeenmakinggoodprogress;however,onexamination
themidwifehasdeterminedthatthebabyisinamentoposteriorfacepresentation.

WhichoneofthefollowingfactorsisNOTtrue?

A) Ifthepositionremainsmentoposteriorthencaesareansectionshouldbeperformed
B) Regularintrapartummonitoringwithsystematicclinicalexaminationsanduseofa
partogramisrecommended
C) Ifthepositionrotatestomentoanteriorthenaspontaneousvaginaldeliveryispossible
D) Iffetalcompromiseissuspected,fetalbloodsamplingshouldbeundertakenbeforea
decisionforcaesareansectionisreached.
E) Themothershouldbemadeawarethattheremaybefacialswellingandbruisingnotedin
thebabysoonafterdelivery;however,itislikelytoresolvewithoutanypermanentdamage

Question117

A35yearoldwomanwithaprevioushistoryofonespontaneousvaginaldelivery,followedbytwo
caesareansectionsforbreechbabiesattendstheclinictodiscussdeliveryofherfourthchild.Ifthe
babyiscephalicattermshewouldliketotryforavaginaldelivery.Duringyourcounsellingyou
mentiontheriskfactorsforuterineruptureduringVBAC.

WhichoneofthefollowingoptionsdoesNOTincreasetheriskofuterinerupture?

A) Pretermlabour
B) Shorterinterdeliveryinterval
C) Twoormorepreviouscaesareansections
D) Inductionoflabour
E) Fetalmacrosomia

Question118

Incounsellingwomenregardingtherisksofvaginaldeliveryonthebackgroundofoneprevious
caesareansection,whichoneofthefollowingwouldnotgenerallybeconsideredanabsolute
contraindicationtoaVBACattempt?

A) Lowlyingplacentaatterm
B) Previousuterinerupture
C) Twinpregnancy
D) ApreviousTshapedincision
E) Apreviousclassicalcaesareansection

Question119

A38yearoldwomanwhohadanemergencycaesareansectionat5cmforfetaldistressinher
previouslabouriscontemplatinghersubsequentmodeofdelivery.Shewouldliketoknowthebest
availableevidenceregardingtherisksassociatedwithVBAC.

WhichoneofthefollowingstatementsisNOTtrueregardingtheriskofVBAC?

A) NIHCDdatagivesa1in200riskofuterinerupturefollowingonepreviouslowersegment
caesareansection
B) Hysterectomyisrequiredfortwothirdsofcasesofuterinerupture
C) TheaddedriskofanadverseperinataloutcomewhenoptingforVBACis1in400
D) ItisassociatedwithanalmostdoublingintheriskofbloodtransfusioncomparedwithERCS
E) TheriskofmaternaldeathislowerthanwithERCS

Question120

A22yearoldprimigravidadevelopsHELLPsyndromeat34weeksofgestationwithacuterenaland
liverdysfunction.AfterdeliverysheistransferredtoCriticalCare.

Whichoneofthefollowingistrueregardinghermanagement?

A) IntravenousNacetylcysteinemaybeofbenefit
B) Renalreplacementtherapyisnotrequireduntilserumcreatinineconcentrationexceeds
1000mol/L
C) Centralvenousaccessandarteriallineplacementispreventedbyaplateletcountof75
109/L
D) Magnesiumsulphateasseizureprophylaxisshouldnotbegivenbecauseofherrenal
impairment
E) Ifherclottingisimpairedthenaggressiveearlytransfusionofbloodproductsisrequired

Question121

A30yearoldwomandevelopssepticshock7daysafterdeliveryandrequiresorgansupport.

Whichoneofthefollowingistrueregardinghersubsequentmanagement?

A) IfIntravenousnoradrenalineisrequiredthensheshouldstopexpressingbreastmilk
 B) Theuseofintravenoushydrocortisonemaybebeneficialinthissetting
C) TheuseofactivatedproteinCshouldbeconsidered
D) Atemperatureof35oCexcludessepsis
E) Thematernalleucocytosisof15109/Lcouldbeexplainedbydeliveryalone

Question122

A29yearoldwomanpresentsinherfirstpregnancyat13weeksgestation,wishingtodiscuss
vaccination.HerpartnerisMalawianandsheintendstoflythereat34weeksforthebirth.She
completedtheUKchildhoodvaccinationprogrammebutdoesnotthinkshehashadanyfurther
vaccinationssince.Shehasnopastmedicalhistoryandnoallergies.Currentvaccination
recommendationsforadultstravellingtoMalawiarediphtheria,tetanus,typhoid,hepatitisAand
rabies.

Whichoneofthefollowingistrueregardinghervaccinations?

A) Asshehascompletedthechildhoodvaccinationprogramme,thereisnoneedforpertussis
immunisation
B) Influenzaandpertussisvaccinesshouldbegiventogetherat28weeks
C) Tetanusandpolioboostersaredueregardlessofhertravelplans
D) HepatitisAandtyphoidvaccinesarecontraindicated,astheirsafetyinpregnancyis
unknown
E) Rabiesvaccinationisnotrequired

Question123

A35yearoldwomansustainsathirddegreeanalsphincterinjuryatthedirectoccipitoposterior
forcepsdeliveryofherfirstbaby.

WhichofthefollowingstatementsisNOTtrueregardingherfollowup?

A) Sheshouldbecounselledaboutthefutureriskoffaecalincontinence
B) Perinealpainanddyspareuniaarecommonat6weekfollowup
C) Sheshouldbecounselledagainstthefutureuseofloperamideifloosestoolsareaconcern
D) Sheshouldbereferredtoacolorectalsurgeonifshehassymptomsoffaecalincontinence
E) Ifshehasabnormalendanalultrasoundorneurophysiologyteststhensheshouldbeoffered
deliverybycaesareansectionforhernextbaby

Extended Matching Questions

Question124

Fromthelistofvaccinationsbelow(AO)choosethemostappropriateoptionstoanswerthe
questionsi)tovi).Eachoptioncanbeusedonce,morethanonce,ornotatall.

A) Measles
B) Pertussis
C) Polio
D) BCG
 E) Pneumococcal
F) Varicella
G) Rabies
H) Mumps
I) Influenza
J) YellowFever
K) Diphtheria
L) Rubella
M) Tetanus
N) Anthrax
O) Noneoftheabove

i) Threevaccinesthatarecontraindicatedinpregnancy
ii) Ifthisvaccineisgivenduringpregnancy,terminationisrecommended
iii) Twovaccinesthatexistinliveattenuatedandinactivatedforms
iv) Twovaccinesrecommendedtoallwomenduringpregnancy
v) Fourvaccinationsgivenasasingleinjection,marketedintheUKasRepevax
vi) Routinevaccinationagainstthisinfectionisrecommendedoutsideofpregnancyto
specificallypreventteratogenicity

Question125

Belowisalist(AJ)ofsymptomsandemotionsthatmayoccurinthepostpartumperiod.Fromthis
list,choosetheoptionswhichbestanswerthequestionsi)andii)givenafterwards.

A) Fear
B) Disorientation
C) Lowmood
D) Shouting
E) Hearingavoiceoutsideherheadtellinghersheisindanger
F) Falsebeliefsthatsomeoneiswatchingthepatient
G) Falsebeliefsthatsomeonewantstokillthebaby
H) Perplexity
I) Confusion
J) MessagesfromtheTVthattheQueenisthepatientssister

i) Identifythefourmostcommonlyexperiencedsymptomsinpostpartumpsychosis
ii) Identifytwosymptomsthatmoststronglysuggestthisisnotpostpartumpsychosis

Question126

YouaretheST5obstetricsandgynaecologytraineeonthelaboursuite.Youarriveforhandoverat
thestartofyourshiftat8.30am.WorkingwithyoutodayareanST1obstetricsandgynaecology
traineeandananaestheticsST4trainee.Theconsultantobstetricianandgynaecologistcoveringthe
laboursuiteisinameeting.

Room Parity Gestation

1 P2 Postnatal Normalbirthat6.30am.Trickling.Raggedmembranesat
delivery
+1
2 P0 36 DCDAtwins,spontaneouslabour8cmdilated
3 P3 41+5 InductionawaitingARM
4 P1 Postnatal Readmission,5dayspostnatal,offensivelochia,pyrexial,
tachycardicandhypotensive.Awaitingreview.
5 P0 38+5 Spontaneouslabour6cmdilated
6 P0 39+2 Breech,2cmdilatedcontracting,normalCTG
7 P1 Postnatal Awaitingsuturing
8 P1 41 Augmentationwithsyntocinonat7cmdilated,requesting
epidural
9 P1 39 Fullydilatedandpushing,pathologicalCTG
10 P1 35+2 Brittleasthmatic,tachypnoeicandhypoxic.Awaitingreview

Foreachquestionbelow(iv),choosetheroomnumberthatisthebestmatch:

(i)WhichroomshouldtheanaestheticST4traineereviewfirst?

(ii)WhichroomshouldtheO&GST5traineereviewfirst?

(iii)WhichroomshouldtheO&GST1traineereviewfirst?

(iv)Whichroomshouldthecoordinatingmidwifereviewfirst?

(v)TheobstetricST5traineeshouldreviewthiswomanwhentimeallows

A) Room1
B) Room2
C) Room3
D) Room4
E) Room5
F) Room6
G) Room7
H) Room8
I) Room9
J) Room10

Questions127130

Withreferencetothescenarioandboardinquestion126;itisnow4hourslaterandtherehave
beennonewadmissionstothelaboursuiteandthewomenremaininthesameroomsasbefore.
Foreachofthefollowingsituationsselectthesinglemostappropriateactionfromthelistofoptions
given.

Question127

Thewomaninroom6isnow8cmdilatedwithabreechpresentationandanormalCTG.After
discussionregardingmodeofdeliverysheisadamantthatshewantsacaesareansection.The
womaninroom5isnow7cmdilatedwithapathologicalCTGandafetalbloodsamplehasbeen
carriedoutwithapH7.18.

Whichisthebestcourseofaction?

A) Performacategory1CSforroom5
B) Opentwotheatresforcategory1CSforbothrooms5and6
C) Performacategory2CSforroom5
D) Performacategory1CSforroom6andasktheST1torepeattheFBSinroom5in30
minutes
E) Giveterbutalinetoroom6andperformacategory1CSforroom5

Question128

Themultiparouswomaninroom3hasprogressedveryquicklytofulldilatationfollowing
amniotomy.Shehasbeenpushingfor1hourwithanormalCTG.Onvaginalexaminationsheisfully
dilatedwithanoccipitotransversepositionwithevidenceof2+caputand2+mouldingandthe
presentingpartisatthespines.Theprimiparouswomaninroom5hasbeenpushingfor1hourwith
anormalCTG.

Whatwouldbeyourbestcourseofaction?

A) Allowbothwomentopushforanotherhour
B) Offerinstrumentalbirthtotheprimip(room5)first
C) Deliverthemultiparouswomaninroom3,andasktheST1ormidwifetosuture,andthen
proceedimmediatelytodeliverroom5,theprimip
D) Deliverthemultiparouswomenintheatrefirst
E) Callyourconsultanttodooneofthedeliveries

Question129

Thewomaninroom5hasbeencontracting34in10andisnow9cmwithapathologicalCTGand
meconium.Thewomaninroom2ishasdelivered40minutesagobuttheplacentahasnotdelivered
yet.Sheishaemodynamicallystableandtheestimatedbloodlossis300ml.

Whatwouldbeyourbestcourseofaction?

A) Takethewomaninroom2totheatreforamanualremovalandthenperformanFBSin
room5
 B) DoanFBSinroom5andthen,ifthepHisnormal,dothemanualremoval
C) Calltheconsultanttodooneofthesetasks
D) SendtheST1intoroom5todotheFBSwhilstyoudothemanualremoval
E) Giveterbutalinetoroom5whilstyoudothemanualremovalfirst

Question130

Thewomaninroom8remains7cmdilatedwithadeflexedoccipitoposteriorpositionandevidence
ofcaputandmoulding.TheCTGissuspicious.Maternaltemperatureis38.1Cinspiteofhavingi.v.
paracetamolandantibiotics.Thewomaninroom3hasspontaneouslyrupturedhermembranesand
adecelerationwasheardonintermittentauscultation.TheCTGisnowpathological.Onvaginal
examinationsheis4cmdilated.

Whatwouldbeyourbestcourseofaction?

A) DoanFBSinroom8,andthenroom3todecidewhohasaCSfirst
B) Offeranother4hoursofSyntocinonaugmentationtothewomanin8andinthemeantime
doacategory1CSforroom3
C) DoanFBSinroom3anddeliverthiswomanbyemergencyCSifthepH<7.2
D) Calltheconsultanttoassessoneofthesewomen
E) OpentwotheatrestodobothCSimmediatelyandcalltheconsultanttodooneofthem

Multiple Choice Questions

Question131

Answertrueorfalse

Whencounsellingwomenwithahistoryofpreviouscaesareandeliveries:

A) Inductionoflabourisassociatedwitha23foldincreaseinuterinerupturerisk
B) Theriskofperipartumhysterectomyexceeds1%onthefourthsection
C) Theriskofplacentaaccretaonlyexceeds1%afterthefourthsection
D) SteroidsshouldbeadministeredforERCSat3738+weeksgestation
E) Theantepartumstillbirthrateafter39weeksgestationisgreaterforwomenwithahistory
ofpriorCS.

Question132

Regardingprincipleswithinmedicalnegligencelaw:

A) Inamedicalnegligenceclaim,thestandardofproofrequiredisbeyondallreasonable
doubt
B) TheBolamdefenceprecededtheBolithocase
C) Itisenoughtodefendadoctorifabodyofexpertssupporthis/heractions
D) Provingbreachofdutyisinsufficientforasuccessfulmedicalnegligenceclaim
E) Anexpertwitnessshouldgivedifferentadvicedependingonwhethertheyareinstructedby
theclaimantsorthedefendantssolicitor

Question133

Answertrueorfalse

Postpartumgenitaltractsepsis

A) wasthesecondmostcommoncauseofdirectmaternaldeathintheUKinthe20062008
triennium
B) isdecliningasacauseofmaternaldeathintheUK
C) shouldbetreatedwithantibioticsonlywhenthecausativeorganismsareknown
D) incasesofmaternalmortalityismostoftenassociatedwithbetahaemolyticStreptococcus
LancefieldGroupB
E) isreducedbyroutineantibioticprophylaxisgivenatcaesareansection

Question134

Answertrueorfalse

TheSepsisSixincludesthefollowingsteps:

A) Give100%oxygen
B) Takebloodcultures
C) Giveoralantibiotics
D) Checkinghaemoglobinandurate
E) Inserturinarycatheterandmeasurehourlyurineoutput

Question135

Answertrueorfalse

Regardingumbilicalcordbloodstemcells:

A) Someofthemaremesenchymal
B) Usingthemreliablyforbonemarrowtransplantationremainsaresearchaim
C) Theyieldisreducedbydelayedcordclamping
D) TheRCOGrejectstheneedforautologouscordbloodcollection
E) Theyieldfromasinglecordharvestisusuallysufficientforanadultbonemarrowtransplant

Question136

Regardingpertussisvaccinationinpregnancy,arethefollowingtrueorfalse?

A) Itisprimarilyformaternalbenefit
B) Itisaliveattenuatedvaccine
C) Womenwhohavebeenvaccinatedinapreviouspregnancydonotrequirevaccinationin
furtherpregnancies
D) Thevaccineshouldideallybegivenbetween28and32weeksgestation
E) Vaccinationshouldbeperformedpostpartumifitisnotpossibleantenatally

Question137

Answertrueorfalse

Regardingadviceatthebookingappointment:

A) Upto5unitsofalcoholperweekisconsideredsafe
B) Dietingshouldbeavoidedduringpregnancy
C) Lowdoseaspirinshouldbetakenifthewomanhastype2diabetes
D) VitaminDsupplementsshouldbetakenroutinely
E) AnoralglucosetolerancetestshouldbeperformedoncetheBMIexceeds35

Question138

Answertrueorfalse

Thirdandfourthdegreetears:

A) Aretheleadingcauseoffaecalincontinenceinwomen
B) Aremorecommonfollowingforcepsdelivery
C) Arepreventedbyroutinemediolateralepisiotomy
D) haveabetterlongtermoutcomefollowingoverlaprepairtechniquescomparedwithend
toend
E) requireprophylacticantibioticcoverduringrepair

Question139

Answertrueorfalse

Withregardtofacepresentation:

A) Themostfavourablepositionforvaginaldeliveryismentoposterior
B) Itisassociatedwithcongenitalanomalies
C) Continuousexternalfetalmonitoringshouldbeutilised
D) Aninstrumentaldeliverybyventouseorforcepscanbeperformedintheeventof
prolongedsecondstage
E) Anexperiencedneonatalpractitionershouldbepresentatthedelivery

Question140

Answertrueorfalse

Inthecontextofdelayinprogressinthefirststageoflabour:

A. Attentionmustbemadetoensureadequatehydration
B. Amniotomyincreasesthevaginaldeliveryrate
 C. Oxytocinusedecreasesthecaesareansectionrate
D. Oxytocinshouldbeincreasedevery10minutes
E. Continuouselectronicfetalmonitoringshouldbeutilisedinwomenfollowing
amniotomy

Question141

Answertrueorfalse

Regardingperinatalmortality:

A) Thedefinitionincludesantepartumstillbirths,intrapartumstillbirthsandallneonataldeaths
B) 24completedweeksisusedintheUKasthelowergestationallimittodefineaperinatal
death
C) Ratescaneasilybecomparedbetweencountries
D) Alivebornneonateat23weeksgestationwhosubsequentlydiesonday5oflifeisclassified
asaperinataldeath
E) Anintrauterinedeathat23weeksand6daysgestationisclassifiedasaperinataldeath

Question142

Answertrueorfalse

Withrespecttotheepidemiologyofterm,deliveryrelated,perinataldeath:

A) Theratecanbeusedasamarkerofthequalityofintrapartumcare
B) Intrapartumanoxiaandmechanicalcausesaretheleadingcausesofneonataldeathin
normallyformedfetusesatterm
C) Theincidenceinhighincomecountriesis1in2000forprimiparouswomen
D) Theincidenceisfalling
E) Theincidenceisdirectlyrelatedtothecaesareansectionrate

Question143

Answertrueorfalse

Termrelatedperinataldeath:

A) isassociatedwithsmoking
B) Isnotaffectedbymaternalage
C) inprimiparouswomenisinfluencedbytheplaceofbirth
D) isassociatedwithmacrosomia
E) isreducedbytheuseofcontinuouselectronicfetalmonitoring(EFM)inlabour

Question144

Answertrueorfalse
Thefollowingoutcomesaremorecommoninteenagepregnanciescomparedwiththoseofwomen
intheir20sand30s:

A) Stillbirth
B) Pretermlabour
C) Maternalmortality
D) Exomphalos
E) Deliverybycaesareansection

Question145

Answertrueorfalse

Thefollowingareacceptedindicationsforinductionoflabour:

A) Macrosomia
B) Previouscaesareansection
C) Intrauterinefetaldeath
D) Historyofprecipitatelabour
E) Maternalrequest

Question146

Answertrueorfalse

Regardinginductionoflabour

A) AnintravenousoxytocininfusionisrecommendedbytheNICEguidelinesasthepreferred
methodofinductionoflabour
B) Womenwithonepreviouscaesareansectionhaveanoverallriskofuterineruptureof
approximatelyfivepercentiftheyareinduced
C) Ifuterinehyperstimulationoccursduringanoxytocininfusion,deliverybycaesareansection
isindicatedimmediately
D) Womenreceivinganoxytocininfusionareatriskofdevelopinghypernatremia
E) ABishopsscoregreaterthan5ispredictiveofasuccessfulinduction

Question147
Answertrueorfalse
Thefollowingarerecognisedriskfactorsforplacentalmorbidadherence:

A) Previouscaesareansection
B) IVF
C) Previousuterinecurettage
D) Historyofendometritis
E) Uterinefibroids

Question148
Answertrueorfalse
ThefollowingarecomponentsoftheTriplePprocedureformanagementofplacentalmorbid
adherence:

A) Pelvicdevascularisation
B) Preopuretericstenting
C) Perioperativeplacentallocalisation
D) Patientsterilisation
E) Placentalnonseparationandmyometrialexcision

Question149
Answertrueorfalse
Withregardtoexpectantmanagementofplacentalmorbidadherence(IntentionalRetentionof
Placenta)

A) Thepatientshouldbecounselledaboutthe1in3chanceofneedingahysterectomyatsome
point
B) Antibioticsshouldbeprescribed
C) Thereisqualityevidencesupportingtheuseofmethotrexate
D) SerialHCGmeasurementsshouldbeperformedpostnatally
E) Interventionalradiologywillnotbeinvolved

Question150

Answertrueorfalse

RoutineantenatalprophylacticAntiDadministrationisnotnecessaryforthefollowingRhDnegative
women:

A) Thosewhohaveplanstobesterilisedafterthebirth
B) Multiparouswomen
C) ThosewithaRhDnegativepartner
D) WomenisoimmunisedtotheRhDprotein
E) Thosewomenplanningdeliverybyelectivecaesareansection

Question151

Thefollowingaretrueofadherencetoprescriptions:

A) Nonadherenceiscurrentlydefinedastakinglessthan7080%ofmedications
B) Atleast3050%ofmedicationsarenottakenasrecommended
C) Nonadherenceprimarilyoccursbecauseofpatientfactors
D) Adherenceistheextenttowhichapatientsbehaviourmatchesagreedprescribers
recommendation
E) Beingateenagerisoneofthereasonsthatpatientsdonottaketheirmedication

Question152

Answertrueorfalse

Withregardtotherisksofcaesareansection:

A) TheriskofbladderinjuryduringCSis1%
B) Theriskoffetallacerationis12%
C) ThelikelihoodofcomplicationsduringanelectiveCSisapproximatelythesameasduringan
emergencyCSperformedinearlylabour
D) TheriskofhysterectomyduringCSinapatientwithamorbidlyadherentplacentais25%
E) ItisperfectlyreasonabletoperformsterilizationatthetimeofanemergencyCSforfailure
toprogress

Question153

Answertrueorfalse
Regardingamnioticfluidembolism(AFE):

A) Itisassociatedwithgoodmaternalandfetaloutcomesifnonfatal

B) CasesshouldonlybereportedtoUKOSSonceconfirmedatpostmortem

C) FetalcompromisemaybeduetoAFE,eveninaninitiallyasymptomaticwoman

D) Fetalsquamesareaninvariablefindinginmaternallungsatpostmortem

E) Itisnotfatalinthemajorityofcases

Question154

Answertrueorfalse
Thefollowingarecontraindicationstoepiduralinsertion:

A) Severepreeclampsia
B) Aorticstenosis
C) Plateletcountof70109/L
D) Cellulitisoftheleg
E) Idiopathicintracranialhypertension

Question155

Answertrueorfalse
Regardingtheuseofopioidsinlabourforanalgesia:

A) Theriskofneonataldepressionwithpethidineishighestifgiven6hoursbeforedelivery
B) Patientcontrolledanalgesiashouldbediscontinuedduringthesecondstageoflabour
C) Remifentanilshouldbeavoidedinwomenwithrenalimpairment
D) FentanylisassociatedwithlowerneonatalApgarscores
E) Midwivescangiveintramuscularpethidinewithoutadoctorsprescription


Question156

Answertrueorfalse

RiskfactorsforVitaminDdeficiencyinclude:

A) Obesity
B) Pigmentedskintypes
C) Vegetariandiet
D) Useofantiepilepticdrugs
E) Limitedsunexposure

Question157

Answertrueorfalse

RegardingVitaminDandpregnancy

A) Insufficiencyisamoreseriousstatethandeficiency
B) Deficiencycanbecorrectedbydailyadministrationof10gperday
C) Deficiencyisdetectedbymeasuringlevelsof1,25dihydroxyvitaminD
D) Inadequatelevelsareassociatedwithgestationaldiabetes
E) VitaminDsupplementshelptopreventchildhoodrickets

Question158

Answertrueorfalse

Thepatientandtheirfamilycanrequesttosee:

A) Acopyoftheclinicalnotes
B) Statementsfromtheindividualsinvolved
C) CopyoftheRCA
D) Instructionstosolicitors
E) Statementsmadeafteraclaimhasbeensubmitted

Maternal Medicine
SBAs
Question159

MissGHisa40yearoldwoman,withmildasthma,inhersecondpregnancy.Inherfirstpregnancy
MissGHdevelopedsevereearlyonsetpreeclampsiarequiringdeliveryat25weeksgestation.This
babydied3daysfollowingdelivery.SubsequentlyMissGHwasdiagnosedwithessential
hypertensionandiscurrentlytakingtheangiotensinconvertingenzyme(ACE)inhibitorenalapril,10
mgoncedaily.MissGHpresentstoyoufollowingapositivepregnancytest.Bookingscanreveals
MissGHtobeapproximately7weekspregnant.

Whatisthebestcourseofaction?

A) Commencelowdoseaspirinandrecommendfourweeklyfetalgrowthscansfrom26weeks
gestation
B) Changeenalapriltomethyldopaandrecommendaspirinandlowmolecularweightheparin
injections
C) Commencelowdoseaspirinandchangeenalapriltolabetalol
D) Commencelowdoseaspirin,changeenalapriltomethyldopaandperformuterineartery
Dopplermeasurementsat23weeksgestation
E) Alterenalapriltonifedipineandperformregulargrowthscansfrom30weeksgestation

Question160

TheriskofwhichofthefollowingisNOTincreasedabovethegeneralpopulationduringpregnancy
inwomenwithsicklecelldisease?

A) Thrombosis
B) Placentapraevia
C) Gallstonedisease
D) Pulmonaryhypertension
E) Haemolyticdiseaseofthenewborn

Question161

WhichofthefollowingisNOTarecognisedcomplicationofpregnancyinwomenwithcysticfibrosis?

A) Inuterogrowthrestriction
B) Gestationaldiabetes
C) Pretermdelivery
D) Shortenedmaternalsurvivalasaresultofpregnancy
E) Reversiblelossoflungfunctionduringpregnancy

Question162

Whichofthefollowingiscorrectregardingmycobacteriumtuberculosisinpregnancy:

A) TheMantouxtestisnotapplicableinpregnancy
B) Thediagnosisisconfirmedonlywithpositivewashingsfrombronchoscopy
C) TreatmentofTBinpregnantwomenshouldbethesameasthatinnonpregnantwomen
withexceptionofstreptomycin
D) Rifampicinmaycausematernalhepatotoxicityandshouldbeavoided
E) Theneonatedoesnotneedprophylacticisoniazidtreatmentifthemotherissputumpositive

Question163
Whichofthefollowingfactorsdoesnotincreaseinnormalpregnancy:

A) Fibrinogen
B) Tissueplasminogenactivator
C) FactorVII
D) FactorXI
E) VonWillebrandFactor

Question164

WhichofthefollowingistrueregardingverticalHIVtransmission:

A) InuntreatedHIV,thisriskisapproximately80%
B) Breastfeeding,asamechanism,contributeslessthantransplacentalandintrapartum
transmissions
C) Theriskisreducedto5%inwomenwithundetectablelevelsofthevirus
D) Coinfectionwithmalariaincreasestherisk
E) Womenwithanundetectableviralloadonzidovudinemonotherapyneednotbe
recommendedtohaveanelectivecaesareanbirth

Question165

MrsJSisa31yearoldwomanwithahistoryofchronickidneydiseaseduetorefluxnephropathy
andchronicpyelonephritis.Shereceivedarenaltransplant6yearsagowithnoepisodesofrejection.
Shecontinuedtosufferfromintermittenturinarytractinfectionsafterhertransplantbuthasnot
hadanyepisodesfor18months.Shealsohashypertension.

Currentmedicationsareprednisolone5mgod,mycophenolate1gbd,tacrolimus4mgbd,ramipril
5mgodandnifedipineLA30mgod.Herbloodpressureis129/75,serumcreatinine113mol/l,
estimatedGFR52ml/minandurinedipsticknegative.

Sheisconsideringherfirstpregnancyandattendsyourclinicforpreconceptioncounselling.

Whatisthebestmanagementoptionforyoutorecommendtoher?

A) Avoidpregnancyforanother2years
B) Stopthetacrolimusandincreaseherdoseofprednisolone.Explainthatthechancesofa
successfulpregnancyoutcomeareapproximately70%
C) Stopthemycophenolateandramipril,startazathioprineandadviseherofahighchanceofa
goodoutcome
D) Stoptheramiprilandadviselowdoseaspirinbecauseofher50%riskofpreeclampsia
E) Stopthetacrolimusandramiprilandprepareherforasignificantriskofneedingdialysis
duringthepregnancy

Question166

WhichofthefollowingisNOTtrueregardingsystemiclupuserythematosus(SLE)inpregnancy:

A) Ifthepatientisonwarfarinpreconceptually,thismaybesafelycontinuedforthedurationof
thepregnancy
 B) Preeclampsiaismorecommoninwomenwithpreviousglomerulonephritis
C) IncreasingamountsofproteinintheurineinwomenwithSLEmaysignaltheonsetofpre
eclampsia
D) Pregnancyoutcomeisrelatedtopreconceptualbaselinerenalfunction
E) Activediseaseinthe6monthspriortoconceptionisassociatedwithaworseprognosisfor
thepregnancy

Question167

Whichofthefollowingistrueregardingdermatologicalconditionsinpregnancy:

A) Pruriticurticarialpapulesandplaquesofpregnancy(PUPP)requiresclosefetalmonitoring
duetoanincreasedriskofstillbirth
B) PUPPtypicallysparesthesolesofthefeetandpalmsofthehands
C) Pemphigoidgestationisoccursinwomenwithactiveoraprevioushistoryofherpes
D) Patientswithpustularpsoriasisofpregnancypresentswithpruriticerythematousplaques
withringsofpustules
E) Pustularpsoriasisofpregnancyisabenignconditionandisnotassociatedwithadversefetal
outcome

Question168

A23yearoldprimigravidapresentstoyouat11weeksgestation.Shehasalonghistoryofasthma,
diagnosedinherchildhood,withtwoadultadmissionsforsevereasthmarequiringoralsteroids.At
present,shetakesSymbicort(Budesonide100mcgandformoterol6g)twopuffsb.i.d.and
salbutamol(100g)twopuffsaboutthreetimesperweekasneeded.Recentlyshehashadmild
symptomsonlyprecipitatedbyexercise.Shewouldliketostopherinhaledcorticosteroidassheis
concernedaboutharmingherbaby.

Whichofthefollowingisacorrectstatementregardinghermanagement?

A)ShecanstopherSymbicortbecauseherasthmaisnowwellcontrolled

B)Inhaledcorticosteroidshavebeenshowntohaveanegativeimpactonfetaldevelopment
andtheiruseshouldbeminimizedduringpregnancy

C)Sheshouldtrytoreducehercurrentactivitylevelsduringthepregnancyasexerciseis
precipitatinghersymptoms

D)Oralsteroidsshouldnotbewithheldinsevereasthmaattacks

E)Theophyllinesshouldnotbeusedifherasthmadeteriorates

Question169

A32yearoldnulligravidawithlupusdiagnosed6yearsagopresentsforprepregnancycounselling.
Atdiagnosis,shehadhightitresofANA,dsDNA,lowcomplement(C3andC4)andpositiveantiRo
antibody.Hertypicalsymptomsincludeasymmetricarthritis,malarrashandoralulcers.Shehasno
hypertension,respiratoryorrenaldisease.Twomonthsagoshehadaflarethatrespondedtooral
steroidsandshenowhasnosymptoms.Sheiscurrentlytakinghydoxychloroquine400mgdaily,
Azathioprine100mgdailyandPrednisolone10mgdaily(taperedfrom20mg2monthsago).

WhichofthefollowingisNOTtrueregardinghermanagement?

A) Sheshouldbeencouragedtowaitatleast6monthsafterherrecentflarebefore
tryingtoconceive
B) Hydroxychloroquinereducestheriskoflupusflares
C) Maternalsteroidsupplementationduringlabourisonlynecessaryforpatientson
greaterthan7.5mgofprednisolonedailyforgreaterthan2weeks
D) Azathioprinemaybecontinuedduringpregnancy
E) Cyclosporinshouldneverbeusedduringpregnancy

Question170

Whichofthefollowingphysiologicalrespiratoryvariableswouldbeexpectedtoincreaseduring
normalpregnancy?

A) Vitalcapacity
B) FEV1
C) PeakFlow
D) TidalVolume
E) PaCO2

Question171

Theserumlevelofwhichofthefollowingisnotincreasedduringpregnancy?

A) Totalthyroidhormonelevel
B) Thyroidbindingglobulin
C) Alkalinephosphatase
D) Albumin
E) Progesterone

Question172

Anobese36yearoldprimiparouswomanundergoesaroutinescreeningoralglucosetolerancetest
at29weeksgestation,inviewofherBMIandfamilyhistory(hermotherisatype2diabetic).Her
fastingbloodglucoseis10mmol/Landher2hourresultis15mmol/L.Bloodglucosemonitoring
overthenextfewdaysshowssimilarearlymorningandpostmealvaluesandanultrasoundscan
showsamacrosomicfetuswithadegreeofpolyhydramnios.Thepregnancyisotherwise
straightforwardandshereportsgoodfetalmovements.

Whatwouldbeyourmanagementatthispoint?
 A) Admitandoffertherapeuticamniodrainage
B) Commenceglibenclamide
C) Commenceinsulin
D) Commencemetformin
E) Givelifestylerecommendationsandreviewin2weekstime

Question173
Whichoneofthefollowingistrueregardinggestationaldiabetes?

A) Themajorityofwomenrequireinsulintherapyatdiagnosis
B) Dietandexerciseshouldbetrialledforatleast4weekstoassessresponse
C) Ultrasoundmonitoringoffetalgrowthandamnioticfluidvolumeshouldbeperformed
every4weeksbetween2836weeks
D) Bloodglucoseshouldbemaintainedbetween710mmol/lduringlabouranddelivery
E) Themajoritywillhavepersistentfrankdiabetesorimpairedglucosetoleranceat612
weekspostpartum

Question174
Whichofthefollowingstatementsiscorrectregardingthromboembolisminpregnancy:

A) Theuseofaperfusionventilationscaniscontraindicatedinpregnancy
B) DDimertestingshouldbeusedtodiagnosevenousthromboembolisminpregnancy
C) Oralanticoagulantsaresuitableforthetreatmentofantenatalvenousthromboembolism
inneedlephobicwomen
D) VTEistheleadingcauseofdirectmaternaldeathsinthemostrecentConfidential
EnquiryintoMaternalDeaths
E) IfVTEissuspectedtreatmentshouldbestartedwhileawaitingadefinitediagnosis

Question175

Whichofthefollowingwomenshouldbescreenedforgestationaldiabetesbyasingleoralglucose
tolerancetestat2628weeksgestation:

A) Awomanwithagrandparentwithdiabetes
B) Awomanwithaprevioushistoryofgestationaldiabetes
C) AwomanwithaBMIof41kg/m2
D) AMiddleEasternwoman
E) Awomanwhosepreviousbabyweighed4.3kg

Question176

Whichoneofthefollowingmedicationsshouldbestoppedduringpregnancycomplicatedbypre
existingdiabetes:

A) Glargine
B) Ramipril
 C) Aspart:afastactinginsulinanalogue
D) Aspirin
E) Metformin

Question177

A25yearoldprimiparouswomanwithhypertensionandsignificantproteinuriaisinducedat39
weeksgestation.Shehasanepiduralduringlabourandlabourendsasaforcepsdeliveryofahealthy
babygirl.Within12hoursofthebirth,themothermobilisesanddevelopsseverehypertension
(175/115),agradualonsetheadacheanddifficultiesseeingnormally.AnMRIscanshowsbilateral
oedemawithinthewhiteandgreymatterintheposterioraspectsofthecerebralhemispheres.

Fromtheoptionsbelow,whichisthemostlikelydiagnosis?

A) Migraine
B) Corticalveinthrombosis
C) PRES
D) Subarachnoidhaemorrhage
E) Postpartumcerebralangiopathy

Question178

Whichofthefollowingantipsychoticdrugsfromthelistbelowwouldbefirstlinechoicein
pregnancy:
A) Imipramine
B) Olanzapine
C) Haloperidol
D) Mirtazapine
E) Clozapine

Question179

Youareaskedtoseeawomanforprepregnancycounsellingwhoisafitandwell28year
oldnonsmokerwithnosignificantpersonalorfamilyhistoryofnote.Shetravels,byplane,
fromLondontoParis(return)onamonthlybasisandhasconcernsabouthowthismight
impactonthepregnancy.

Whichofthefollowingpiecesofadvice,orrecommendation,isnotappropriate?

A) Mostairlineswillletawomanwithanuncomplicatedsingletonpregnancyflyuntil
37weeksgestation
B) Shewouldbeadvisedtouselowmolecularweightheparininjectionstoreducethe
thrombosisrisk
C) Sheshouldtakeadvicefromtheindividualairline
 D) Theincreasedcosmicradiationexposureisunlikelytobeofharm
E) Herriskofmiscarriageinthefirsttrimesterwillnotbesignificantlyincreased

Extended Matching Questions

Question180
Belowisalist(AJ)ofcausesofthrombocytopaeniainpregnancy.Pickthemostappropriate
diagnosisfortheconditionsdescribedini)tovi).

A) HELLP
B) TTP
C) VonWillebrandsdiseasetypeIIB
D) AFLP
E) Gestationalthrombocytopaenia
F) ITP
G) NAIT
H) DIC
I) HUS
J) Viralinfection

i) Anautosomaldominantdisordercausedbytheabnormalbindingofaproteinto
platelets
ii) AthromboticmicroangiopathycausedbyadeficiencyintheproteinADAMTs13
iii) Asyndromeofhaemolyticanaemia,thrombocytopaeniaandrenalfailurecommonly
linkedtobacterialinfection
iv) Apossibleconsequenceofamnioticfluidembolism
v) Aconditionusuallypresentingwithvomiting,abnormalliverenzymes,veryhighuric
acidlevelsandhypoglycaemia
vi) Aconditionpresentingwithhypertension,proteinuriaandhepaticnecrosis

Question181

Belowisalist(AK)ofdermatologicalconditionswhichmayoccurduringpregnancy.Fromthislist,
pickthemostsuitablediagnosisforthequestionsoutlinedini)tov).Eachanswermaybeusedonce,
morethanonce,ornotatall.

A) Atopicdermatitis
B) Acnevulgaris
C) Erythemanodosum
D) Pruriticurticarialpapulesandplaquesofpregnancy(PUPP)
E) Striaegravidarum
F) Pemphigus
G) Pustularpsoriaisisofpregnancy
H) Erythemamultiforme
I) Pemphigoidgestationis
J) Seborrhoeicdermatitis
K) Pemphigus

 i) Anautoimmuneconditionthatissometimesassociatedwithneonatalcutaneous
manifestations
ii) Theonlyskinconditionlistedwhichcarriesanincreasedriskofpregnancyloss
iii) Arashwhichstartscentrally,butoftensparestheperiumbilicalregion
iv) Askinrashwhichmayoccurasadrugreaction,orinassociationwithsystemicinfection
v) Aconditionthatisalsoknownaspolymorphiceruptionofpregnancy

Question182

Belowisalistofdrugs(AQ).Fromthelist,choosethemostsuitableforuseintheclinical
endocrinesituationsdescribedinquestionsitoix.

A) carbimazole
B) propanolol
C) cholecalciferol
D) cabergoline
E) fludrocortisones
F) DDAVP
G) carbamazepine
H) propylthiouracil
I) octreotide
J) spironolactone
K) ergocalciferiol
L) metyrapone
M) phenoxybenzamine
N) ketoconazole
O) prednisolone
P) dexamethasone
Q) amiloride

i) Twodrugsusedtotreathyperthyroidism
ii) Twodrugsusedinthetreatmentofphaeochromocytoma
iii) Themaintenancedrugofchoiceforapregnantwomanwithcongenitaladrenalhyperplasia
(CAH)whohasanoncarriermalepartner
iv) Twodrugsusedtotreatdiabetesinsipidus
v) ThedrugofchoiceforCushingssyndromeinpregnancy
vi) Thedrugusedtopreventfetalmasculinisationwhenthemotherandfatherarebothcarriers
forCAH

Multiple Choice Questions

Question183

Answertrueorfalse

AfemalesurvivorofWilmstumourtreatment,whichincludedabdominalirradiation,has:

A) a3foldincreaseintheriskofpretermlabour
B) a2foldincreaseintheriskoflowbirthweight
C) a3foldincreaseinfirsttrimestermiscarriagerisk
 D) astillbirthrateof1in30
E) adoubledriskofcongenitalanomaliesintheiroffspring

Question184

Answertrueorfalse

Regardingscreeningfor,anddiagnosisof,gestationaldiabetes:

A) Dipstickurinalysisforglucoseisagoodscreeningtest
B) Ifrequired,biochemicalscreeningforgestationaldiabetesisusuallyperformedbetween24
28weeksgestation
C) Womenwithpreviousgestationaldiabetesshouldbeofferedbiochemicalscreening(Oral
GlucoseToleranceTestor1weekofselfmonitoringofbloodglucose)at1618weeks
D) Diagnosticcriteriaarethesameworldwide
E) Diagnosticcriteriaarethesameasfordiabetesoutsideofpregnancy

Question185
Answertrueorfalse
Thefollowingfindingscanbenormalforpregnancy:
A) Apalpablepraecordialthrill
B) Athirdheartsound
C) AraisedJVP
D) Adiastolicmurmur
E) Ventricularectopics

Question186
Answertrueorfalse
ThefollowingchangesonanECGmaybenormalforpregnancy:
A) Sinustachycardia
B) MildSTelevation
C) STdepression
D) BroadenedQRScomplex
E) Twaveinversion

Question187
Answertrueorfalse
ThefollowingarekeyfeaturesintheTorontoriskscoringsystemformaternaloutcomesof
cardiacdiseaseinpregnancy:

A) Leftventricularoutflowgradientof>30mmHg
B) Maternalsmoking
C) Leftventricularejectionfraction<50%
2
D) Mitralvalveareaof<2.0cm
E) BaselineNewYorkHealthAssociationclassofIIIorIV

Question188
Answertrueorfalse

ThefollowingareknownriskfactorsforVTEinpregnancy:

A) Increasedmaternalage
B) LowmaternalBMI
C) Postpartumhaemorrhage
D) Thrombophilia
E) PreviousVTE

Question189

Answertrueorfalse

Regardinganaesthesiaoftheheadinjuredobstetricpatient:

A) Apregnantpatientisathigherriskofdesaturationoninductionofanaesthesia
B) Ventilatoryparametersarethesameasforanonpregnantpatient
C) Cerebralperfusionpressureisthedifferencebetweensystolicbloodpressureand
intracranialpressure
D) Aheaduppositionwillhelptoreduceintracranialpressure
E) Whenunderanaesthesia,adropinfetalheartrateandlossofvariabilityrepresentfetal
compromise

Question190

Answertrueorfalse

Regardingobstetriccholestasis:

A) Raisedbilesaltsarediagnostic

B) Fetaloutcomescanbeimprovedwithultrasoundsurveillance

C) Itisassociatedwithmeconiumstainingofliquor

D) Serumlevelsofliverenzymemustberaisedtomakeadiagnosis

E) Combinedoralcontraceptiveuseshouldbeavoidedinwomenthathavehadobstetric
cholestasis

Question191

Answertrueorfalse

WithregardtochronichepatitisBinfectioninpregnancy

A) ThepresenceofmaternalHBeantibodiesindicatesahighinfectivitystate
B) AllnewbornsofchronichepatitisBcarriersshouldreceiveactiveandpassiveimmunisation
C) VerticaltransmissionratesareinfluencedbymaternalHBeantigenpositivity
 D) Antiviralagentsarecommonlyprescribedinthethirdtrimester
E) Itisnotanindicationfordeliverybycaesareansection

Question192
Answertrueorfalse
Withregardstoepilepsyandpregnancy:

A) VitaminKshouldbeprescribedtoallwomenwithepilepsyfrom36weeksgestation
B) Womenonlamotriginedonotusuallyneedtoincreasethedoseoftheirmedicationoverthe
courseoftheirpregnancy
C) Intheeventofaseizure,whichisnotselflimiting,intravenouslorazepamisagoodchoiceof
treatment
D) Theneonateshouldbegiven1mgofintramuscularVitaminKtopreventhaemorrhagic
diseaseofthenewborn
E) Theriskofhavingaseizureinthefirst24hourspostdeliveryisapproximately1020%

Question193
Answertrueorfalse
Inmultiplesclerosisduringpregnancy

A) Tomakeaclinicaldiagnosis,theremustbeevidenceofatleastoneCNSlesion
B) Vaginaldeliveryandepiduralanaesthesiaarenotcontraindicated
C) Patientsareatincreasedriskofrecurrenturinarytractinfections
D) Highdosecorticosteroidsarecontraindicated
E) Baclofencanbeusedtorelievespasticity

Fetal Medicine
SBAs
Question194

A30yearoldwoman,currently9weeksintoherfirstpregnancy,isconcernedabouttherisksof
DownsyndromeandconfusedabouttestingavailableintheNHSscreeningprogramme.Shemeets
withyouforcounselling.

WhichofthefollowingistrueregardingDownsyndromescreening?

A) ThequadrupletestreachescurrentNSCstandards
B) Theriskthresholdforofferinginvasivetestingwithcombinedorquadruplescreeningis1in
200
C) NoninvasivefreefetalDNAtestinghasahigherfalsedetectionratethancombined
screening
D) Bestpracticerecommendsofferingascreeningtestwithadetectionrateof90%ormore,
withascreenpositiverateofnomorethan2%
E) IfanNTcannotbeobtained,theNSCrecommendsintegratedbiochemicaltesting

Question195
ForwhichONEofthefollowingconditionsismaternalintravenousimmunoglobulin(IVIG)
consideredthefirstlineoftreatment?

A) Preventionoffetalcongenitalheartblock
B) Fetalalloimmunethrombocytopaenia
C) RhesusDisoimmunisation
D) Preventionoffetalvirilisationincongenitaladrenalhyperplasia
E) Fetalparvovirusinfections

Question196

A40yearoldwomanat20weeksinherthirdongoingpregnancyhasbeenexposedtoCMVduring
herworkasacarerforchildrenwithlearningdisabilities.ShehasapositiveCMVIgMtitre,which
wasnegativeatbooking.Sheisveryworriedaboutthepossibilityofharmtoherfetus.

WhichofthefollowingistrueregardingCMVinfectioninpregnancy?

A) Itisacauseofrecurrentmiscarriage
B) Theriskofitoccurringwithmaternalinfectionishighestinthethirdtrimester
C) ItisdiagnosedbyarisingtitreofcytomegalovirusspecificIgMlevelsfollowing
recentinfection
D) Itisassociatedwithanincreasedincidenceofneuraltubedefects
E) Itcanbeexcludedbyanormalultrasoundscan

Question197

WhichofthefollowingoptionsisNOTcorrectregardinggenetics?

A) Allelesareanexampleofepigeneticvariability
B) Epigeneticchangescanbeinheritedfromonegenerationtothenext
C) Methylationcanpromoteorsuppressgeneexpression
D) Epigeneticchangesarereversible
E) ImprintingdisordersaremorecommonfollowingIVF

Question198

A36yearoldwomanpresentsforprepregnancycounselling.Thecouplesfirstdaughterwas
diagnosedafterbirthwithcongenitaladrenalhyperplasia(21hydroxylasedeficiency).Theyare
highlyanxiousabouttheriskstoasubsequentpregnancy.

Whichofthefollowingstatementsisincorrectabouttheirsubsequentpregnancies?

A) Thechanceofhavinganaffectedchildis25%
B) Steroidtherapyshouldbeginby5weeks
C) Noninvasiveprenataldiagnosis(NIPD)candeterminefetalsexat7weeksgestation
D) FetalsexingusingnoninvasiveprenataldiagnosisisbasedonthedetectionofY
chromosomespecificsequences
E) Ifmalesexisconfirmedsteroidsshouldbecontinued


Question199

Followingtesting,acouplehavebeeninformedthattheirfetushasafemurlength<3rdcentileand
thatserumanalytetestinghasrevealedalowPAPPA<0.1MoM.Theyareconsideringgenetic
testingforthepregnancy,andwouldlikemoreinformationaboutthetestsavailable.

Whichofthefollowingstatementsistrueaboutcurrentlyavailablegenetictesting?

A) Sequencingcandetectcopynumbervariations(deletionsandduplications)
B) ArrayComparativeGenomicHybridisation(arrayCGH)candetectsmallerdeletionsthan
karyotyping
C) Fluorescentinsituhybridisation(FISH)analysiscanbeusedtoconfirmapointmutation
D) Noninvasiveprenataldiagnosiscanbeusedtodetectmaternalmutationsonly
E) Noninvasiveprenataldiagnosisperformslesswellthancombinedscreeningfortrisomy21
detection

Question200

Chorionicityisoneofthebestdeterminantsofriskinatwinpregnancy.Whichofthefollowing
statementsistrueregardingdeterminingthechorionicityofatwinpregnancy?

A) Itisbestdeterminedbyascanat8weeksgestation
B) Thelambdasignisdiagnosticofdichorionicityinthefirsttrimester
C) Itcanbeaccuratelyassessedat20weeksgestation
D) Adividingmembranethicknessof<2mmisdiagnosticofmonochorionicity
E) Ifthisremainsuncertainthepregnancyshouldbemanagedasmonochorionic

Question201

Avarietyofgeneticandchromosomaldiseasescanbedetectedusingpreimplantationgenetic
diagnosis.WhichofthefollowingisNOTarecogniseduseofthistechnique?

A) Huntingtonsdisease
B) Duchennemusculardystrophy
C) EarlyonsetAlzheimersdisease
D) Savioursiblings
E) Familybalancing

Extended Matching Questions

Question202

FromthelistofstatisticaltermsAK,choosethemostappropriateoneforeachofthedescriptions
detailedinquestionsi)tov).

A) Sensitivity
 B) Positivepredictivevalue
C) Oddsratio
D) Screenpositiverate
E) Falsenegativerate
F) Accuracy
G) Likelihoodratio
H) Truepositiverate
I) Negativepredictivevalue
J) Falsepositiverate
K) Specificity

i) Theabilityofascreeningtesttoidentifyunaffectedindividuals
ii) Thelikelihoodthatanindividualscreenedpositivefortheconditionactuallyhasthedisease
iii) Theproportionofindividualswhoscreenpositivebutdonotactuallyhavethecondition
iv) Theproportionofthescreenedpopulationwhohaveapositiveresult
v) Theabilityofatesttoidentifyaffectedindividuals

Question203
Fromthelistbelow(AJ),choosewhichdisorder(s)bestfit(s)thestatements(iii)thatfollow.Each
optionmaybeusedonce,morethanonceornotatall.

A) Betathalassaemia
B) Cysticfibrosis
C) Duchennemusculardystrophy
D) Huntingtonsdisease
E) MELASsyndrome
F) CRESTsyndrome
G) FragileXsyndrome
H) LeschNyhansyndrome
I) Sicklecelldisease
J) Raynaudssyndrome

i) Autosomaldominantdisorder(s)forwhichPGDispossible.
ii) Mitochondrialdisorder(s)forwhichPGDispossible.
iii) Disorder(s)notsuitableforPGD.
iv) AutosomalrecessiveconditionsamenabletoPGD

Multiple Choice Questions

Question204

Answertrueorfalse

InDownsyndromepregnancies

A) TheserumHCGtendstobehigherthannormal
B) Theawaveintheductusvenosusismorelikelytobepositive
C) Tricuspidregurgitationiscommon
D) Thenasalboneiscommonlyabsentorhypoplastic
E) PAPPAlevelstendtobehigherthannormal


Question205

Answertrueorfalse

Withregardtochickenpoxinpregnancy:

A) Cardiacdefectsarethemostcommonteratogeniceffect
B) Thediseaseisonlyinfectiousoncetherashappears
C) Over90%ofUKwomenareimmunetochickenpox
D) Theriskofvaricellaembryopathyisgreaterwithmaternalinfectionat16weeksthanat8
weeksgestation
E) Therisktothebabyisminimalwithmaternalinfectionsoccurringatterm

Question206
Answertrueorfalse
Regardingnonalloimmunethrombocytopaenia(NAIT):

A) ItismostcommonlycausedbyantibodiesbindingtoglycoproteinIIaIIIa
B) Itisaclinicaldiagnosismadebyexcludingothercausesofneonatalthrombocytopaenia
C) Itwillalwaysrecurinfuturepregnancies
D) Complicationsaremostcommonlypreventedbyuseofimmunoglobulins
E) ManagementmaybeassistedbyfreefetalDNAstudies

Question207

Answertrueorfalse

Twintotwintransfusion:

A) Occursin1730%ofmonochorionictwinpregnancies
B) Canbediagnosedbydiscordantliquorvolumes
C) Isbesttreatedbyserialamniodrainage
D) CanbeclassifiedusingtheQuinteroclassification
E) Canbemanagedbyselectivecordocclusion

Question208

Answertrueorfalse

Withregardtotheroutinedetailedanatomyscanat1821weeksgestationinalowriskpopulation:

A) Fourfifthsofallmajoranomalieswillbedetected
B) Theincidenceofmajoranomalieswillbe12%
C) Almostallseriouscardiacabnormalitieswillbedetected
D) Threequartersofallcleftlipswillbedetected
E) Only1in50casesofanencephalyshouldbemissed

Question209
Answertrueorfalse
Folicacid:
A) IsthepopularnameforvitaminB9
B) Isfoundmostlyinredmeat
C) IscrucialinthesynthesisoftheDNAconstituentcytosine
D) Isabsorbedbetterasasupplementthanfromnaturalfoodsources
E) Levelsareaffectedbygeneticvariants

Question210
Answertrueorfalse
ACochraneanalysisconcludesthatpericonceptualfolicacidsupplementationhelpstopreventthe
followingpregnancycomplications:

A) Microcyticmaternalanaemia
B) Neuraltubedefects
C) Cleftlipandpalate
D) Placentalabruption
E) Fetalgrowthrestriction

Question211
Answertrueorfalse
Thefollowinggroupsofwomenshouldbeadvisedtotake5mgofpericonceptualfolicacid:

A) Thosewithahistoryofapregnancywithfetalmyelomeningocoele
B) Thosewithahistoryofgestationaldiabetes
C) WomenwithaBMIgreaterthan30
D) Thosewithapreviouspregnancycomplicatedbycongenitalheartdisease
E) Alcoholabusers

Question212

Answertrueorfalse
RegardingDopplersinfetalgrowthrestriction(FGR):

A) TheumbilicalarteryDopplervaluesusuallyliewithinthenormalrangeinlateonset
FGR
B) MiddlecerebralarteryDopplerPulsatilityIndex(PI)increasesinFGR
C) AhighcerebroumbilicalDopplerindexisreassuring
D) ChangesintheuterinearteryDopplervaluesoccurlate
E) ChangesintheMCADopplerPIareakeydeterminantinthetimingofdeliveryofearly
pretermgrowthrestrictedfetuses

Obstetrics
General Obstetrics
SBAs
Question102

Youreviewapatientinclinicwhodeliveredheronlychild5yearsagoat28weeksgestation
followingaspontaneouspretermlabour.

Whichofthecounsellingpointsgivenbelowwouldbeappropriateadviceforher?

Answer102

E) Fetalfibronectinswabat22weeksmayhelpdeterminetheriskinthiscase

Theriskofpretermlabourinasubsequentpregnancyishighertheearlieringestationtheprevious
deliveryoccurred.Antenatalcervicalultrasoundassessmentsforcervicallengthmayhelptopredict
theriskofsubsequentpretermlabourinthispregnancy.Acervicallengthshorterthan25mm
confersanincreasedriskofpretermdeliveryandconsiderationofacervicalsuturetoreducethe
risks.TherecentRCOGguidelinesdonotrecommendcervicalsuturesbasedonhistoryalone.
Insteadsheshouldbeofferedultrasoundmonitoringofcervicallength.Prophylacticprescriptionof
steroidsisnotrecommended.Thisisbecausethebenefitofcorticosteroidstotheneonateis
maximalat24hoursto7days.Becauseofconcernsrelatingtorepeateddosing,onlyasinglecourse
isrecommended.Therefore,timingofthesinglecourseisparamount.Thepatient,despiteher
history,isstillmorelikelynottodeliverearly.Therefore,administeringthecorticosteroidsshouldbe
reserveduntilshepresentswithsymptomsandsignsofpretermlabour.Fetalfibronectinshouldnot
bepresentinthecervicalsecretionsat22weeksgestation.Anegativeswabresulthasanexcellent
negativepredictivevaluefordeliveringprematurely,thereforecanassistinthepredictioninthis
pregnancy.

Question103

Youarecalledtolabourwardtoseeapatientwhohasbeenadmittedwithregularcontractionsand
intactmembranesat28weeksgestation.Hercervixisclosedandisfoundtobe1cmlongon
speculumexamination.

Whichoneofthefollowingstatementsistrue?

Answer103

E) Magnesiumsulphatemaybeofbenefit
Themajorityofwomenadmittedwithsymptomsofpretermlabourdonotgoontodeliver
prematurely.Thisisabigproblemforclinicaltrials(asalargenumberofwomendonothavethe
disease)andalsoforfocussingmanagementonthelabourward.Acervicalsutureisofnobenefitat
thisgestation.AlthoughAtosibanmaydelaydeliveryforupto7days,nostudieshavebeenableto
showanyneonatalbenefits.Routineuseofantibioticsinthepresenceofintactmembranesisnotof
benefitwithoutclinicalevidenceofinfection,andinfacttheORACLEIIstudysuggestedthatthey
maybeassociatedwithharm.Magnesiumsulphateisofnouseasatocolytic,butevidencesupports
itsuseinordertopreventcerebralpalsyintheinfant.Althoughstudiesshowbenefit,thedose
regimeandprotocolisasyetunclear.Somesuggestadministrationatthesamedoseasusedforpre
eclampsia,givenatmorethan4cmdilatation.Unlikesteroids,whereaminimumof24hoursis
neededforbenefit,magnesiumisshortacting,sobenefitwithinonly4hoursofdeliveryisreported.

Question104
A30yearoldprimigravidaat41weeksgestationhadaspontaneousvaginaldelivery.Duringthe
secondstageoflabour,itwasnotedthatherliquorwasstainedwiththickmeconium.Thebaby
wasborningoodconditionwitha5minuteApgarscoreof9.
Whichofthefollowingisthemostappropriatemanagementstep:

Answer104
E) Closemonitoringat1and2hourspostdelivery,followedby2hourlyobservationsfor12
hours
Managementoftheneonatewilldependonitsconditionatbirthandthedegreeof
meconiumstaining.Regardlessoftheviscosityofthemeconium,currentNICEguidelines
suggestoropharyngealandnasopharyngealsuctioningattheperineumhasnoeffectonthe
incidenceofmeconiumaspirationsyndromeandthereforetheadviceistoavoidthis
practiceunlessthenewbornisinapoorconditionatdelivery.Mostvigorousbabiesborn
throughthickmeconiumstainedamnioticfluiddonotrequireanyinterventionsexcept
monitoringforsignsofrespiratorydistress.Thisshouldbedoneat1hourand2hoursafter
birthforanyvigorousbabybornthroughmeconiumstainedliquor.Ifbornthroughthick
meconium,thebabywillrequire2hourlyobservationsfor12hours.Althoughmeconiumis
apotentialmarkerforneonatalsepsis,evidencedoesnotsupportroutineadministrationof
antibioticstoallbabiesbornthroughmeconium.

Question105
Whichoneofthefollowingstatementswithregardstothereductioninriskofmeconium
aspirationsyndrome(MAS)istrue:

Answer105
D) Avoidinginductionoflabourwithvaginalmisoprostolisadvisable
Meconiumstainedamnioticfluid(MSAF)canbeasignoffetalcompromisebutithasalow
predictivevalue.Therefore,itisimportanttoassessfetalwellbeingbyothermeans
(continuousfetalcardiotocography)ratherthanexpeditinglabouronthebasisofMSAF
alone.ThereareseveralrecognizedmethodsforreducingtheriskofMAS.Preventing
prolongedpregnancyhasbeenshowntoreducetheriskofMSAFandsubsequentlyMAS,
perinatalmorbidityandcaesareansectionrates.Althoughfurtherresearchisrequiredinthis
area,thereissubstantialevidencelinkingmedicationsuchasmisoprostolanddinoprostone
toanincreasedriskofMSAF.Thecurrentevidenceadvisesagainsttheuseofamnioinfusion
asitisassociatedwithcomplicationssuchascordprolapse,uterinescarruptureand
chorioamnionitis,withnosignificantimprovementinMAS,perinatalmorbidityorcaesarean
sectionrates;ifthereareCTGabnormalities,theappropriatecourseofactionshouldbea
fetalbloodsample.Thereareseveralothermethodssuggestedintheliteratureforreducing
theriskofMASincludingmaternalnarcotics,physiotherapy(posturaldrainage)andcricoid
pressurefortheneonate,butnonehavebeenshowntobeofbenefitandarenot
recommended.

Question106

Aprimipisinducedforsuspectedfetalgrowthrestrictionwithprostaglandins.Thesymphysiofundal
heightisonly33cmat38weeksgestationandaseriesofscanssuggestcrossingoftheabdominal
circumferencecentiles,althoughliquorvolumeandumbilicalarteryDopplerrecordingsareinthe
normalrange.Hermembranesarerupturedartificiallyat2cmdilatationandSyntocinonstarted.
Withinanhoursheiscontractingregularly34every10minutesandafurtherexamination3hours
afterthisshowssheis3cmdilated.Afurther3hourslateryouareaskedtoreviewthesituation
becausethemidwifehasconcernsabouttheCTG.Youfindabaselinerateof155bpm(previously
135bpm),variabilityof<5bpmfor50minutesandtypicalvariabledecelerationsforthelast2hours,
occurringwiththemajorityofthecontractions.Onexamination,youfindhertobe4cmdilatedwith
a1cmthickcervixandmeconiumstainedliquor.Shehasketonuriaandisrequestingmorepain
relief,havingsofarreceivedcodeine.

Whichofthefollowingoptionswouldbethemostappropriatecourseofaction?

Answer106

B) Proceedtocategory2caesareansection

Thisisalabourwithriskfactors(fetalgrowthrestrictionandmeconium)forfetalcompromise.At
thepointofyourCTGreview,itispathological.Therearetwononreassuringfeatures(reduced
variabilityfor50minutesandtypicalvariabledecelerationswithover50%contractionsoccurringfor
morethan90minutes)soitshouldbeclassifiedaspathological.Itisentirelyappropriateto
resuscitatethefetusbychangingmaternalposition,turningoffSyntocinon,possiblygivingmaternal
facialoxygenandevengivingterbutaline,butthiswouldbeinsufficientandfurtheractionis
indicated.IftheCTGispathological,theneitherdeliveryofthebabyormoresensitiveassessmentof
thefetalcondition(i.e.fetalbloodsampling)isrequired.AlthoughFBSmightbepossiblehere,it
wouldnotbesafetositeanepiduralfirst,duringwhichtimeapossiblyalreadycompromisedfetus
mightdeterioratefurther.Furthermore,whentakeninthewholecontextofthelabour,the
pathologicalCTGearlyoninthishighrisklabourisbetterrespondedtobydeliveryofthebabyby
caesareansection.ThefetalpHmaybenormalatthispoint,butistherearealisticprospectof
reachingfulldilatationandeffectingasafevaginalbirth?Probablynot.Progressisnotparticularly
good,andthecervixisntevenfullyeffaced.Whencategorisingthecaesareansectiononeshould
considerifthereisimmediatethreattothelifeofmotherorbaby.Afastcategory2wouldbe
appropriate.Demandingageneralanaestheticwouldbeunnecessaryandanattemptatregional
anaesthesiawouldbeappropriate.

Question107
Amultiparouspatientpresentswithsevereabdominalpainat36weeksgestation,precededbymild
uterinetighteningfollowingacleargushoffluidpassedpervaginam2daysbefore,whichshe
thoughtwasurine.Shehasntvomited,butfeelssickandhasnoticedshouldertippain.Shehasa
historyofbiliarycolic,apreviouscaesareansectionandmoderateasthma.Sheisapyrexialbut
tachycardiconexamination,withabloodpressureof85/45.Shehasreboundtenderness,guarding
andrigidityandabsentbowelsounds.Speculumexaminationrevealsaclosedcervix,butblood
stainedliquor.TheCTGshowsafetaltachycardiawithpoorvariabilityandunprovoked
decelerations.HerHbis87g/landherwhitecellcountis13.7109/l.
Whichisthemostlikelydiagnosis?

Answer107

E)Uterinerupture

Chorioamnionitisandabruptionwouldbepossiblediagnoses,butwouldntcausesignsand
symptomsofperitonealirritation(shouldertippain,guarding,rebound,etc.).Appendicitiswould
causeperitonealirritation,butaprecedinghistoryofprelabourmembranerupture,andblood
stainingtotheliquorwouldbeunlikely.Althoughgallstonesareariskfactorforcholecystitis,this
wouldnotusuallybeassociatedwithafallinhaemoglobin,orsuchmarkedgeneralisedperitonism.
Thepreviouscaesareansectionisariskfactorforuterinerupture,particularlyifcontractionshave
begunfollowingmembranerupture.Bloodintheperitonealcavitywillirritatetheperitoneumand
causetheshouldertippain.CTGabnormalitieswilleventuallydevelopinthissituation.

Question108

Whichofthefollowingfeaturesofamnioticfluidembolismisunlikelytobethepresentingproblem?

Answer108

C) Haemorrhage

Alloftheclinicalproblemsinthislistcanoccurwithamnioticfluidembolism;however,
haemorrhageusuallyoccursasasomewhatlatercomponentofthewholepicture.Moreimmediate
thaneffectsontheclottingsystemaresuddencardiorespiratorychanges.Suddenfetalcompromise
maybethepresentingfeaturesecondarytohypotensionorhypoxiainthemother.

Question109
Whichofthefollowingproposedriskfactorshasthestrongestassociationwithamnioticfluid
embolism?

Answer109

B) Caesareansection

AlthoughtherelationshipbetweencaesareansectionandAFEisacomplexone,withsome
emergencycaesareansectionsoccurringbecauseanAFEhascausedproblems,thedatastillsuggest
astrongcausallink,probablyevenstrongerthanthatwhichexistsforinductionoflabour.Advanced
maternalagehasnotbeenconvincinglyshowntobeariskfactorifallracialgroupsarestudied.
Thereislittle,ifany,evidencetosupportplacentapraevia,uterinehyperstimulationand
polyhydramniosasriskfactorsforAFE.

Question110

Whichoneofthefollowingistrue:maternityclaimstopatientsarepaidby:

Answer110

C) ClinicalNegligenceSchemeforTrusts(CNST)

TheClinicalNegligenceSchemeforTrustspaysoutthedamagestoplaintiffswhosuccessfullysue
theNHS.TheyactastheinsurerfortheNHS,andpremiumsarepaidbyeachTrustintoCNST,ona
yearlybasis.

Question111

A28yearoldwomanisdeliveringhersecondbabyafterinductionoflabourforpostmaturityat42
weeksgestation.ThereisthickmeconiumandapathologicalCTGinthesecondstage,soaventouse
deliveryisperformed.

Whichoneofthefollowingstatementsiscorrectregardingdeliverymanagement?

Answer111

E) Positivepressureventilationbymaskisnotcontraindicated

Routinenasopharyngealsuctionatanypoint,orintubation,isnotrecommended.Nasopharyngeal
suctioningmayinduceabradycardia.Thesemanoeuvresshouldbepreservedforbabieswithsigns
ofupperairwayobstruction,orthosethatfailtorespondtoinitialresuscitativemeasures,including
positivepressureventilationbymask.Whenresuscitatinganewborn,careneedstobetakenin
maintaininganeutralposition.Flexion,orextension,atthenewbornneckwillobstructtheairway.


Question112

A39yearoldwomanisinpretermlabourwithherfirstbabyat27+2weeks.Shewishestoknow
whatwillbedoneforthebabyatbirth.

Whichoneofthefollowingstatementsiscorrectregardingmanagementinthissituation?

Answer112

D) Cordclampingwillbedelayedifthebabyisvigorous

Itisnotnecessarilythecasethatallverypretermnewbornsneedtobeelectivelyintubatedatbirth,
orgivensurfactant.ItmaybepossibletostabilisethebabywithCPAPandthismayresultinless
chroniclungdisease.Althoughhypothermiaincreasesmetabolicacidosisandisapotentialproblem
forallnewbornbabies,theverypretermshouldnotbedriedand,instead,theyshouldbeplacedina
plasticbagtotheleveloftheirneck.Delayedcordclampingisthecorrectthingtodoatall
gestations,ifthebabyisnotinneedofimmediatemajorresuscitativeefforts.

Question113

Whichoneofthefollowingoptionsiscorrectregardinginfectioninpregnancy?

Answer113

B) Screeningforsyphilisindevelopedcountrieshasreducedstillbirthsattributedtothis
infection

Malariaislikelytoberesponsibleformorethan30%ofstillbirthsinAfrica.20%ofwomenof
reproductiveageareinfectedwithsyphilisinAfrica,ascomparedwithonly0.02%ofwomeninhigh
incomecountrieswhereitisroutinelyscreenedforatbooking.Treatmentischeap,andwouldbe
availableinlowincomecountriesalsoifscreeningbecamecommonplace.Syphiliscausesalarge
proportionofstillbirthsinAfrica,Russia,AsiaandSouthAmerica.Thefetallossrateassociatedwith
maternalCMVisnomorethan2030%.ToxoplasmosisisaveryrareinfectionintheUK(incidence
2/1000).Theearlierinpregnancytheinfectionisacquired,themoredevastatingtheeffectsonthe
fetus.E.coliisacommoncauseofstillbirth,inassociationwithprolongedrupturedmembranes,due
toascendinggenitaltractinfection.

Question114

A40yearoldwomaninherfirstpregnancypresentsat34weekswithaheadacheandreducedfetal
movements.Herbloodpressureonadmissionis170/110,with4+proteinintheurine.Immediate
stepsaretakentostabilisethematernalcondition.

Whichoneofthefollowingistrueregardinghermanagement?


Answer114

C) Aprotein:creatinineratioof30mg/mmolisequivalenttoa24hourprotein
excretionof300mg
Nifedipineisacalciumchannelantagonistandpotentantihypertensive.Itshouldnotbe
givensublinguallyasitcancauseaprecipitatefallinbloodpressure,whichmayleadtofetal
compromise.Methyldopaisacentrallyactingantihypertensivewhichinhigherdosesis
associatedwithincreasingadverseeffects,particularlysedationanddepression.An
elevatedprotein:creatinineratioofgreaterthan30mg/mmolcorrelateswitha24hour
urineexcretiongreaterthan300mgandmaybeusedtocheckforsignificantproteinuria.
Followingcommencementofmagnesiumsulphatecontinuouspulseoximetry,hourlyurine
outputanddeeptendonreflexesshouldberecordedregularly.Signsofmagnesiumsulphate
overloadincludeabsentbicepsreflexandarespiratoryrate<12/min.Theantidoteto
magnesiumsulphateoverdoseis10ml10%calciumgluconategivenslowlyintravenously.

Question115

A20yearoldwomaninherfirstlabourhasbeenpushingforover1hourwhenthemidwifeasksfor
areview.Subsequentexaminationrevealsthatthebabyisinanoccipitoposteriorposition.

WhichoneofthefollowingfactorsisNOTassociatedwithapersistentoccipitoposteriorposition?

Answer115

E) Youngmaternalage

Occipitoposterior(OP)positionoccursduetoslightdeflexionofthefetalvertexwhilecomplete
extensionoffetalheadresultsinafacepresentation.OPpositionisassociatedwithprolonged
labour,increaseduseofoxytocin,epiduralanalgesia(whichrelaxesthepelvicfloor),operative
interventionsandperinealinjuries.ThemajorityofOPpositionedheadswillrotatetooccipito
anteriorinlabour.IncaseswithpersistentOPposition,withgooduterinecontractionsandroomy
pelvis,spontaneousdeliverycanoccurinthedirectOPposition.Thisisknownasthefacetopubis
delivery.InmostothercasesofpersistentOPpositionsinthesecondstage,vaginaldeliverymaybe
achievableeitherbyrotationtooccipitoanteriorpositionmanually,orwithaninstrument,ora
directOPdelivery(facetopubis)byuseofaninstrument.

Question116

A20yearoldwomaninherfirstlabourhasbeenmakinggoodprogress;however,onexamination
themidwifehasdeterminedthatthebabyisinamentoposteriorfacepresentation.

WhichoneofthefollowingfactorsisNOTtrue?

Answer116
D) Iffetalcompromiseissuspected,fetalbloodsamplingshouldbeundertakenbeforea
decisionforcaesareansectionisreached.

Whenfacepresentationisdiagnosedduringlabourthewomanshouldbeinformedofthefindings
andsheshouldbemadeawarethattheremaybefacialswellingandbruisingnotedinthebabysoon
afterdelivery,butthatitislikelytoresolvewithoutanypermanentdamageoverthenextfewdays.
Regularabdominalandgentlevaginalexaminationsshouldbeundertakentomonitorprogresswhile
avoidinginjurytofetalorbits/face.Ifprogressisgoodandthepositionismentoanterior(orrotating
roundtomentoanterior)thenvaginaldeliverycanbeanticipated.Ifprogressissloworarrests,orif
thepositionremainsmentoposterior,caesareansectionisindicated.Fetalbloodsampling,useofa
fetalscalpelectrode,andventousedeliveryareallcontraindicatedwithafacepresentation.

Question117

A35yearoldwomanwithaprevioushistoryofonespontaneousvaginaldelivery,followedbytwo
caesareansectionsforbreechbabiesattendstheclinictodiscussdeliveryofherfourthchild.Ifthe
babyiscephalicattermshewouldliketotryforavaginaldelivery.Duringyourcounsellingyou
mentiontheriskfactorsforuterineruptureduringVBAC.

WhichoneofthefollowingoptionsdoesNOTincreasetheriskofuterinerupture?

Answer117

A) Pretermlabour

Largerbabies,aninterdeliveryintervaloflessthan12months,andinductionoflabourareall
associatedwithanincreaseintheriskofuterinerupture.Pretermlabourandahistoryofprior
vaginalbirthareassociatedwithalowerriskofuterinerupture.

Question118

Incounsellingwomenregardingtherisksofvaginaldeliveryonthebackgroundofoneprevious
caesareansection,whichoneofthefollowingwouldnotgenerallybeconsideredanabsolute
contraindicationtoaVBACattempt?

Answer118

C)Twinpregnancy

TheriskofuterineruptureduringVBACafterpreviousuterineruptureisunknown,butislikelytobe
atleastashighasthatafteraTshapedorclassicalincision(29%).VBACinthesescenariosiswidely
thoughttobeabsolutelycontraindicated.Theuterineruptureriskwithahistoryoftwolower
segmentcaesareansections,orwithatwinlabouronthebackgroundofonepreviouscaesarean
section,maybeslightlyhigherthanwithasingletonlabourwithoneprevioussectionbutthe
increaseisnotfelttobesignificantandthesemightonlybeconsideredrelativecontraindications,if
atall.Inthesecases,acarefulriskbenefitanalysisneedstobeexploredwiththewomanandadding
furthertotherisk,forexamplebyinducinglabour,maybeconsideredinappropriate.

Question119

A38yearoldwomanwhohadanemergencycaesareansectionat5cmforfetaldistressinher
previouslabouriscontemplatinghersubsequentmodeofdelivery.Shewouldliketoknowthebest
availableevidenceregardingtherisksassociatedwithVBAC.

WhichoneofthefollowingstatementsisNOTtrueregardingtheriskofVBAC?

Answer119

B) Hysterectomyisrequiredfortwothirdsofcasesofuterinerupture

AnNIHCDmetaanalysisofthedataonruptureriskassociatedwithVBAChasgivenanoverallriskof
1in200,butthisishigherincertaingroups(e.g.wherelabourisinduced),andlowerinothers(e.g.
priorvaginalbirth).Whenruptureoccursinlabour,uptoonethirdofwomenrequireperipartum
hysterectomy.Adverseperinataloutcomesincludeantepartumstillbirth,HIEandperipartumrelated
death.InchoosingVBAC,awomanacceptsanextra1in400riskofoneoftheseeventshappening.
Althoughtheriskofneedingabloodtransfusion,ordevelopingfebrilemorbidityishigherinthe
womenchoosingVBAC,theirriskofdeathislower.

Question120

A22yearoldprimigravidadevelopsHELLPsyndromeat34weeksofgestationwithacuterenaland
liverdysfunction.AfterdeliverysheistransferredtoCriticalCare.

Whichoneofthefollowingistrueregardinghermanagement?

Answer120

A) IntravenousNacetylcysteinemaybeofbenefit

ThereisanabsenceoftrialdataofNacetylcysteineuseinnonparacetamolrelatedacuteliver
failure;however,itisincommonuseattertiarylivercentresforwomenwithHELLPorAFLP.Thereis
noabsolutethresholdofureaorcreatinineconcentrationabovewhichrenalreplacementtherapyis
required.Dialysisisinstitutedtoreducepotassiumlevels,correctfluidoverloadormetabolic
acidosis,ortreattheconsequencesofuraemia,suchasencephalopathy.Althoughaplateletcount
of75109/Lislowerthanthenormalrange,establishingarterialandvenousaccessisstill
permitted,andshouldnotpreventthisifrequired.Thereisagreaterriskofmagnesiumtoxicitywith
renalimpairmentbutthisisnotanabsolutecontraindication.Increasedmonitoringformagnesium
toxicityisrequiredwithfrequentplasmalevels.Thecoagulopathythatcandevelopmainlyasa
resultofhepaticinvolvementinHELLPmayrequirecorrectionwithvitaminKandbloodproducts
includingfreshfrozenplasma,butcarefulattentionmustalsobepaidtohervolumestatus.

Question121

A30yearoldwomandevelopssepticshock7daysafterdeliveryandrequiresorgansupport.

Whichoneofthefollowingistrueregardinghersubsequentmanagement?

Answer121

B) Theuseofintravenoushydrocortisonemaybebeneficialinthissetting

Intravenousnoradrenalinecanbeusedevenifthewomanisplanningtocontinuebreastfeedingasit
hasaveryshorthalflifeandisnotabsorbedorally.Intravenoussteroidreplacementmaybeof
benefitinthissetting,butactivatedproteinCisnolongerusedinsepsis.Thediagnosticcriteriafor
SIRSincludeatemperatureofbelow36oCorabove38oC,sohypothermiacertainlydoesnotruleout
sepsis.Althoughamildleucocytosiscanbeseeninpregnancyandjustafterdelivery,atotalwhite
cellcountofthislevel7daysfollowingdeliverycannotbeexplainedbydeliveryalone.

Question122

A29yearoldwomanpresentsinherfirstpregnancyat13weeksgestation,wishingtodiscuss
vaccination.HerpartnerisMalawianandsheintendstoflythereat34weeksforthebirth.She
completedtheUKchildhoodvaccinationprogrammebutdoesnotthinkshehashadanyfurther
vaccinationssince.Shehasnopastmedicalhistoryandnoallergies.Currentvaccination
recommendationsforadultstravellingtoMalawiarediphtheria,tetanus,typhoid,hepatitisAand
rabies.

Whichoneofthefollowingistrueregardinghervaccinations?

Answer122

C) Tetanusandpolioboostersaredueregardlessofhertravelplans

Aswithallpregnantwomen,influenzaandpertussisvaccinationshouldberecommended.Influenza
shouldbegivenassoonaspossibletoprotectagainstmaternaldisease,whereaspertussis
vaccination,whichisprimarilyforneonatalprotection,shouldbedelayeduntil2832weeks.

Unrelatedtothepregnancy,tetanusandpolioboostersareoverdue.Duringthetemporarypertussis
vaccinationprogrammetheseshouldbecombinedwiththerequiredpertussisvaccineinthe

Repevax vaccine.AsRepevax isrecommendedafter28weekstherearetwooptions:vaccinate

withTd(tetanusanddiphtheria)vaccineimmediatelyandthenwithRepevax at28weeks,ordelay
tetanusvaccinationuntil28weeks.Thisisaclinicaljudgementand,asthereislowriskoftetanus
anddiphtheriaintheUK,eitheroptionisacceptable.Itisrecommendedtohavea4weekperiod
betweentwotetanuscontainingvaccines.
Withregardstotravel,therisksofflyingandexposuretotropicaldiseasesshouldbediscussed.If
shechoosestoproceed,hepatitisAandtyphoidvaccinesshouldberecommended.Sheshould,
however,becounselledthatthereisinadequatedatatocommentontheirsafety,but,inthiscase,
benefitwouldoutweighrisk.Rabiesvaccinationshouldalsoberecommendedandisnotassociated
withanyadverseoutcomes.Iflivinginlocalaccommodation,sheisathigherriskofmeningitisCand
cholerathanmosttouristsandthesevaccinationsshouldbeoffered.Again,thecholeravaccinehas
nosafetydatainpregnancy.

Question123

A35yearoldwomansustainsathirddegreeanalsphincterinjuryatthedirectoccipitoposterior
forcepsdeliveryofherfirstbaby.

WhichofthefollowingstatementsisNOTtrueregardingherfollowup?

Answer123

C) Sheshouldbecounselledagainstthefutureuseofloperamideifloosestoolsareaconcern

Womenmaybeasymptomaticatthetimeoffollowupandshouldbecounselledabouttheriskof
futurefaecalincontinenceandhowtoaccessmedicalcareifthisoccurs.Perinealpainand
dyspareuniahasbeenreportedinupto50%ofwomenfollowingprimaryanalsphincterrepairand
canpersistformanyyears.

Loosestoolsanddiarrhoeaaremoredifficultfortheanalsphinctercomplextocontrol.Loperamide
hasbeenproventoproduceafirmerandthereforemorecontrollablestool.

Womenwithongoingsymptomsshouldbereferredtoacolorectalsurgeon.EAUS(endoanal
ultrasound)andmanometrygiveinformationonpersistentsphincterdefectsandfunctionandcan
helpinthefuturemanagement.Availableevidenceatthetimeofwritingthisreviewsupports
electivecaesareansectioninsymptomaticwomenandthosewithpersistentdefectsonEAUS.More
researchisrequiredinthisarea.

Extended Matching Questions

Question124

Fromthelistofvaccinationsbelow(AO)choosethemostappropriateoptionstoanswerthe
questionsi)tovi).Eachoptioncanbeusedonce,morethanonce,ornotatall.

i) Threevaccinesthatarecontraindicatedinpregnancy
ii) Ifthisvaccineisgivenduringpregnancy,terminationisrecommended
iii) Twovaccinesthatexistinliveattenuatedandinactivatedforms
iv) Twovaccinesrecommendedtoallwomenduringpregnancy
v) Fourvaccinationsgivenasasingleinjection,marketedintheUKasRepevax
 vi) Routinevaccinationagainstthisinfectionisrecommendedoutsideofpregnancyto
specificallypreventteratogenicity

Answer124

i) AnythreeofA,D,F,H,L.MMRisthetripleliveattenuatedvaccineagainstmeasles,mumps
andrubella.BCGandvaricellavaccinesarealsoliveattenuatedvaccinesand,assuch,
arecontraindicatedduringpregnancy.
ii) O(none).Althoughliveattenuatedvaccinesareusuallycontraindicatedinpregnancy,
terminationisnotrecommendedbecauseevidencepointingtoasignificantriskofharm
tothefetusislacking.
iii) AnytwoofI,CandN(influenza,polioandanthrax).Ifvaccinationisrequiredduring
pregnancy,theinactivatedvaccineisusuallyrecommended.
iv) IandB(influenzaandpertussis).Influenzavaccinationisnowrecommendedintheautumn
toallpregnantwomenfollowingtherecognitionthatinfluenzaviralinfectionscarry
greaterriskofseveremorbidityandmortalityinthepregnantpopulation.Pertussis
vaccinationisnowrecommendedtoconferincreasedimmunitytotheneonate.
v) B,C,KandM(pertussis,polio,diphtheriaandtetanus).Womencurrentlybeingvaccinated
againstpertussisintheUKduringpregnancyarealsobeingvaccinated,orboosted,
againstpolio,diphtheriaandtetanusbecausethesefourvaccinesarecombinedinto
Repevax.
vi) L(rubella).Rubellaandvaricellainfectionsduringpregnancycancauseteratogenicity.Only
rubellaisroutinelyvaccinatedagainstintheUK,althoughavaricellavaccinecanbe
giventowomenpriortoconceptioniftheyareknowntobevaricellanonimmune.

Question125

Belowisalist(AJ)ofsymptomsandemotionsthatmayoccurinthepostpartumperiod.Fromthis
list,choosetheoptionswhichbestanswerthequestionsi)andii)givenafterwards.

i) Identifythefourmostcommonlyexperiencedsymptomsinpostpartumpsychosis
ii) Identifytwosymptomsthatmoststronglysuggestthisisnotpostpartumpsychosis

Answer125

i) A,E,GandH.Fear,hearingvoicesoutsideofherheadthatsheisindanger,falsebeliefs
thatsomeonewantstohurtherbaby,andperplexity.
ii)BandI.Disorientationandconfusion.

Question126

YouaretheST5obstetricsandgynaecologytraineeonthelaboursuite.Youarriveforhandoverat
thestartofyourshiftat8.30am.WorkingwithyoutodayareanST1obstetricsandgynaecology
traineeandananaestheticsST4trainee.Theconsultantobstetricianandgynaecologistcoveringthe
laboursuiteisinameeting.

Room Parity Gestation

1 P2 Postnatal Normalbirthat6.30am.Trickling.Raggedmembranesat
delivery
+1
2 P0 36 DCDAtwins,spontaneouslabour8cmdilated
3 P3 41+5 InductionawaitingARM
4 P1 Postnatal Readmission,5dayspostnatal,offensivelochia,pyrexial,
tachycardicandhypotensive.Awaitingreview.
5 P0 38+5 Spontaneouslabour6cmdilated
6 P0 39+2 Breech,2cmdilatedcontracting,normalCTG
7 P1 Postnatal Awaitingsuturing
8 P1 41 Augmentationwithsyntocinonat7cmdilated,requesting
epidural
9 P1 39 Fullydilatedandpushing,pathologicalCTG
10 P1 35+2 Brittleasthmatic,tachypnoeicandhypoxic.Awaitingreview

Foreachquestionbelow(iv),choosetheroomnumberthatisthebestmatch:

(i)WhichroomshouldtheanaestheticST4traineereviewfirst?

(ii)WhichroomshouldtheO&GST5traineereviewfirst?

(iii)WhichroomshouldtheO&GST1traineereviewfirst?

(iv)Whichroomshouldthecoordinatingmidwifereviewfirst?

(v)TheobstetricST5traineeshouldreviewthiswomanwhentimeallows

Answer126

(i)JRoom10

TheanaestheticST4shouldbeavailabletoreviewthewomaninroom10whohasapotential
breathingproblemlikelysecondarytoexacerbationofherasthma.

(ii)ARoom1

TheobstetricST5shouldreviewthewomaninroom1todecidewhethershewillneedtransferto
theatreforexaminationunderanaesthesia.Sheisatriskofacirculatoryproblemfromapostpartum
haemorrhageandmustbeproactivelymanagedtopreventdeterioration.Sheneedsintravenous
accesstobeestablishedwithatleastonewideborecannula.Afullbloodcountandgroupandsave
shouldbetaken.SheshouldbestartedonanObstetricEarlyWarningScoreifthishasnotalready
beendone.Ifthereisevidenceofincreasingbleedingorhaemodynamicinstability,shewillneedan
examinationunderanaesthesiaintheatre.

(iii)DRoom4
TheobstetricST1sfirstpriorityforreviewshouldbethewomaninroom4astheobservations
stronglysuggestseveresepsissecondarytopossibleendometritis.Sheneedsbloodcultures,ahigh
vaginalswabandmidstreamurinesamplestobesentformicroscopy,cultureandsensitivities.Afull
bloodcount,coagulationscreen,Creactiveproteinandserumlactateshouldbesent.Broad
spectrumantibioticsandfluidresuscitationshouldbecommencedimmediately.Noneofthese
interventionsrequirespecialistskillsinobstetricsandanST1shouldhavetheskillsforthe
immediatemanagementofaseverelysepticpatient.

(iv)IRoom9

Thewomaninroom9couldinitiallybereviewedbythecoordinatingmidwifewhocanassess
progressinsecondstagetoestablishwhetherdeliveryisimminent.Ifitisnot,inthismultiparous
womanwithapathologicalCTG,anassessmentwithaviewtooperativedeliveryisrequired;the
obstetricST5wouldthenneedtoreview.

(v)FRoom6

Thewomaninroom6willneedafulldiscussionofoptionswitharelativelyseniormemberofthe
obstetricteamwhichinthissituationistheobstetricST5.Althoughthisisnoturgent,itisbest
accomplishedbeforelabourestablishes.IfECVistobeoffered,itwillbemostlikelytobesuccessful
ifdoneinearlylabour.Itshouldnotbeattemptediftheamnioticmembranehasruptured.

Questions127130

Withreferencetothescenarioandboardinquestion126;itisnow4hourslaterandtherehave
beennonewadmissionstothelaboursuiteandthewomenremaininthesameroomsasbefore.
Foreachofthefollowingsituationsselectthesinglemostappropriateactionfromthelistofoptions
given.

Question127

Thewomaninroom6isnow8cmdilatedwithabreechpresentationandanormalCTG.After
discussionregardingmodeofdeliverysheisadamantthatshewantsacaesareansection.The
womaninroom5isnow7cmdilatedwithapathologicalCTGandafetalbloodsamplehasbeen
carriedoutwithapH7.18.

Whichisthebestcourseofaction?

Answer127

A) Performacategory1CSforroom5

Thewomaninroom5requiresacategory1caesareansectionasthereisconfirmedfetalacidaemia.
Giventheworkloadonthelaboursuiteasecondtheatreshouldnotbeopenedforthewomanin
room6.Theextrarisksassociatedwithavaginalbreechdelivery,whentheCTGisnormal,donot
exceedthoseofoccupyingboththeatres(andthetheatreteams).Itwouldnotnormallybe
consideredappropriatetogiveatocolyticinthissituation,unlesstheCTGwascausingconcerns.

Question128

Themultiparouswomaninroom3hasprogressedveryquicklytofulldilatationfollowing
amniotomy.Shehasbeenpushingfor1hourwithanormalCTG.Onvaginalexaminationsheisfully
dilatedwithanoccipitotransversepositionwithevidenceof2+caputand2+mouldingandthe
presentingpartisatthespines.Theprimiparouswomaninroom5hasbeenpushingfor1hourwith
anormalCTG.

Whatwouldbeyourbestcourseofaction?

Answer128

D) Deliverthemultiparouswomenintheatrefirst

Instrumentaldeliveryinthetheatreshouldbecarriedoutforroom3assheisamultiparouswoman
whohasbeenpushingforanhourandspontaneousdeliveryisnotimminent.Inviewofhervaginal
examinationfindings,itisbesttocarryouttheprocedureintheatreasthereisapossibilityofa
failedinstrumentaldelivery.Thisshouldtakepriorityoverroom5asshebeingprimiparous,can
pushfor2hwithoutmedicalreviewifthereisevidenceofprogressandnoconcernsregardingfetal
wellbeing.

Question129

Thewomaninroom5hasbeencontracting34in10andisnow9cmwithapathologicalCTGand
meconium.Thewomaninroom2ishasdelivered40minutesagobuttheplacentahasnotdelivered
yet.Sheishaemodynamicallystableandtheestimatedbloodlossis300ml.

Whatwouldbeyourbestcourseofaction?

Answer129

B) DoanFBSinroom5andthen,ifthepHisnormal,dothemanualremoval

Afetalbloodsampleshouldbecarriedoutinroom5toguidethetimingofdelivery.Thewomanin
room2willrequireamanualremovalofplacentabutthiscanbedelayeduntilthewellbeingofthe
fetusinroom5hasbeendeterminedassheishaemodynamicallystable.However,inthemeantime,
shewillneedintravenousaccesswithatleastonewideborecannula,afullbloodcountandgroup
andsaveshouldbetaken.SheshouldbestartedonOEWSchartandherbladderneedstobe
emptied.Ifthereisevidenceofincreasingbleedingorhaemodynamicinstability,anurgentmanual
removalofplacentashouldbeconsidered.ItwouldnotbesensibletosendtheST1todotheFBS.
Theymaynotyetbecompetent,buteveniftheywere,ifthepHis<7.2thenyou,theregistrar,and
thetheatreteam,willbeoccupiedwiththemanualremoval.

Question130

Thewomaninroom8remains7cmdilatedwithadeflexedoccipitoposteriorpositionandevidence
ofcaputandmoulding.TheCTGissuspicious.Maternaltemperatureis38.1Cinspiteofhavingi.v.
paracetamolandantibiotics.Thewomaninroom3hasspontaneouslyrupturedhermembranesand
adecelerationwasheardonintermittentauscultation.TheCTGisnowpathological.Onvaginal
examinationsheis4cmdilated.

Whatwouldbeyourbestcourseofaction?

Answer130

C) DoanFBSinroom3anddeliverthiswomanbyemergencyCSifthepH<7.2

Thewomeninroom8androom3potentiallybothrequiredelivery.However,room3shouldhavea
fetalbloodsampletodeterminewhetherthepathologicalCTGrepresentsanacidoticfetus.Ifthe
FBSisnormalacaesareansectioncanbeundertakeninroom8.IftheFBSresultissuchthatroom3
needsacategory1caesareansectionthenadecisionneedstobemadeastowhethertwotheatres
needtobeopened.

Multiple Choice Questions

Question131

Whencounsellingwomenwithahistoryofpreviouscaesareandeliveries:

A) Inductionoflabourisassociatedwitha23foldincreaseinuterinerupturerisk
B) Theriskofperipartumhysterectomyexceeds1%onthefourthsection
C) Theriskofplacentaaccretaonlyexceeds1%afterthefourthsection
D) SteroidsshouldbeadministeredforERCSat3738+weeksgestation
E) Theantepartumstillbirthrateafter39weeksgestationisgreaterforwomenwithahistory
ofpriorCS.

Answer131

A) True
B) True
C) False
 D) True
E) True

Inductionoraugmentationoflabourisassociatedwitha23foldincreaseintheriskofuterine
rupture,andalsoalowerchanceofsuccessfulVBAC.Morbidplacentaladherenceisdiscoveredat2
3%offourthcaesareansections,andtheriskofneedinghysterectomyissimilar.Therisksofthese
complicationscontinuetoincreasewithhighernumbersofpreviouscaesareanbirths.Thereisgood
qualityevidenceshowingthattheincidenceofrespiratorydistressinneonatesbornbyelectiveCSat
3738+6weeksissignificantandcanbereducedbyadministeringsteroidsmorethan48hoursprior
totheplannedbirth.Asmallriskofantepartumstillbirth,whichcanbeavoidedbyelective
caesareansectionat39weeks,existsinallpregnanciescontinuingbeyondthistime.Indeedtherisk
is1.52timeshigherinwomenwithahistoryofpreviouscaesareansection.

Question132

Regardingprincipleswithinmedicalnegligencelaw:

A) Inamedicalnegligenceclaim,thestandardofproofrequiredisbeyondallreasonable
doubt
B) TheBolamdefenceprecededtheBolithocase
C) Itisenoughtodefendadoctorifabodyofexpertssupporthis/heractions
D) Provingbreachofdutyisinsufficientforasuccessfulmedicalnegligenceclaim
E) Anexpertwitnessshouldgivedifferentadvicedependingonwhethertheyareinstructedby
theclaimantsorthedefendantssolicitor

Answer132

A) False
B) True
C) False
D) True
E) False

Inacivilnegligenceclaim(forexamplemedicalnegligence)thestandardofproofrequiredisona
balanceofprobabilities(i.e.morethan50%likely).Criminalclaimsrequirebeyondallreasonable
doubt(i.e.basically,absolutecertainty).TheBolithocasecameaftertheBolamdefenceand
effectivelymeantthatitwasnolongersufficientforagroupofdoctorstosupporttheactionsofan
accuseddoctorifaclaimweretobeeffectivelydefended.TheBolithocasemodifiedthissothatthe
courtalsohadtobesatisfiedthatthisopinionhadalogicalbasis.

Asuccessfulmedicalnegligenceclaimrequirestheclaimanttoshowthattherewasadutyofcare,
thatthiswasbreachedbythedoctor,andlastlythatthisbreachofdutycaused,orcontributedto,
thedamage(causation).

Question133

Postpartumgenitaltractsepsis

A) wasthesecondmostcommoncauseofdirectmaternaldeathintheUKinthe20062008
triennium
B) isdecliningasacauseofmaternaldeathintheUK
C) shouldbetreatedwithantibioticsonlywhenthecausativeorganismsareknown
D) incasesofmaternalmortalityismostoftenassociatedwithbetahaemolyticStreptococcus
LancefieldGroupB
E) isreducedbyroutineantibioticprophylaxisgivenatcaesareansection

Answer133

A) False
B) False
C) False
D) False
E) True

PostpartumgenitaltractsepsiswascitedastheleadingdirectcauseofmaternaldeathintheUKin
thetriennium20062008.Thetriennialreportalsonotedthattherehasbeenanincreaseincasesof
sepsis.Itisvitalthatwheresepsisissuspected,womenarepromptlytreatedwithbroadspectrum
antibioticsaftercultureshavebeentakenbutnotwaitingforthesensitivities.Theadviceofa
microbiologistismosthelpfulandshouldbesoughtearlyandespeciallywhenthepatientisveryill
orhasnotrespondedtoinitialtreatmentafter2448hours.WhilstbetahaemolyticStreptococcus
LancefieldGroupBisamajorcauseofperinatalmorbidityandmortality,itisGroupAthatis
associatedwithmaternaldeath.NICEguidanceoncaesareansectionrecommendsroutineantibiotic
prophylaxis.

Question134

TheSepsisSixincludesthefollowingsteps:

A) Give100%oxygen
B) Takebloodcultures
C) Giveoralantibiotics
D) Checkinghaemoglobinandurate
E) Inserturinarycatheterandmeasurehourlyurineoutput

Answer134

A) True
B) True
C) False
D) False
 E) True

The'SepsisSix'isausefulaidfortheinitialmanagementofseveresepsiswhichcanbeinitiatedby
cliniciansincludingnonspecialiststaff.Itshouldbeinitiatedwithin1hourofrecognisingthata
womanisseriouslyill.Thisinvolvessixsimplesteps:giving100%oxygen,takingbloodcultures,
givingintravenousantibiotics(notoral),startingintravenousfluidresuscitation,checking
haemoglobinandlactate(noturate)andinsertingaurinarycatheterandensuringhourlyurine
output.

Question135

Regardingumbilicalcordbloodstemcells:

A) Someofthemaremesenchymal
B) Usingthemreliablyforbonemarrowtransplantationremainsaresearchaim
C) Theyieldisreducedbydelayedcordclamping
D) TheRCOGrejectstheneedforautologouscordbloodcollection
E) Theyieldfromasinglecordharvestisusuallysufficientforanadultbonemarrowtransplant

Answer135

A) True
B) False
C) True
D) True
E) False

Althoughitisthehaematopoieticstemcellswhichhavefeaturedpredominantlyinclinical
applicationsofar,cordbloodalsocontainsmesenchymalstemcells.Theseofferthepotential
promiseofotherformsoftransplantation,otherthanjusthaematological.Atleastafifthofallbone
marrowtransplantsworldwidenowoccurusingcordbloodstemcellsandthisproportionwouldbe
muchhigherifcorddonationprogrammesweremorewidespread.Itispossiblethatdelayedcord
clampingwouldlimitthis,ifthisthirdstagemanagementtechniquebecamemorepopular(as
evidencesuggestsitshould).Itisnotusuallythecasethattheyieldofstemcellsfromasinglecord
donationissufficientforanadultbonemarrowtransplant,andtwoorthreestoredmatched
collectionsmayneedtobeusedforasingletransplant.Commercialcordbloodbankinghasgained
popularitybutisnotsupportedbytheRoyalColleges(asopposedtothealtruisticdonationofcord
bloodsintoNHSstemcellbanks).Couplesspendalargeamountofmoneysavingthecordblood
fromthebirthoftheirchildontheverysmallchance(lessthan1in5000)thatthischildwilllater
needabonemarrowtransplantandthattheirowncellscanbeused(autologous).Furthermore,
thereisonlya1in4chancethatthesecellscanbeusedifoneoftheirsiblingsneedsthem.Ifnotco
ordinatedproperly,thecollectionofcordbloodcanseriouslyinterferewithnormalcareatthetime
ofdelivery,ofthewomanandhernewborn.Farbetterthanthiscommercialbankingisanational
programmeofaltruisticdonationinaselectnumberofNHSunits,withagoodracialmix,where
trainedstaffworkseamlesslyalongsidemidwivesandobstetriciansandwheretheappropriate
facilitiesandsystemsareinplaceforthistoworkwell.Thisisverymuchsupportedbyour
professionalbodies.

Question136

Regardingpertussisvaccinationinpregnancy,arethefollowingtrueorfalse?

A) Itisprimarilyformaternalbenefit
B) Itisaliveattenuatedvaccine
C) Womenwhohavebeenvaccinatedinapreviouspregnancydonotrequirevaccinationin
furtherpregnancies
D) Thevaccineshouldideallybegivenbetween28and32weeksgestation
E) Vaccinationshouldbeperformedpostpartumifitisnotpossibleantenatally

Answer136

A) False
B) False
C) False
D) True
E) True

PertussisvaccinationisgivenintheformofRepevax whichcontainstetanusanddiphtheria
toxoids,acellularpertussisandinactivatedpolio.Itisprimarilyforneonatalbenefit,asitisinfants
under6monthswhohavebornethemortalityburdenofthecurrentoutbreak.Infantsofvaccinated
mothersareprotectedpassivelybymaternalantibodytransferand,asmaternalinfectionwillbeless
likely,alsobyreducedpathogenexposure.Placentalantibodytransferincreasesthroughoutthe
pregnancyandsoimmunisationbetween28and32weeksisoptimal;balancinghighplacental
transferwithprovidingprotectiontoprematureneonates.Tomaximiseplacentalantibodytransfer,
vaccinationshouldberepeatedinfurtherpregnancies.Ifantenatalvaccinationisnotpossible,
postpartumimmunisationshouldbeoffered,astheneonatewillstillgainsomeprotectionfrom
antibodiesinbreastmilkandreducedpathogenexposure.

Question137

Regardingadviceatthebookingappointment:

A) Upto5unitsofalcoholperweekisconsideredsafe
B) Dietingshouldbeavoidedduringpregnancy
C) Lowdoseaspirinshouldbetakenifthewomanhastype2diabetes
D) VitaminDsupplementsshouldbetakenroutinely
E) AnoralglucosetolerancetestshouldbeperformedoncetheBMIexceeds35

Answer137
 A) False
B) True
C) True
D) True
E) False

ThereisnolevelofalcoholintakeduringpregnancythatisdeemedsafebytheNICEguideline,
althoughtheriskofharmislikelytobelowwith<5unitsperweek.Dietingisnotrecommended
duringpregnancy,andallwomenshouldberecommendedtotakevitaminDsupplements.Thereare
anumberofriskfactorsthatareconsideredtocarryahighriskofcausingpreeclampsiaandwhere
lowdoseaspirinshouldberecommended.Maternaltype2diabetesisoneofthese.Similarly,there
areanumberofwellrecognisedriskfactorsforgestationaldiabeteswhichshouldprompttheoffer
ofanOGTT,includingaBMI>30.

Question138

Thirdandfourthdegreetears:

A) Aretheleadingcauseoffaecalincontinenceinwomen
B) Aremorecommonfollowingforcepsdelivery
C) Arepreventedbyroutinemediolateralepisiotomy
D) haveabetterlongtermoutcomefollowingoverlaprepairtechniquescomparedwithend
toend
E) requireprophylacticantibioticcoverduringrepair

Answer138

A) True
B) True
C) False
D) False
E) True

Obstetricanalsphincterinjuryistheleadingcauseoffaecalincontinenceinwomen.Assisted
delivery,andinparticulartheuseofforceps,hasbeenshowntobeariskfactorforsphincterinjury.
Routinemediolateralepisiotomyhasnotbeenproventopreventsphincterinjury.Cochranereview
ofrepairtechniquesshowsnodifferenceinoutcomesbetweenendtoendandoverlaprepairwhen
experiencedindividualsperformrepairunderasepticconditionswithregionalorgeneral
anaesthesia,andwhenusingroutineprophylacticantibioticsandpostoperativelaxatives.

Question139

Withregardtofacepresentation:
 A) Themostfavourablepositionforvaginaldeliveryismentoposterior
B) Itisassociatedwithcongenitalanomalies
C) Continuousexternalfetalmonitoringshouldbeutilised
D) Aninstrumentaldeliverybyventouseorforcepscanbeperformedintheeventof
prolongedsecondstage
E) Anexperiencedneonatalpractitionershouldbepresentatthedelivery

Answer139

A) False

B) True

C) True

D) False

E) True

Afetusinamentoposteriorpositioncannotusuallydelivervaginally,unlessthefetusisparticularly
preterm.Thisisbecausethefetalneckisalreadyatmaximumextensionandcannotextendunder
thesymphysistoallowforavaginaldelivery.Ifrotationtomentoanteriorpositionoccursthen
vaginaldeliverymaybeachievable;otherwiseacaesareansectionisindicated.Facepresentationis
associatedwithcongenitalanomaliesthatareassociatedwithneckextensionsuchasneckmasses,
orwherethesizeoftheheadisnotfittingintothepelvisnormallysuchasventriculomegaly.
Continuousexternalfetalmonitoringshouldbeutilisedinallcaseswhenfacepresentationhasbeen
diagnosedasthereisanincreasedriskofalowercordpHatdeliveryandlowerApgarscores.An
instrumentaldeliverybyforcepscanbeconsideredinfacepresentation,butaventousemustnotbe
usedasitcouldcausedamagetothefacialstructures,especiallytheeyes.Anexperiencedneonatal
practitionershouldbepresentatdeliverysincethereisanincreasedriskoflowerApgarscoresanda
riskofneckoedemanecessitatingintubation.

Question140

Inthecontextofdelayinprogressinthefirststageoflabour:

A. Attentionmustbemadetoensureadequatehydration
B. Amniotomyincreasesthevaginaldeliveryrate
C. Oxytocinusedecreasesthecaesareansectionrate
D. Oxytocinshouldbeincreasedevery10minutes
E. Continuouselectronicfetalmonitoringshouldbeutilisedinwomenfollowing
amniotomy

Answer140
 A) True
B) False
C) False
D) False
E) False

Oneofthefeaturesassociatedwithpooruterineactivityisdehydration.Itisthereforeimportantto
ensureadequatehydrationforwomenwithdelayinthefirststageoflabour.Amniotomyhasnot
beenshowntohaveanyeffectonvaginaldeliveryrates.Oxytocinusereducesthelengthoftimein
labourbuthasnotshownadecreaseincaesareansectionrates.Oxytocininfusionsshouldbe
increasedevery30minutesinthefirststageoflabour.Continuouselectronicfetalmonitoringisnot
requiredfollowingamniotomyiftherearenoriskfactorsforfetalcompromise;intermittent
auscultationcancontinue.Continuouselectronicfetalmonitoringisnecessaryifawomanis
commencedonoxytocin.

Question141

Regardingperinatalmortality:

A) Thedefinitionincludesantepartumstillbirths,intrapartumstillbirthsandallneonataldeaths
B) 24completedweeksisusedintheUKasthelowergestationallimittodefineaperinatal
death
C) Ratescaneasilybecomparedbetweencountries
D) Alivebornneonateat23weeksgestationwhosubsequentlydiesonday5oflifeisclassified
asaperinataldeath
E) Anintrauterinedeathat23weeksand6daysgestationisclassifiedasaperinataldeath

Answer141

A) False
B) True
C) False
D) True
E) False

Perinataldeathencompassesantepartumstillbirths,intrapartumstillbirthsandearlyneonatal
deaths.Earlyneonataldeathisdeathofaliveborninfantupto7daysoflife.Neonataldeath,
however,isdefinedasdeathofaliveborninfantupto28daysoflife.Thetermperinatalmortality
wascoinedmorethan50yearsagotoexaminedeathsthatmaybeattributedtoobstetricevents
andisconsideredtobeanimportantmeasureofantenatalandintrapartumobstetriccare.
Internationally,thelowergestationalparametersofperinataldeathvary.IntheUnitedKingdom,itis
definedasfrom24completedweeks.However,theWHOutiliseanearliergestationof22
completedweeks.Becauseofthis,therearehugevariationsbetweencountriesondefinitionsand
reportingofperinataldeathmakinginternationalcomparisonsdifficult.Indeed,withintheUnited
Kingdom,alivebornneonatedeliveredbefore24completedweeksofgestationwhoshows
definitivesignsoflifewillbeclassifiedasaperinataldeath.

Question142

Withrespecttotheepidemiologyofterm,deliveryrelated,perinataldeath:

A) Theratecanbeusedasamarkerofthequalityofintrapartumcare
B) Intrapartumanoxiaandmechanicalcausesaretheleadingcausesofneonataldeathin
normallyformedfetusesatterm
C) Theincidenceinhighincomecountriesis1in2000forprimiparouswomen
D) Theincidenceisfalling
E) Theincidenceisdirectlyrelatedtothecaesareansectionrate

Answer142

A) True
B) True
C) False
D) True
E) False

Deathsinnormallyformedfetusesattermarecollectivelyreferredtoasdeliveryrelatedperinatal
deathatterm.Inhighincomecountries,theincidenceoftermintrapartumstillbirthandneonatal
deathisrare,beingonly1in1000forprimiparous,and1in2000formultiparous,women.Several
studieshavehighlightedthatthefallinintrapartumstillbirthis,inmostpart,duetoareductionin
intrapartumanoxicrelateddeaths.Changesinobstetricpracticesuchasimprovedmultidisciplinary
educationtrainingandseniorclinicalsupervisionarelikelytohaveinfluencedthisreduction.
Althoughthedeclineinintrapartumstillbirthratecoincideswitharisingcaesareansectionrate,it
wouldbespeculativetoconcludethatthisassociationiscausative.

Question143

Termrelatedperinataldeath:

A) isassociatedwithsmoking
B) Isnotaffectedbymaternalage
C) inprimiparouswomenisinfluencedbytheplaceofbirth
D) isassociatedwithmacrosomia
E) isreducedbytheuseofcontinuouselectronicfetalmonitoring(EFM)inlabour

Answer143

A) False
B) False
 C) True
D) True
E) False

Antepartumstillbirthisassociatedwithsmokingandlowersocioeconomicstatus,howeverthese
factorshavenotbeenfoundtoinfluencetermrelatedperinataldeath.Maternalfactorsassociated
withtermrelatedperinataldeathincludematernalageandobesity.Nulliparouswomenhavinga
homebirthareatincreasedriskoftermrelatedperinataldeathwhencomparedtomultiparous
women,however,theoverallincidenceofanadverseeventisstilllow.AlthoughcontinuousEFMis
regularlyusedonlabourwardstoidentifyfetusesatriskofasphyxia,thisscreeningtesthasahigh
falsepositiverateandpoorpredictivevalue.Itsuseiscurrentlyonlyadvocatedinthepresenceof
riskfactorsforintrapartumhypoxia.

Question144

Thefollowingoutcomesaremorecommoninteenagepregnanciescomparedwiththoseofwomen
intheir20sand30s:

A) Stillbirth
B) Pretermlabour
C) Maternalmortality
D) Exomphalos
E) Deliverybycaesareansection

Answer144

A) True
B) True
C) False
D) False
E) False

Theriskofstillbirthinteenagersisapproximately1.4timesthatofwomenintheir20sand30s.Itis
unclearwhetherthisisduetoagerelatedbiologicalfactors,orifitisbecauseofotherbehaviours,
lifestylechoicesandriskfactorsassociatedwithyoungerwomen.Theriskofpretermlabouris
doubledinteenagers.Again,thecauseiscomplexandlikelytobemultifactorial.Veryyoungwomen
arelesslikelytodieinchildbirthandaremorelikelytohaveavaginalbirth.Theincidenceof
gastroschisisiselevatedintheyoung,butnotexomphalos.

Question145

Thefollowingareacceptedindicationsforinductionoflabour:
 A) Macrosomia
B) Previouscaesareansection
C) Intrauterinefetaldeath
D) Historyofprecipitatelabour
E) Maternalrequest

Answer145

A) False
B) False
C) True
D) False
E) False

Althoughcommonlyencountered,thereisnoevidencetosuggesteithermaternalorfetalbenefit
forinducingsuspectedmacrosomicfetusesorwomenwhohaveahistoryofprecipitatelabour.
Womenwithapreviouscaesareansectionmaybeinducedifabsolutelynecessaryafterappropriate
counsellingregardingtheincreasedrisksofuterinerupture.Althoughwomenwhohavesuffered
fromanintrauterinefetaldeathwillmostlikelylabourspontaneouslyifmanagedexpectantly,
intrauterinefetaldeathisanacceptedindicationforinductionoflabour.

Question146

Regardinginductionoflabour

A) AnintravenousoxytocininfusionisrecommendedbytheNICEguidelinesasthepreferred
methodofinductionoflabour
B) Womenwithonepreviouscaesareansectionhaveanoverallriskofuterineruptureof
approximatelyfivepercentiftheyareinduced
C) Ifuterinehyperstimulationoccursduringanoxytocininfusion,deliverybycaesareansection
isindicatedimmediately
D) Womenreceivinganoxytocininfusionareatriskofdevelopinghypernatremia
E) ABishopsscoregreaterthan5ispredictiveofasuccessfulinduction

Answer146

A) False
B) False
C) False
D) False
E) True

VaginalPGE2istherecommendedmethodofinductionoflabourunlessotherwisecontraindicated.
TheRoyalCollegeofObstetriciansandGynaecologistsrecommendsthatwomenarequotedariskof
uterineruptureof74/10,000whenlabourisinducedandthereisahistoryofoneprevious
caesareansection.Oxytocinhasasimilarstructuretoantidiuretichormone(ADH)andmayalsobind
totheADHreceptor.Ifhyperstimulationoftheuterusoccurstheoxytocininfusionshouldbe
ceased,maternaloxygenandintravenousfluidsadministered,themotherplacedintheleftlateral
position,andtocolysisusingauterinerelaxantsuchasterbutalinemaybeconsidered.Hyponatremia
mayoccurfollowingprolongedexposuretohighdoseoxytocinincombinationwithexcess
administrationofhypotonicintravenousfluids.TheBishopsscoreisthebestavailabletoolfor
predictingtheprobabilityofasuccessfulinduction.

Question147
Thefollowingarerecognisedriskfactorsforplacentalmorbidadherence:

A) Previouscaesareansection
B) IVF
C) Previousuterinecurettage
D) Historyofendometritis
E) Uterinefibroids

Answer147

A) True
B) True
C) True
D) True
E) False

Anythingthatmaydamagethedeciduasbasaliscanpredisposetomorbidadherence,
particularlypreviousuterinesurgery,butalsoinfection.However,advancingmaternalageand
IVFarealsoindependentriskfactors.

Question148
ThefollowingarecomponentsoftheTriplePprocedureformanagementofplacentalmorbid
adherence:

A) Pelvicdevascularisation
B) Preopuretericstenting
C) Perioperativeplacentallocalisation
D) Patientsterilisation
E) Placentalnonseparationandmyometrialexcision

Answer148
A) True
B) False
C) True
D) False
 E) True

TheTriplePprocedureisbeingheraldedasanalternativetoIntentionalRetentionofPlacenta
andperipartumhysterectomyforthemanagementofmorbidadherence.Ascanisperformed
preoperativelytopreciselylocatetheplacentalposition,allowingincisionoftheuterusaway
fromtheplacenta.Thebabyisdelivered,butratherthanattemptingtoremovetheadherent
placenta,orintentionallyleavingitinsitu,theadherentpartandtheunderlyingmyometriumis
electivelyexcisedandthenthedefectclosed.Bloodlossduringthisprocedureislikelytobe
minimisedbyusinginterventionalradiologicaltechniquestoreducebloodflowtotheuterus,or
byprogressivelydevascularisingtheuterusbysurgicallytyingoffthemainarterialsupplies.Pre
operativeuretericstentingmayberequiredincasesinvolvingthebladder,orwherethe
placentaextendsintothebroadligament,butthisisnotaroutinepartofthisprocedure.The
womanmaychoosetobesterilisedatthetimeofaTriplePprocedure,butthisisnot
mandated.

Question149
Withregardtoexpectantmanagementofplacentalmorbidadherence(IntentionalRetentionof
Placenta)

A) Thepatientshouldbecounselledaboutthe1in3chanceofneedingahysterectomyatsome
point
B) Antibioticsshouldbeprescribed
C) Thereisqualityevidencesupportingtheuseofmethotrexate
D) SerialHCGmeasurementsshouldbeperformedpostnatally
E) Interventionalradiologywillnotbeinvolved

Answer149
A) False
B) True
C) False
D) True
E) False

Theriskofawomanultimatelyrequiringahysterectomywhenexpectantmanagementofmorbid
adherenceisfollowedisapproximately1in5.Thereislittlegoodqualityevidencetoguide
practice,althoughantibioticsandserialHCGmeasurementsareadvised.Thereislittletosupport
theuseofmethotrexateroutinelyandastherearepotentialrisksinvolvedthisshouldonlybeused
inselectedcases.Interventionalradiologyhasmuchtoofferinthemanagementofplacental
morbidadherence,whatevermanagementoptionischosen.Thismaybereductionofbloodlossat
thetimeofdeliverywithuterinearteryballoonsordefinitivetreatmentwithembolisingagents
whensurgicalmethodshavefailedtobringbleedingundercontrol.

Question150
RoutineantenatalprophylacticAntiDadministrationisnotnecessaryforthefollowingRhDnegative
women:

A) Thosewhohaveplanstobesterilisedafterthebirth
B) Multiparouswomen
C) ThosewithaRhDnegativepartner
D) WomenisoimmunisedtotheRhDprotein
E) Thosewomenplanningdeliverybyelectivecaesareansection

Answer150

A) True
B) False
C) True
D) True
E) False

Womenwhoareabsolutelycertainthattheywillnothaveanyfurtherpregnanciesfollowingtheir
currentonemaywellchoosetodeclineprophylacticAntiD.Ofcourse,iftheydohappentochange
theirmindatalaterdate,thereisariskthattheywillhavebeenisoimmunisedbythepregnancy
duringwhichtheydeclinedtheAntiD.Carefulcounsellinganddocumentationisrequired.Ifa
womaniscertainthatherpartnerisRhDnegative,andthatheisthefatherofthebaby,thenthereis
noneedforroutineAntiDadministration;thefetuswillbeRhDnegative.Everyeffortmustbemade
toensurethatthepartnerisindeedRhDnegativehowever.Womenwhoarealreadyisoimmunised
willgainnobenefitfromAntiDadministration.Parityandmodeofdeliverymakenodifferenceto
therecommendationsregardingAntiDforotherwomenwhoareRhDnegative.MassfreefetalDNA
testingat28weeksgestationmay,inthefuture,meanthatwewillknowwhichRhDnegative
womenarecarryingRhDnegativefetuses,soavoidingunnecessaryAntiDadministrationinthese
pregnancies.

Question151

Thefollowingaretrueofadherencetoprescriptions:

A) Nonadherenceiscurrentlydefinedastakinglessthan7080%ofmedications
B) Atleast3050%ofmedicationsarenottakenasrecommended
C) Nonadherenceprimarilyoccursbecauseofpatientfactors
D) Adherenceistheextenttowhichapatientsbehaviourmatchesagreedprescribers
recommendation
E) Beingateenagerisoneofthereasonsthatpatientsdonottaketheirmedication

Answer151

A) False
B) True
C) False
 D) True
E) True

Adherencedescribestheextenttowhichapatientsbehaviourmatchesagreedprescriber
recommendations.Thekeywordhereisagreedandimpliespatientinvolvementintheprescribing
process.Complianceisabetterwordtouseifthepatienthasnotbeenactivelyinvolvedinthe
decisionmakingprocess.Thereisnostrictthresholdatwhichpointapatientcanbedescribedas
nonadherent.Ahugeproportionofprescribedmedicationsarenotused,andtherearemany
complexreasonswhythisisthecase.Someoriginatefromthepatient(e.g.youngerage),andsome
fromtheclinician(e.g.poorinformation).

Question152

Withregardtotherisksofcaesareansection:

A) TheriskofbladderinjuryduringCSis1%
B) Theriskoffetallacerationis12%
C) ThelikelihoodofcomplicationsduringanelectiveCSisapproximatelythesameasduringan
emergencyCSperformedinearlylabour
D) TheriskofhysterectomyduringCSinapatientwithamorbidlyadherentplacentais25%
E) ItisperfectlyreasonabletoperformsterilizationatthetimeofanemergencyCSforfailure
toprogress

Answer152

A) False
B) True
C) True
D) True
E) True

Theriskofbladderinjuryisrareat1per1000.Theriskofcomplicationsduringanelectiveprocedure
is16per100,whereasduringearlylabouritis17per100.Performingasterilisationwilldependon
thecircumstances.IfithasbeendiscussedantenatallyandthereasonforemergencyCSisfailureto
progresswithnofetalconcerns,itwouldstillbereasonabletoperformasterilisation.

Question153
Regardingamnioticfluidembolism(AFE):

A) Itisassociatedwithgoodmaternalandfetaloutcomesifnonfatal

B) CasesshouldonlybereportedtoUKOSSonceconfirmedatpostmortem

C) FetalcompromisemaybeduetoAFE,eveninaninitiallyasymptomaticwoman
 D) Fetalsquamesareaninvariablefindinginmaternallungsatpostmortem

E) Itisnotfatalinthemajorityofcases

Answer153

A) False
B) False
C) True
D) False
E) True

HighlevelsofneurologicalmorbidityarewellrecognisedinwomenwhosurviveAFE,whichisalso
associatedwithahighriskoffetalmortality,hypoxicischaemicencephalopathyandcerebralpalsy.
CaseswhichmeettheUKOSSdiagnosticcriteriashouldbereported,whetherfatalornonfatalto
www.npeu.ox.ac.uk/UKOSS.Fatalcasesshouldalsobereportedtotheconfidentialenquiryat
www.npeu.ox.ac.uk/mbrraceuk.Suddenfetalcompromiseisanotedfeaturein20%ofcasesand
mayprecedeonsetofmaternalsymptoms.Indeed,UKOSSdatasuggeststhat56%ofAFEpresent
priortobirthofthebaby.Althoughfetalsquamesinthematernallungsremainthesinglebest
diagnostictestforAFE,therecentCMACEreportdocumentsatleastonecasewhichwasaccepted
asAFE,duetoatypicalclinicalpresentationandbecausethoroughpathologicalexaminationhad
excludedothercauses,wherefetalsquameswerenotidentified.Thisraisesthequestionsasto
whethersquamesmaybeamarkerforAFEbutnotnecessarilythecause.Casefatalityratesare
approximately20%intheUK.

Question154

Thefollowingarecontraindicationstoepiduralinsertion:

A) Severepreeclampsia
B) Aorticstenosis
C) Plateletcountof70109/L
D) Cellulitisoftheleg
E) Idiopathicintracranialhypertension

Answer154

A) False
B) False
C) True
D) False
E) False

Epiduralanalgesiaisnotcontraindicatedinpreeclampsiaperse,unlessthereisassociated
thrombocytopaeniaoraprecipitousdecreasingtrendinplateletcount.Infactitmaybeofbenefitin
theconditionduetovasodilatationimprovingflowtotheuteroplacentalunit.Leftsidedcardiac
outflowtractlesions,suchasaorticstenosis,dopresentarealchallengetotheanaesthetist.The
fixedoutputfromtheleftsideoftheheartmeansthatadropinperipheralvascularresistance
associatedwitharegionalblockmaycauseseverehypotension,syncopeandreducedcoronary
perfusion.However,thesuperiorpainreliefaffordedbyepiduralshelpstolimitpaininduced
tachycardia.Thisisbeneficialbecausetachycardiamayimpairventricularfillingandcardiacoutput.
Withmodifications,andmoreintensivemonitoring(e.g.arterialline),epiduralscanbeusedsafely
andeffectivelyinlabourforwomenwithaorticstenosis.Theplateletcountthresholdforperforming
anepiduralis80109/L.Infectionoftheskinoverlyingthelumbarregionwouldprecludeepidural
insertion,butnotatmoredistantsites.Epiduralsandspinalshavebeenuseduneventfullyinlabour
forwomenwithidiopathicintracranialhypertension,withoutreportsofuncalherniation.RaisedICP
causedbyamasslesionwouldbeacontraindicationtoneuraxialmethodsofanalgesiaand
anaesthesia.

Question155

Regardingtheuseofopioidsinlabourforanalgesia:

A) Theriskofneonataldepressionwithpethidineishighestifgiven6hoursbeforedelivery
B) Patientcontrolledanalgesiashouldbediscontinuedduringthesecondstageoflabour
C) Remifentanilshouldbeavoidedinwomenwithrenalimpairment
D) FentanylisassociatedwithlowerneonatalApgarscores
E) Midwivescangiveintramuscularpethidinewithoutadoctorsprescription

Answer155

A) False
B) False
C) False
D) False
E) True

Theriskofneonataldepressionfollowingpethidineishighestifgiven23hourspredelivery.PCA
canbesafelycontinuedrightuptodelivery.Remifentanilismetabolisedbynonspecificesterases
andisthereforenotdependentonrenalorhepaticfunctionforclearance.Assuchitcanbesafely
usedinwomenwithrenalimpairment.Thereisnoevidencetosuggestthateitherfentanylor
remifentanilareassociatedwithlowerApgarorneurobehaviouralscores.IntheUKmidwivesare
abletoadministerintramuscularpethidinewithoutadoctorsprescription.Thisinpartaccountsfor
itscontinuedhighrateofuse.

Question156

RiskfactorsforVitaminDdeficiencyinclude:

A) Obesity
B) Pigmentedskintypes
C) Vegetariandiet
D) Useofantiepilepticdrugs
E) Limitedsunexposure

Answer156
 A) True
B) True
C) True
D) False
E) True

Question157

RegardingVitaminDandpregnancy

A) Insufficiencyisamoreseriousstatethandeficiency
B) Deficiencycanbecorrectedbydailyadministrationof10gperday
C) Deficiencyisdetectedbymeasuringlevelsof1,25dihydroxyvitaminD
D) Inadequatelevelsareassociatedwithgestationaldiabetes
E) VitaminDsupplementshelptopreventchildhoodrickets

Answer157

A) False
B) False
C) False
D) True
E) True

VitaminDinsufficiencyisthetermusedwhenbloodlevelsare<50nmol/landdeficiencywhen
thelevelsare<25nmol/l.ManypregnantwomenhaveinadequateVitDlevels,andallwomenare
recommendedtotake10gsupplementsduringpregnancy,althoughthisisaninadequatedosefor
womenwhoaretrulydeficient.VitaminDstatusismeasuredusingserum25hydroxyvitaminD
levels,themaincirculatingbutmostlyinactiveform.Althoughsupplementsaregivenduring
pregnancytoimprovefetalandneonatalvitaminDlevels,andsohelppreventchildhoodrickets,
thereisincreasingevidenceofaplethoraofotherbenefitsofhavingnormallevelsofvitaminD
duringpregnancy,includingapossiblereductionintheriskofgestationaldiabetes.

Question158

Thepatientandtheirfamilycanrequesttosee:

A) Acopyoftheclinicalnotes
B) Statementsfromtheindividualsinvolved
C) CopyoftheRCA
D) Instructionstosolicitors
E) Statementsmadeafteraclaimhasbeensubmitted

Answer158
 A) True
B) True
C) True
D) False
E) False

Itisimportantfordoctorsandallhealthcarestafftoknowthatpatientsareentitledtoaccesscopies
oftheirnotes,statementsmadebystafffollowingapooroutcomeornearmiss,andtherootcause
analysisperformedbytheTrustfollowinganincident.ThereisadutyofcandourandtheTrust
mustbeopenandhonest.However,onceformallegalproceedingshavebeenbroughtagainstthe
Trust,allcommunicationmustcomethroughsolicitorsandnotalldocumentationand
communicationafterthatpointneednecessarilybedisclosed.

Maternal Medicine
SBA Quiz
Question159

MissGHisa40yearoldwoman,withmildasthma,inhersecondpregnancy.Inherfirstpregnancy
MissGHdevelopedsevereearlyonsetpreeclampsiarequiringdeliveryat25weeksgestation.This
babydied3daysfollowingdelivery.SubsequentlyMissGHwasdiagnosedwithessential
hypertensionandiscurrentlytakingtheangiotensinconvertingenzyme(ACE)inhibitorenalapril,10
mgoncedaily.MissGHpresentstoyoufollowingapositivepregnancytest.Bookingscanreveals
MissGHtobeapproximately7weekspregnant.

Whatisthebestcourseofaction?

Answer159

D) Commencelowdoseaspirin,changeenalapriltomethyldopaandperformuterineartery
Dopplermeasurementsat23weeksgestation

MissGHshouldbereferredtoahighriskmaternalfetalmedicineclinicassheisathighriskof
recurrenceofpreeclampsia.Thisriskrangesfrom2565%.MissGHshouldbereviewedfortnightly
withbloodpressureandurinechecksateachvisit.MissGHshouldbecommencedonaspirin75mg
dailyuntil36weeksgestation.ThephysicianshoulddiscontinuetheenalaprilandstartMissGHon
methyldopaornifedipine.Labetalolisbestavoidedbecauseofherasthma.Regularultrasound
assessmentoffetalgrowthandumbilicalarteryDopplerindicesshouldberecommendedand
regimeswillvary.Growthscansshouldstartquiteearly(<30weeks)inviewofherpreviousearly
onsetpreeclampsia.AuterinearteryDopplermaybeperformedat2223weeksgestationtohelp
guidethefrequencyofmaternalandfetalsurveillancethereafter.

Question160

TheriskofwhichofthefollowingisNOTincreasedabovethegeneralpopulationduringpregnancy
inwomenwithsicklecelldisease?

Answer160

B) Placentapraevia

Pulmonaryhypertension,cholelithiasisandthromboembolismaremorecommoninindividualswith
sicklecelldiseaseandpregnancyfurtherincreasestheserisks.Patientswithsicklecelldiseaseare
likelytohavereceivedbloodtransfusionspriortothepregnancyandmayhavedevelopedredcell
antibodiesthatcarrytheriskofcausingfetalorneonatalhaemolysis.Thereisnoincreaseinthe
likelihoodofplacentapraevia.

Question161

WhichofthefollowingisNOTarecognisedcomplicationofpregnancyinwomenwithcysticfibrosis?

Answer161

D) Shortenedmaternalsurvivalasaresultofpregnancy

MostseriesofpregnanciesinwomenwithCFhaveshownthatwithcarefulplanningandmonitoring
byadedicatedteam,pregnancyoutcomesarefavourable.Commonlyreportedadverseeventsare
fetalgrowthrestrictionandprematuritywhichincludesiatrogenicearlydeliveryformaternal
benefit.

WomenwithCFareatanincreasedriskofdevelopinggestationaldiabetes.Inarecentseriesof20
pregnanciesinwomenwithCF,adversefetaloutcomeswassignificantlyhigherinwomenwithan
FEV1<60%and/orprepregnancyBMI<20.Gestationaldiabetesoccurredin43%.

Pregnancydoesnotappeartoinfluencethelongtermcourseofdiseaseandisnotassociatedwitha
shortenedsurvivalormorerapiddeclineinlungfunction.Maternalmortalityisnogreaterthannon
pregnantagematchedwomenwithCFexceptinthepresenceofpulmonaryhypertension,cyanosis,
arterialhypoxaemia,moderate/severelungdisease(FEV1<60%predicted)and/ormalnutrition
whenbothmaternalandfetaloutcomearepoor.

Althoughthereisusuallylossoflungfunctionduringpregnancy,thisisregainedfollowingdelivery.

Question162

Whichofthefollowingiscorrectregardingmycobacteriumtuberculosisinpregnancy:

Answer162

C) TreatmentofTBinpregnantwomenshouldbethesameasthatinnonpregnantwomen
withexceptionofstreptomycin
TheMantouxtestisnotaffectedbypregnancy.Thediagnosiscanbeconfirmedwithsputum
examinationforacidfastbacilli(ZiehlNeelsenstain).Cultureoftheorganismtakesabout6weeks.If
thereisnosputum,washingsfrombronchoscopymustbeobtained.

TreatmentofTBinpregnantwomenshouldbethesameasthatinnonpregnantwomen,except
thatstreptomycinshouldbeavoidedbecauseoffetalototoxicity.

Theusualdrugsarerifampicin(noprovenadversefetaleffectsbutriskofmaternalhepatotoxicity),
isoniazid(incombinationwithpyridoxine50mg/dtoreducetheriskofperipheralneuritis),
pyrazinamideandethambutolfor2monthsfollowedby4monthsofisoniazidandrifampicin.Liver
functionshouldbemonitoredmonthly.Intheeventthatthetransaminasesmorethandouble,all
antituberculouschemotherapyshouldbetemporarilywithdrawnandthenindividualagents
introducedinastepwisefashionwhileliverfunctiontestsaremonitoredclosely.

Theneonateshouldbegivenprophylacticisoniazidtreatmentifthemotherissputumpositive,and
vaccinatedassoonaspossible.

Question163
Whichofthefollowingfactorsdoesnotincreaseinnormalpregnancy:

Answer163
D)FactorXI
Pregnancyisaprothromboticstatewithelevatedlevelsoffactorspromotingclotting(Fibrinogen,
FactorVIIandVWF)andthoseinhibitingfibrinolysis(e.g.tPA).AreductioninfactorXIandproteinS
levelarealsoprothrombotic.

Question164

WhichofthefollowingistrueregardingverticalHIVtransmission:

Answer164

D) Coinfectionwithmalariaincreasestherisk

ManyfactorsaffecttheverticaltransmissionriskofHIV.HighviralloadsandlowCD4countscarrya
transmissionriskof40%ifthebabyisbornvaginallyandbreastfed.Placentaldamagefrominfection
(e.g.syphilis,malaria)ordruguse(e.g.cocaine)canincreasetherisk.Suppressingviralloadsto
undetectablelevelsbyusingHAARTcanbringthetransmissionriskto<0.5%,evenwithvaginalbirth.
Transplacentalspreadintheabsenceofplacentalpathologyisrelativelyunlikely.Vaginaldelivery
andbreastfeedingarethemorecommontimesforandmechanismsforverticaltransmission.
However,vaginalbirthisrecommendednowiftheviralloadisundetectableandthewomanisusing
HAART.Eveniftheviralloadislow,acaesareansectionisstillrecommendedifthewomanisonly
takingzidovudine(monotherapy).

Question165
MrsJSisa31yearoldwomanwithahistoryofchronickidneydiseaseduetorefluxnephropathy
andchronicpyelonephritis.Shereceivedarenaltransplant6yearsagowithnoepisodesofrejection.
Shecontinuedtosufferfromintermittenturinarytractinfectionsafterhertransplantbuthasnot
hadanyepisodesfor18months.Shealsohashypertension.

Currentmedicationsareprednisolone5mgod,mycophenolate1gbd,tacrolimus4mgbd,ramipril
5mgodandnifedipineLA30mgod.Herbloodpressureis129/75,serumcreatinine113mol/l,
estimatedGFR52ml/minandurinedipsticknegative.

Sheisconsideringherfirstpregnancyandattendsyourclinicforpreconceptioncounselling.

Whatisthebestmanagementoptionforyoutorecommendtoher?

Answer165

C) Stopthemycophenolateandramipril,startazathioprineandadviseherofahighchanceof
agoodoutcome

Stopmycophenolateandramiprilandadviseherofahighchanceofagoodoutcome

Mycophenolateandramiprilareassociatedwithteratogenicityandshouldbeexchangedfor
alternativeagentspriortopregnancy.Mycophenolatecouldbeswappedwithazathioprineafter
discussionwiththetransplantnephrologyteam,withorwithoutanincreaseddoseofprednisolone
toreducetheriskofrejection.Troughtacrolimuslevelsshouldbemeasuredevery24weeksduring
pregnancyandthepuerperium.Targetlevelsvarybetweentransplantcentresandshouldbe
discussedwiththelocaltransplantteam.

Intheabsenceofproteinuria,thereisnostrongindicationtoremainonramipriluntilpregnancyis
confirmed.Itcanbediscontinuedandbloodpressuremonitored.Ifincreasedtherapyisneeded,the
nifedipinedosecouldbeincreasedandmethyldopaorlabetaloladded.

Folicacidsupplementsshouldberecommendedasperstandardadvice.Lowdoseaspirinshouldbe
recommendedasprophylaxisagainstpreeclampsia.

MrsJSappearsoptimisedforpregnancyfollowingherrenaltransplant.Sheisover1yearfrom
transplantwithnorejectionorproteinuriaandwellcontrolledbloodpressure.Herserumcreatinine
isnotnormalbut,atlessthan125mol/l,shehasa<5%riskofrequiringdialysisorsufferinga
significant(25%)lossofrenalfunctionbecauseofthepregnancy.Herriskofpreeclampsiais
approximately2025%,however.Athercurrentlevelofrenalfunction,thereisa95%chanceofa
successfulpregnancy.Observationaldataneverthelessshowsthatthereisanincreasedchanceof
pretermdelivery(<37weeks,30%),growthrestriction(25%)andneonatalcareadmission(3040%),
predominantlyassociatedwiththeincreasedincidenceofpreeclampsia.

Question166

WhichofthefollowingisNOTtrueregardingsystemiclupuserythematosus(SLE)inpregnancy:

Answer166
A) Ifthepatientisonwarfarinpreconceptually,thismaybesafelycontinuedfortheduration
ofthepregnancy

Warfarinisteratogenicbetween6and12postmenstrualweeksofgestation,andthereforeshould
bestoppedbefore6weeksofgestationandthewomanconvertedtolowmolecularweightheparin
(LMWH)fortheremainderofthepregnancy.

Womenwithpreviouslupusnephritisareatanincreasedriskofdevelopingpreeclampsia,which
maybedifficulttodistinguishfromarenalflare.

ProteinuriainwomenwithSLEcanheraldthestartofpreeclampsia,butisnotpathognomonic.It
maybeextremelydifficulttodifferentiatearenalflarefrompreeclampsia.C3and4maybenormal
orraisedinpreeclampsia,whiletheymaybelowinarenalSLEflare,anddoublestrandedDNA
antibodymayalsoberaisedinaflare,whichcanhelptodifferentiatebetweenthetwoconditions.

Significantpreexistingrenalimpairmentisassociatedwithapoorfetaloutcome.Aserumcreatinine
levelgreaterthan140mol/lisassociatedwith50%pregnancylossandthisincreasesto80%ifthe
serumcreatininelevelisgreaterthan400mol/l.Womenwithlupusnephritiswhohaveactive
diseaseinthe6monthspriortoconceptionaremorelikelytohaveactivediseaseduringpregnancy
andhavealowerlivebirthrate.

Question167

Whichofthefollowingistrueregardingdermatologicalconditionsinpregnancy:

Answer167

B) PUPPtypicallysparesthesolesofthefeetandpalmsofthehands

PUPPisnotassociatedwithadversepregnancyoutcomes,althoughthepatientsqualityoflifecan
beextremelyimpairedsecondarytointensepruritus.Increasedfetalmonitoringisnotindicatedin
patientswithPUPP.Theabdomenisthemostcommonlyaffectedarea,withperiumbilicalsparing,
andthepapulescanspreadfromtheretoanyareaofthebodyresultinginintensepruritus.The
soles,palmsandfaceareusuallyspared.Incontrast,pruritusinthesoles,palmsandfaceis
consistentwithobstetriccholestasis.Pemphigoidgestationiswaspreviouslyreferredtoasherpes
gestationis,butthetermisnolongerusedasitisacceptedthattheconditionhasnoassociation
withanyactiveorpreviousherpesinfection.Thetriggerforthedevelopmentofautoantibodiesin
personswithpemphigoidgestationisisunknown.

Patientswithpustularpsoriasisofpregnancypresentwithnonpruriticerythematousplaqueswith
ringsofpustules.Itisassociatedwithadversefetaloutcomes,includingmiscarriage,fetalgrowth
restrictionandstillbirth.

Question168
A23yearoldprimigravidapresentstoyouat11weeksgestation.Shehasalonghistoryofasthma,
diagnosedinherchildhood,withtwoadultadmissionsforsevereasthmarequiringoralsteroids.At
present,shetakesSymbicort(Budesonide100mcgandformoterol6g)twopuffsb.i.d.and
salbutamol(100g)twopuffsaboutthreetimesperweekasneeded.Recentlyshehashadmild
symptomsonlyprecipitatedbyexercise.Shewouldliketostopherinhaledcorticosteroidassheis
concernedaboutharmingherbaby.

Whichofthefollowingisacorrectstatementregardinghermanagement?

Answer168

D)Oralsteroidsshouldnotbewithheldinsevereasthmaattacks

Thispatienthasahistoryofsevereasthmaandisatriskofdeteriorationduringthelaterstagesof
herpregnancy.Symbicortincorporatesaninhaledcorticosteroid,isacontrollingmedication,should
notbestoppedinpregnancyandisnotarisktothefetus.Severeasthmaattacksareariskto
maternalandfetalwellbeing.Educatingpatientsaboutthesafetyofmedicationsisnecessaryfor
compliance.Partofanemergencyselfmanagementplaninasthmainpregnancyshouldinclude
monitoringforsignsandsymptomsofdeteriorationincontrolandearlypresentationtohospital.

Question169

A32yearoldnulligravidawithlupusdiagnosed6yearsagopresentsforprepregnancycounselling.
Atdiagnosis,shehadhightitresofANA,dsDNA,lowcomplement(C3andC4)andpositiveantiRo
antibody.Hertypicalsymptomsincludeasymmetricarthritis,malarrashandoralulcers.Shehasno
hypertension,respiratoryorrenaldisease.Twomonthsagoshehadaflarethatrespondedtooral
steroidsandshenowhasnosymptoms.Sheiscurrentlytakinghydoxychloroquine400mgdaily,
Azathioprine100mgdailyandPrednisolone10mgdaily(taperedfrom20mg2monthsago).

WhichofthefollowingisNOTtrueregardinghermanagement?

Answer169

E)Cyclosporinshouldneverbeusedduringpregnancy

Pregnancyisahighrisktimefordiseaseexacerbationinlupuspatients.Womenwithquiescent
diseaseforthe6monthspriortoconceptionareatreducedriskofantepartumflares.
Hydroxychloroquineandazathioprinemaybecontinuedinpregnancyinsevereconditionswhere
benefitisconsideredgreaterthanrisk.Supplementalsteroidsshouldbeconsideredforthelabour
anddeliveryperiodinwomenwhohavebeenongreaterthan7.5mgofprednisoloneforgreater
than2weekspriortodelivery.Otherantiinflammatoryagents,suchascyclosporinandtacrolimus,
havebeenusedduringpregnancy,butthedoseshouldbeminimised,andlesssafetydatais
available.


Question170

Whichofthefollowingphysiologicalrespiratoryvariableswouldbeexpectedtoincreaseduring
normalpregnancy?

Answer170

D)TidalVolume

Oftheoptionsabove,onlythetidalvolumeincreasessignificantlyduringpregnancy(by40%from
500to700ml).ThePEFRandFEV1remainstableandthePaCO2drops.

Question171

Theserumlevelofwhichofthefollowingisnotincreasedduringpregnancy?

Answer171

D)Albumin

Productionofthyroidbindingglobulinisincreasedduringpregnancy,leadingtoanincreaseinthe
leveloftotalT3andT4.Thefreelevelofthyroidhormonedoesnotaltersignificantly.Alkaline
phosphataseisproducedbytheplacenta,meaningitsserumlevelisincreased.Albuminlevelsfall,
possiblyadilutionaleffect.

Question172

Anobese36yearoldprimiparouswomanundergoesaroutinescreeningoralglucosetolerancetest
at29weeksgestation,inviewofherBMIandfamilyhistory(hermotherisatype2diabetic).Her
fastingbloodglucoseis10mmol/Landher2hourresultis15mmol/L.Bloodglucosemonitoring
overthenextfewdaysshowssimilarearlymorningandpostmealvaluesandanultrasoundscan
showsamacrosomicfetuswithadegreeofpolyhydramnios.Thepregnancyisotherwise
straightforwardandshereportsgoodfetalmovements.

Whatwouldbeyourmanagementatthispoint?

Answer172

C)Commenceinsulin

Itiscertainlyappropriatetoinvolveadietician,butimmediateactionisrequiredtobringtheblood
sugarsintoamorenormalrange.Thefetusisalreadyshowingsignsofmacrosomiaand
hyperinsulinaemia.Admissionisunnecessaryandanamniodrainagewillbeofnovalueunlessthe
womanisextremelyuncomfortable,whichisunusualwiththemildpolyhydramnioscharacteristicof
diabeticpregnancies.Oralhypoglycaemicagentsarelesslikelytobesufficientontheirownwhen
thebloodglucoselevelsareashighasthese,sotheuseofinsulinseemsalmostinevitable,eitherin
isolationorincombinationwithmetformin.

Question173
Whichoneofthefollowingistrueregardinggestationaldiabetes?

Answer173
C) Ultrasoundmonitoringoffetalgrowthandamnioticfluidvolumeshouldbeperformed
every4weeksbetween2836weeks
InthemajorityofwomenwithGDM,dietandexerciseplusselfmonitoringofbloodglucoseisthe
initialintervention.AsmallproportionofwomenwithGDMwhohavemoreseveredysglycaemia
shouldbestartedoninsulinatdiagnosis.Durationofexposuretohyperglycaemiashouldbe
minimised.Ifdietandexercisedoesnotachievebloodglucosetargetswithin12weeks
pharmacologicaltherapyshouldbeadded.Ultrasoundmonitoringoffetalgrowthisusefulfor
makingdecisionsabouttimingandmodeofdelivery.Bloodglucoseshouldbemaintainedbetween
47mmol/lduringlabouranddelivery.InthemajorityofwomenwithGDM,bloodglucosereturns
tonormalpostpartum.

Question174
Whichofthefollowingstatementsiscorrectregardingthromboembolisminpregnancy:

Answer174
E) IfVTEissuspectedtreatmentshouldbestartedwhileawaitingadefinitediagnosis
VQscansarenotcontraindicatedinpregnancy,norisaCTPA.However,bothinvolveexposingthe
womanandherunbornbabytoradiation.AVQscanslightlyincreasesthechancesofchildhood
cancerandaCTPAhasanotinsignificantimpactonthewomansriskofbreastcancerlaterinlife.D
Dimersarefrequentlymildlyraisedinnormalpregnancies,andmoresignificantlysoifthereis
impendingoractualpreeclampsia.AntenatalVTEshouldbetreatedwithlowmolecularweight
heparin.Oralanticoagulantsarepotentiallyteratogenicandincreasetheriskofbothmaternaland
fetalbleeding.Inthelastconfidentialenquiryintomaternaldeaths,VTEwasnolongertheleading
causeofdeaths,andthismayreflectbetterpreventionstrategiesandanincreaseintheuseof
LMWH.IfVTEissuspected,treatmentwithLMWHshouldbeginimmediatelyandthenmaybe
stoppedifsubsequentinvestigationsmakethediagnosisunlikely.

Question175

Whichofthefollowingwomenshouldbescreenedforgestationaldiabetesbyasingleoralglucose
tolerancetestat2628weeksgestation:

Answer175

D) AMiddleEasternwoman
Onlyahistoryofdiabetesinafirstdegreerelativeisconsideredsignificantenoughtowarrant
screeningforGDM.Similarly,womenwithaBMI>30andapreviousbabyweighing>4.5kgshould
beofferedscreeningat2628weeks.WomenwithafamilyoriginfromtheCaribbean,MiddleEast
orSouthAsiashouldallbeofferedscreeninginthelatesecondtrimesterasthesearepopulations
withahighbackgroundriskofdiabetes.Womenwithaprevioushistoryofgestationaldiabetes,ora
BMI>40shouldbeofferedscreeningfirstat1618weeks,andagainat2628weeks.

Question176

Whichoneofthefollowingmedicationsshouldbestoppedduringpregnancycomplicatedbypre
existingdiabetes:

Answer176

B)Ramipril

Aspart(Tradename:Novarapid)isafastactinginsulinanalogue,andissafetouseduringpregnancy.
Clinicaltrialshaveshownnomaternalorfetaladverseeffects.Glargineisalongactinginsulin,and
thisisalsosafeinpregnancy.Metformin,acommonlyusedoralhypoglycaemicagent,issafe.

ACEInhibitor(e.g.ramipril)exposureduringpregnancyisassociatedwithanincreasedriskof
congenitalanomalies.Thisriskisalsoassumedtoaffectangiotensinreceptorblockers(ARBs)suchas
losartan.

Question177

A25yearoldprimiparouswomanwithhypertensionandsignificantproteinuriaisinducedat39
weeksgestation.Shehasanepiduralduringlabourandlabourendsasaforcepsdeliveryofahealthy
babygirl.Within12hoursofthebirth,themothermobilisesanddevelopsseverehypertension
(175/115),agradualonsetheadacheanddifficultiesseeingnormally.AnMRIscanshowsbilateral
oedemawithinthewhiteandgreymatterintheposterioraspectsofthecerebralhemispheres.

Fromtheoptionsbelow,whichisthemostlikelydiagnosis?

Answer177

C)PRES

PRES(Posteriorreversibleencephalopathysyndrome).

Althoughalltheoptionslistedcancausesevereheadacheinthepostnatalperiod,migraine,cortical
veinthrombosisandsubarachnoidhaemorrhagewouldnotgivetheMRIfeaturesdescribedhere,
whicharetypicalofPRES,asyndromewhichcancausecorticalblindnessandseizures,andwhichis
mostcommonly,butnotexclusively,foundwithpreeclampsiaandeclampsia.Intracranial
haemorrhageandpostpartumcerebralangiopathytypicallypresentwithathunderclapheadache,
andthelatterconditionusuallyoccursinwomenwhowereotherwisefitandwellandMRI
angiographyshowsbeadingthroughoutcerebralarterialvessels.

Question178

Whichofthefollowingantipsychoticdrugsfromthelistbelowwouldbefirstlinechoicein
pregnancy:

Answer178
C)Haloperidol

Question179

Youareaskedtoseeawomanforprepregnancycounsellingwhoisafitandwell28year
oldnonsmokerwithnosignificantpersonalorfamilyhistoryofnote.Shetravels,byplane,
fromLondontoParis(return)onamonthlybasisandhasconcernsabouthowthismight
impactonthepregnancy.

Whichofthefollowingpiecesofadvice,orrecommendation,isnotappropriate?

Answer179
B) Shewouldbeadvisedtouselowmolecularweightheparininjectionstoreducethe
thrombosisrisk
Mostairlineswillallowpregnantwomenwithuncomplicatedpregnanciestoflyupto37
weeks(36weeksand6days)inasingletonpregnancy,butonlyupto33weeksinatwin
pregnancy.However,womenshouldbeadvisedtospeakdirectlywiththeirairlinewhen
theyaremakingplanstofly.Althoughthefirsttrimestermiscarriageriskhasbeenfoundto
beelevatedincabinstaff,thiseffectissignificantlyreducedbythemworkingfewerhours,
anditisveryunlikelythatamonthlyshortflightwouldhaveanyeffectonmiscarriagerisk,
orradiationexposure.Frequentfliers,travellinglongdistances,mayhavetobemore
cautiousinthefaceofpoorqualitydata.Thiswomanhasnoadditionalriskfactorsfor
thrombosis,andtheflightsareshorthaul.TherewouldbenoneedtoadviseLMWH
injections.

Extended Matching Questions

Question180
Belowisalist(AJ)ofcausesofthrombocytopaeniainpregnancy.Pickthemostappropriate
diagnosisfortheconditionsdescribedini)tovi).

i) Anautosomaldominantdisordercausedbytheabnormalbindingofaproteinto
platelets
 ii) AthromboticmicroangiopathycausedbyadeficiencyintheproteinADAMTs13
iii) Asyndromeofhaemolyticanaemia,thrombocytopaeniaandrenalfailurecommonly
linkedtobacterialinfection
iv) Apossibleconsequenceofamnioticfluidembolism
v) Aconditionusuallypresentingwithvomiting,abnormalliverenzymes,veryhighuric
acidlevelsandhypoglycaemia
vi) Aconditionpresentingwithhypertension,proteinuriaandhepaticnecrosis

Answer180

i) C. VWDtypeIIB
ii) B. TTP
iii) I. HUS
iv) H. DIC
v) D. AFLP
vi) A. HELLP

Question181

Belowisalist(AK)ofdermatologicalconditionswhichmayoccurduringpregnancy.Fromthislist,
pickthemostsuitablediagnosisforthequestionsoutlinedini)tov).Eachanswermaybeusedonce,
morethanonce,ornotatall.

i) Anautoimmuneconditionthatissometimesassociatedwithneonatalcutaneous
manifestations
ii) Theonlyskinconditionlistedwhichcarriesanincreasedriskofpregnancyloss
iii) Arashwhichstartscentrally,butoftensparestheperiumbilicalregion
iv) Askinrashwhichmayoccurasadrugreaction,orinassociationwithsystemicinfection
v) Aconditionthatisalsoknownaspolymorphiceruptionofpregnancy

Answer181

i) I.Pemphigoidgestationis
ii) G.Pustularpsoriasisofpregnancy
iii) D.PUPP
iv) H.Erythemamultiforme
v) D.PUPP

Question182

Belowisalistofdrugs(AQ).Fromthelist,choosethemostsuitableforuseintheclinical
endocrinesituationsdescribedinquestionsitoix.

i) Twodrugsusedtotreathyperthyroidism
 ii) Twodrugsusedinthetreatmentofphaeochromocytoma
iii) Themaintenancedrugofchoiceforapregnantwomanwithcongenitaladrenalhyperplasia
(CAH)whohasanoncarriermalepartner
iv) Twodrugsusedtotreatdiabetesinsipidus
v) ThedrugofchoiceforCushingssyndromeinpregnancy
vi) Thedrugusedtopreventfetalmasculinisationwhenthemotherandfatherarebothcarriers
forCAH

Answer182

i) AandH.Carbimazoleandpropylthiouracil
ii) BandM.Propanolol(betablocker)andphenoxybenzamine(alphablocker).Thepatient
shouldbealphablockedfirst,andonlythenshouldbetablockersbeadded.
iii) O.Prednisoloneisusedinthissituationbecauseitdoesntcrosstheplacentainhigh
quantities.
iv) FandG.DDAVPissafeinpregnancy,despiteitshomologywithoxytocin.Carbamazepinecan
beusedfornephrogenicDI,butconcernsremainwithregardtoitspossibleteratogenic
effects,andtheimpactitmayhaveonneurodevelopment.
v) L.MetyraponeisthedrugofchoiceforCushingssyndromeinpregnancy.Ketoconazoleis
potentiallyteratogenic.
vi) P.Dexamethasone.ThisischosenifthefetusisatriskofCAHbecausebothparentsare
carriers(orifthemotherisaffectedandthefatheracarrier).Inthissituationitisbeing
usedtopreventmasculinisationofafemalefetus,andcanbestoppedifthefetusis
foundtobemale(unlesscorticosteroidisneededtotreatanaffectedmother,inwhich
caseshemayreverttoprednisolone).
vii) K.Ergocalciferol.ThisIMinjectionisgivenevery3months,andprovidesaverysubstantial
boosttoVitaminDlevels.Itisidealforwomenwhoarepooratcomplyingwithoral
replacementregimes.
viii) Q.Amiloride.Thisisabetterchoiceinpregnancythanspironolactone,whichcanmasculinise
afemalefetus.
ix) DandI.Cabergolineoroctreotide.Bromocriptinecanalsobeused.

Multiple Choice Questions

Question183

AfemalesurvivorofWilmstumourtreatment,whichincludedabdominalirradiation,has:

A) a3foldincreaseintheriskofpretermlabour
B) a2foldincreaseintheriskoflowbirthweight
C) a3foldincreaseinfirsttrimestermiscarriagerisk
D) astillbirthrateof1in30
E) adoubledriskofcongenitalanomaliesintheiroffspring

Answer183

A) True
B) True
C) False
D) False
E) False

Abdominalirradiationcompromisestheendometriumandreducesuterinesizeanddistensibility.
DatafromtheBritishchildhoodcancersurvivorssurveyhasrevealeda3foldincreaseintheriskof
pretermlabour,anda2foldincreaseintheriskofhavingasmallbaby.Althoughtheriskoffirst
trimestermiscarriage,orlatestillbirth,maybeslightlygreatertheproofisnotstrongandnoris
theregoodevidencethattheriskofcongenitalanomaliesintheoffspringiselevated.

Question184

Regardingscreeningfor,anddiagnosisof,gestationaldiabetes:

A) Dipstickurinalysisforglucoseisagoodscreeningtest
B) Ifrequired,biochemicalscreeningforgestationaldiabetesisusuallyperformedbetween24
28weeksgestation
C) Womenwithpreviousgestationaldiabetesshouldbeofferedbiochemicalscreening(Oral
GlucoseToleranceTestor1weekofselfmonitoringofbloodglucose)at1618weeks
D) Diagnosticcriteriaarethesameworldwide
E) Diagnosticcriteriaarethesameasfordiabetesoutsideofpregnancy

Answer184

A) False
B) True
C) True
D) False
E) False
ThemajorityofwomenwithGDMdonothaveglycosuriaandthereforedipstickurinalysisisapoor
screeningtestforGDM(lowsensitivity).GDMusuallydevelopsduringthesecondtrimesterand
mostauthoritiesagreethatbiochemicalscreening,ifrequired,shouldbeundertakenbetween24
and28weeks.WomenwithpreviousGDMmaydevelopGDMearlierinsubsequentpregnanciesand
shouldthereforebescreenedat1618weeksandagainat28weeksifthefirsttestisnormal.There
areanumberofdifferentdiagnosticcriteria,however,thereisevidencethatglucoselevelsbelow
thosediagnosticofdiabetesoutsideofpregnancyareassociatedwithadversepregnancyoutcomes
andthereisagreementthatthediagnosticthresholdsforGDMshouldbelowerthanfordiabetes
outsideofpregnancy.

Question185
Thefollowingfindingscanbenormalforpregnancy:
A) Apalpablepraecordialthrill
B) Athirdheartsound
C) AraisedJVP
D) Adiastolicmurmur
 E)Ventricularectopics

Answer185
A) False
B) True
C) True
D) False
E) True

Althoughcardiacmurmurscanbeheardinupto90%ofpregnantwomenbytheendofthethird
trimester,theyareusuallyquietandonlyeversystolic.Aloudmurmur,adiastolicmurmur,orone
associatedwithathrillwillbeasignofpathology.Hearingathirdheartsoundisnormalfor
pregnancy,asisamildlyelevatedJVPinthethirdtrimester,andthefindingofventricularectopics.

Question186
ThefollowingchangesonanECGmaybenormalforpregnancy:
A) Sinustachycardia
B) MildSTelevation
C) STdepression
D) BroadenedQRScomplex
E) Twaveinversion

Answer186
A) True
B) False
C) True
D) False
E) True

AlthoughsmallQwaves,Twaveinversionintheinferiorleads,STdepressionandsinus
tachycardiacanallbeconsiderednormalfeaturesofanECGduringpregnancy,anySTelevation
orprolongationoftheQRScomplexesarelikelytobeasignofpathology.

Question187
ThefollowingarekeyfeaturesintheTorontoriskscoringsystemformaternaloutcomesof
cardiacdiseaseinpregnancy:

A) Leftventricularoutflowgradientof>30mmHg
B) Maternalsmoking
C) Leftventricularejectionfraction<50%
2
D) Mitralvalveareaof<2.0cm
E) BaselineNewYorkHealthAssociationclassofIIIorIV

Answer187
A) True
B) False
C) False
D) True
 E) True

TheTorontogroupfoundthatanumberofmaternalfactorswerepredictiveofpoor
maternaloutcomesofcardiacdiseaseinpregnancy,andalsofoundfurtherfactorsthat
helpedtopredictpoorneonataloutcomes.AnLVOTgradientof>30mmHg,anLVejection
2
fractionof<40%andamitralvalveareaof<2.0cm wereallpredictorsofpoormaternal
outcome,aswasaprepregnancyNYHAclassof>II.Smokingwasapredictorofpoorer
neonataloutcomes.

Question188
ThefollowingareknownriskfactorsforVTEinpregnancy:

A) Increasedmaternalage
B) LowmaternalBMI
C) Postpartumhaemorrhage
D) Thrombophilia
E) PreviousVTE

Answer188
A) True
B) False
C) True
D) True
E) True

Question189

Regardinganaesthesiaoftheheadinjuredobstetricpatient:

A) Apregnantpatientisathigherriskofdesaturationoninductionofanaesthesia
B) Ventilatoryparametersarethesameasforanonpregnantpatient
C) Cerebralperfusionpressureisthedifferencebetweensystolicbloodpressureand
intracranialpressure
D) Aheaduppositionwillhelptoreduceintracranialpressure
E) Whenunderanaesthesia,adropinfetalheartrateandlossofvariabilityrepresentfetal
compromise

Answer189

A) True
B) False
C) False
D) True
E) False

Oxygendemandisincreasedbyupto50%duringpregnancy,andfunctionalresidualcapacityis
markedlyreduced.Thesechangesacttogethertomeanthatthetotalamountofoxygenthatcanbe
heldinthelungsisreduced,whileatthesametimeitisbeingusedatafasterrate,making
desaturationmorelikelythaninthenonpregnantpatient.Thoroughpreoxygenationpriortothe
inductionofanaesthesiacandelaytheonsetofadesaturationepisode.Theminuteventilation(tidal
volumexfrequency)ishigherduringpregnancy,andthearterialpartialpressureofcarbondioxideis
lowerasaresult.IfmaternalCO2isallowedtorisefromthislevel,fetalacidosisislikelytoensue,
howevercaremustbetakennottodroptheCO2toolowasthismayalsocausefetalcompromise.

CerebralperfusionpressureisthedifferencebetweenMEANarterialpressureandintracranial
pressure.Aheaduppositionwillaidvenousdrainagefromthebrainandthusreducethetotal
volumeoftheintracranialcontents(blood,brainandcerebrospinalfluid),leadingtoareduction
inintracranialpressure.Aslightdecreaseinfetalheartrateandalossofvariabilityare
commonlyseenunderanaesthesiaandintheabsenceofotheradversefeaturesarelikelytobea
reflectionofdrugadministrationratherthanduetoachangeinfetalwellbeing.

Question190

Regardingobstetriccholestasis:

A) Raisedbilesaltsarediagnostic

B) Fetaloutcomescanbeimprovedwithultrasoundsurveillance

C) Itisassociatedwithmeconiumstainingofliquor

D) Serumlevelsofliverenzymemustberaisedtomakeadiagnosis

E) Combinedoralcontraceptiveuseshouldbeavoidedinwomenthathavehadobstetric
cholestasis

Answer190

A) False
B) False
C) True
D) False
E) True

OCisadiagnosisofexclusion.Appropriatesymptomsinawomanwithraisedbilesaltsissuggestive
ofthediagnosis,butothercausesofabnormalbilesalts/LFTmustbeexcludedpriortothediagnosis
beingmade.Symptomsoftenprecedechangesinliverfunctiontestsandbileacidlevels.No
screeningmodality(i.e.ultrasound,CTG,serialbloodmonitoring)hasbeenshowntoalterfetal
outcomes.Serialmonitoringofbloodsdoesnotchangeoutcomes.OCisthoughttobeduetothe
cholestaticeffectofoestrogens,sooestrogencontainingmedicationsshouldbeavoided.

Question191

WithregardtochronichepatitisBinfectioninpregnancy
 A) ThepresenceofmaternalHBeantibodiesindicatesahighinfectivitystate
B) AllnewbornsofchronichepatitisBcarriersshouldreceiveactiveandpassiveimmunisation
C) VerticaltransmissionratesareinfluencedbymaternalHBeantigenpositivity
D) Antiviralagentsarecommonlyprescribedinthethirdtrimester
E) Itisnotanindicationfordeliverybycaesareansection

Answer191

A) False
B) False
C) True
D) False
E) True

ThepresenceofmaternalantibodiesagainstthehepatitisBeantigensignifiesalowinfectivitystate
andisusuallyfoundinwomenwhoareeantigennegative,withlowserumlevelsofHBVDNA.These
womenformthemajorityofchronicHBVcarriersinpregnancy.Theydonotneedantiviraldrugsin
thethirdtrimesterandtheiroffspringareonlyactivelyimmunised(vaccinated).Conversely,absence
oftheantibodyandpresenceoftheeantigenintheserumofapregnantpatientisusually
associatedwithhighlevelsofDNAandahighinfectivityrisk,withthehighestratesofvertical
transmission.Thebabiesborntothesewomenshouldreceivebothactiveandpassiveimmunisation,
thelatterrequiringadministrationofhepatitisBimmunoglobulinwithinthefirst24hoursoflife.
Antiviralagentsarenotusedcommonly,butdohelptoreduceviralloadandpresumably
transmissionriskinthemostinfectiouscases.HepatitisBinfectionisnotanindicationforcaesarean
birth,perse.

Question192
Withregardstoepilepsyandpregnancy:

A) VitaminKshouldbeprescribedtoallwomenwithepilepsyfrom36weeksgestation
B) Womenonlamotriginedonotusuallyneedtoincreasethedoseoftheirmedicationoverthe
courseoftheirpregnancy
C) Intheeventofaseizure,whichisnotselflimiting,intravenouslorazepamisagoodchoiceof
treatment
D) Theneonateshouldbegiven1mgofintramuscularVitaminKtopreventhaemorrhagic
diseaseofthenewborn
E) Theriskofhavingaseizureinthefirst24hourspostdeliveryisapproximately1020%

Answer192
A) False
B) False
C) True
D) True
E) False

VitaminK(1020mgorally)shouldbeprescribedfrom36weeksgestationtowomentakinghepatic
enzymeinducingdrugs(carbamazepine,phenytoinandphenobarbitone)toincreasethevitaminK
dependentclottingfactorsinthebabyandtoreducetheincidenceofhaemorrhagicdiseaseofthe
newborn.Womenoncarbamazepine,andespeciallylamotrigine,whichexhibitlittleproteinbinding,
mayneedtoincreasetheirdoseswithadvancingpregnancy,asfreedruglevelstendtofall.Therisk
ofhavingaseizureinthefirst24hourspostdeliveryisapproximately12%sowomenshould,
therefore,notbeleftunattendedduringthistime.

Question193
Inmultiplesclerosisduringpregnancy

A) Tomakeaclinicaldiagnosis,theremustbeevidenceofatleastoneCNSlesion
B) Vaginaldeliveryandepiduralanaesthesiaarenotcontraindicated
C) Patientsareatincreasedriskofrecurrenturinarytractinfections
D) Highdosecorticosteroidsarecontraindicated
E) Baclofencanbeusedtorelievespasticity

Answer193

A) False
B) True
C) True
D) False
E) True

TomakeaclinicaldiagnosisofMS,theremustbeevidenceofatleasttwoCNSlesionsindifferent
placesatdifferenttimes(disseminationintimeandspace),otherwiseitisknownasaclinically
isolatedsyndrome.MSisnotacontraindicationtovaginaldeliveryorepiduralanaesthesia,
howevercarefuldocumentationofpreexistingneurologicaldeficitinthelegsisnecessarytoavoid
anypostpartumMSexacerbationbeingwronglyattributedtotheregionalblock.Patientswithapre
existingneuropathicbladderareatincreasedriskofrecurrenturinarytractinfections,whichrequire
prompttreatmentwithantibiotics,ormorefrequentselfcatheterisations.Severe,acuterelapses
maywarranttreatmentwithhighdosecorticosteroidsduringpregnancyandbreastfeeding.Drugs
usedtorelievespasticity(baclofen),paroxysmalpainordysaesthesiae(carbamazepineand
gabapentin)mayalsobeusedduringpregnancy.

Fetal Medicine
SBAs
Question194

A30yearoldwoman,currently9weeksintoherfirstpregnancy,isconcernedabouttherisksof
DownsyndromeandconfusedabouttestingavailableintheNHSscreeningprogramme.Shemeets
withyouforcounselling.

WhichofthefollowingistrueregardingDownsyndromescreening?

Answer194

D) Bestpracticerecommendsofferingascreeningtestwithadetectionrateof90%ormore,
withascreenpositiverateofnomorethan2%

Thecurrentmodelofbestpracticerecommendsofferingallpregnantwomenascreeningtestfor
Downsyndromewithadetectionrateof90%ormore,forascreenpositiverateofnomorethan
2%.Thecombinedtestcanachievethesestandardswithtightqualitycontrol,butthequadrupletest
fallsshort.Theriskthresholdforinvasivetestinghasrecentlybeensetat1in150forboththe
combinedandthequadrupletest.Althoughcontingencyandintegratedbiochemicalscreening
methodologiesdohavetheirmerits,theyarenotrecommendedbytheNSCduetotheircomplexity.
FailuretoobtainanNTmeasurementshouldprompttheofferofaquadrupletestasanalternative
formofscreening.

Question195

ForwhichONEofthefollowingconditionsismaternalintravenousimmunoglobulin(IVIG)
consideredthefirstlineoftreatment?

Answer195

B) Fetalalloimmunethrombocytopaenia

Fetalandneonatalalloimmunethrombocytopaeniaisnolongermanagedbyserialintrauterine
platelettransfusions,whicharehazardousandnomoreeffectiveatpreventingfetalintracranial
bleedingthanmaternalIVIGadministration.AlthoughseverecasesofRhesusDisoimmunisation
havebeentreatedinasimilarwaywithIVIG,thisisnotfirstlineandisonlyemployedwhenthefirst
transfusionisanticipatedtobeveryearlyinthepregnancy(atlessthan24weeksgestation).Atrial
usingIVIGtopreventcongenitalheartblockintheoffspringofwomencarryingantiRoandantiLa
antibodiesdidnotshowaconvincingbenefit.However,theevidencesupportinghighdosesteroid
regimesisalsopoor.ThelatterareusedtohelppreventvirilisationofafemalefetusinCAH,butnot
IVIG.Norisitusedtotreatparvovirusinfections,whichmayrequireanintrauterinetransfusion.

Question196

A40yearoldwomanat20weeksinherthirdongoingpregnancyhasbeenexposedtoCMVduring
herworkasacarerforchildrenwithlearningdisabilities.ShehasapositiveCMVIgMtitre,which
wasnegativeatbooking.Sheisveryworriedaboutthepossibilityofharmtoherfetus.

WhichofthefollowingistrueregardingCMVinfectioninpregnancy?

Answer196
B) Theriskofitoccurringwithmaternalinfectionishighestinthethirdtrimester

ItismostlyonlyprimaryCMVinfectionswhichcarryasignificantrisktothepregnancy,soCMVisnot
acauseofrecurrentpregnancycomplications.Theriskofverticaltransmissionishighestinthethird
trimester,buttheriskofdamageisgreatestatearliergestations.Fetalinfectionisactually
diagnosedbyperformingaPCRonamnioticfluidforCMVDNA.Thismustbedoneafter2022
weeks,andmorethan6weeksafterthematernalinfection.Ultrasoundabnormalitiesarefoundina
relativelysmallproportionofinfectedfetuses,soanormalscanexcludesneithervertical
transmission,norfetaldamage.

Question197

WhichofthefollowingoptionsisNOTcorrectregardinggenetics?

Answer197

A) Allelesareanexampleofepigeneticvariability

Allelesaretwoormorefunctioningformsofanyoneparticulargene,buttheydifferinDNA
sequence,notepigeneticcharacteristics(suchasmethylationstatus).Epigeneticdifferencesinclude
anyalterationstoDNA,excludingDNAsequencechanges.Despitethis,theyareinheritable
(betweencellsandtheirdaughters,orindeedbetweenoneindividualanditsoffspring).UnlikeDNA
sequencechanges,theyareusuallyreversible.Methylationisoneformofepigeneticchange.
Imprintingdisordersarerare,butillustratewelltheimportanceofepigenetics.Theyaremore
commonintheoffspringofIVFpregnanciesanditremainstobedeterminedwhatitisaboutthis
processthatinfluencesepigeneticmechanisms.

Question198

A36yearoldwomanpresentsforprepregnancycounselling.Thecouplesfirstdaughterwas
diagnosedafterbirthwithcongenitaladrenalhyperplasia(21hydroxylasedeficiency).Theyare
highlyanxiousabouttheriskstoasubsequentpregnancy.

Whichofthefollowingstatementsisincorrectabouttheirsubsequentpregnancies?

Answer198

E) Ifmalesexisconfirmedsteroidsshouldbecontinued

21hydroxylasedeficiencyisthecommonestcauseofCAH.Thereareanumberofdifferent
mutationswhichcausebothclassicandnonclassicforms.IndividualswithclassicCAHhavesevere
enzymedeficiencyand75%areaffectedwithsaltwastingdisease.Thosewithnonclassic21
hydroxylasedeficientCAHarenotvirilisedandtendtopresentlaterwithsymptomsof
hyperandrogenism.Dexamethasonecrossestheplacentatosuppressthefetaladrenalgland
preventingvirilisationoffemalefetuses.

Lowlevelsofcellfreefetalnucleicacidsmeanthatfetalsexingbynoninvasiveprenataldiagnosisis
notpossiblebefore7weeksgestation.Ifamalefetusisconfirmedsteroidscanbestopped.Fora
femaleinfant,steroidsshouldbecontinuedandeitherchorionicvillussamplingoramniocentesis
arranged.Steroidscanthenbestoppedifinvasivetestingrevealsanunaffectedfemale.

InthecaseofapregnantmotherwhohasCAH,herusualsteroidrequirementsshouldbeconverted
todexamethasoneby5weeksgestation.Asimilarprotocolcanbefollowedandconversionbackto
heroriginalsteroidregimearrangedifsheisnotcarryinganaffectedfemalefetus.

Question199

Followingtesting,acouplehavebeeninformedthattheirfetushasafemurlength<3rdcentileand
thatserumanalytetestinghasrevealedalowPAPPA<0.1MoM.Theyareconsideringgenetic
testingforthepregnancy,andwouldlikemoreinformationaboutthetestsavailable.

Whichofthefollowingstatementsistrueaboutcurrentlyavailablegenetictesting?

Answer199

B) ArrayComparativeGenomicHybridisation(arrayCGH)candetectsmallerdeletionsthan
karyotyping

Sequencingisausefultechniquefordetectingpointmutations,butcannotdetectcopynumber
variations.BotharrayCGHandkaryotypingcandetectdosagechanges,buttheresolutionofan
arrayismuchhigherthanakaryotype.Thismeansmuchsmallerchangescanbeidentified.However
akaryotypehastheadvantageofbeingabletodetectchromosomerearrangements,including
translocationsthatwouldnotbepickedupbysequencingoranarray.

FISHanalysiswouldnotbeabletoidentifyapointchange.Itreliesonbeingabletodesignaprobe
thatcanattachtoaspecificlargersequenceofDNA.Absenceofthatsectionmeanstheprobe
cannotbind.FISHcanalsoconfirmatrisomywhenthreecopiesoftheprobeareseenonanalysis.

NIPDcanconfirmpaternalmutationsmuchmoreeasilythanmaternalmutations.Detectionofthe
paternalmutationinmaternalplasmawouldindicatethatthefetushasinheritedthemutationfrom
thefather.Itisfarmoredifficulttoconfirminheritanceofamaternalmutationasthiswould
obviouslybedetectedinherblood.Differentmethodstodetectinheritanceofmaternalmutations
andcaseswherebothparentshavethesamerecessivemutationarebeingresearched.Althougha
numberofcommercialservicesofferingtrisomy21detectionbyNIPDareavailable,thetechniqueis
stillbeingevaluatedbeforeitisbroughtintoroutineuseintheNHS.NIPDforbothachondroplasia
andthanatophoricdysplasiaarealsocurrentlyofferedonaresearchbasis.Thisalsoincludestesting
inmultiplepregnanciesifthereareultrasoundfindingsthatsuggestonetwinisaffected.


Question200

Chorionicityisoneofthebestdeterminantsofriskinatwinpregnancy.Whichofthefollowing
statementsistrueregardingdeterminingthechorionicityofatwinpregnancy?

Answer200

E) Ifthisremainsuncertainthepregnancyshouldbemanagedasmonochorionic

Anearlyscaninthefirsttrimestermayshowentirelyseparateplacentalmassesintwinpregnancies,
suggestingstronglydichorionicity.However,thisisnotalwaysthecase,andascanbetween10and
14weeksisthoughttobethemostreliablefordeterminingchorionicity.Evenwhenalambdasignis
identified,thisisnotanabsoluteindicationofdichorionicity,althoughthesensitivityisveryhigh.
Determiningchorionicityat20weekscanbeverydifficultasthelambdasignmaynolongerbe
present.Discordantexternalgenitaliastronglysuggestdichorionicity,althougheventhisisnotan
absoluteasambiguousgenitaliacanmakeamalefetusappearfemale.Ifthefetusesarethesame
genderthisprovidesnocluesatalltothechorionicity.Athinintertwinmembraneof<2mm
suggestsmonochorionicity,butthereissignificantoverlapinthemembranethicknessbetween
monoanddichorionictwinpregnancies.Ifthereisdoubt,itwouldbebettertomanagethe
pregnancyasmonochorionic.ZygositytestingcanbecarriedoutbylookingatDNApolymorphisms
ineachfetus,butthisrequiresinvasivetesting(amniocentesis)andisrarelyindicated.

Question201

Avarietyofgeneticandchromosomaldiseasescanbedetectedusingpreimplantationgenetic
diagnosis.WhichofthefollowingisNOTarecogniseduseofthistechnique?

Answer201

E) Familybalancing

AwidespectrumofchromosomalandsinglegenedisorderscanbepotentiallydiagnosedusingPGD,
althoughthelaboratorystandardsrequiredarehighlyexacting.Itisnotethicallyappropriatetouse
PGDtogenderselectoffspringwherethepurposeisforsocialsexselection,andwherethereisno
medicalbenefitinhavingachildofaparticularsex.

Extended Matching Questions

Question202
FromthelistofstatisticaltermsAK,choosethemostappropriateoneforeachofthedescriptions
detailedinquestionsi)tov).

i) Theabilityofascreeningtesttoidentifyunaffectedindividuals
ii) Thelikelihoodthatanindividualscreenedpositivefortheconditionactuallyhasthedisease
iii) Theproportionofindividualswhoscreenpositivebutdonotactuallyhavethecondition
iv) Theproportionofthescreenedpopulationwhohaveapositiveresult
v) Theabilityofatesttoidentifyaffectedindividuals

Answer202

i) K.Specificity
ii) B.Positivepredictivevalue
iii) J.Falsepositiverate
iv) D.Thescreenpositiverate(Falsepositivesplustruepositives)
v) A.Sensitivity

Question203
Fromthelistbelow(AJ),choosewhichdisorder(s)bestfit(s)thestatements(iii)thatfollow.Each
optionmaybeusedonce,morethanonceornotatall.

i) Autosomaldominantdisorder(s)forwhichPGDispossible.
ii) Mitochondrialdisorder(s)forwhichPGDispossible.
iii) Disorder(s)notsuitableforPGD.
iv) AutosomalrecessiveconditionsamenabletoPGD

Answer203
i)D.Huntingtonsdiseaseistheonlyautosomaldominantconditioninthislist.
ii)E.MELASsyndromeisamitochondrialdisorder.
iii)FandJ.RaynaudsandCRESTsyndromesarenotsinglegenedisordersandarethereforenot
suitableforPGD.
iv)A,B,andI.Betathalassaemia,cysticfibrosisandsicklecelldiseaseareallautosomalrecessive
diseasesamenabletoPGD.

Multiple Choice Questions

Question204

InDownsyndromepregnancies

A) TheserumHCGtendstobehigherthannormal
B) Theawaveintheductusvenosusismorelikelytobepositive
C) Tricuspidregurgitationiscommon
D) Thenasalboneiscommonlyabsentorhypoplastic
E) PAPPAlevelstendtobehigherthannormal

Answer204

A) True
B) False
C) True
D) True
E) False

InDownsyndromepregnancies,maternalserumHCGlevelstendtobehigherandPAPPAlevels
lowerthaninnormalpregnancies.Absentorhypoplasticnasalbone,tricuspidregurgitationand
reversaloftheawaveintheductusvenosusareallmuchmorecommoninDownsyndrome
pregnancies.

Question205

Withregardtochickenpoxinpregnancy:

A) Cardiacdefectsarethemostcommonteratogeniceffect
B) Thediseaseisonlyinfectiousoncetherashappears
C) Over90%ofUKwomenareimmunetochickenpox
D) Theriskofvaricellaembryopathyisgreaterwithmaternalinfectionat16weeksthan
at8weeksgestation
E) Therisktothebabyisminimalwithmaternalinfectionsoccurringatterm

Answer205

A) False
B) False
C) True
D) True
E) False

Abnormalitiesoftheeyes,skin,limbsandcentralnervoussystemarecharacteristicofvaricella
embryopathy.Fortunately,thisisuncommonwithmaternalinfections,affecting1%ofpregnancies
below13weeksand2%ofpregnancieswherethemotherdevelopschickenpoxbetween13and20
weeks.After20weeks,thefetusisnotatriskofteratogeniceffects;however,latematernal
infectionsoccurringupto4weeksbeforethebirth,or7daysafter,carryahighchanceofneonatal
varicella,anotherverydangerousanddamagingmanifestationofverticaltransmission.
Unfortunatelythediseaseisinfectiousbeforetherashdevelops;however,90%ofwomenintheUK
arevaricellaimmune,includingmanywhobelievetheyhaveneverhadchickenpox.Varicella
immunoglobulincanbeadministeredtononimmunewomenwhohavebeeninclosecontactwith
someonewhohas,orsoonafterdevelops,chickenpoxandthismayprotectthem,andtheirfetus,
againstinfection.Evenifchickenpoxdoesneverthelessdevelopthereisreasontobelievethatthe
VZIGmayhelpprotectthefetusagainstembryopathy.

Question206
Regardingnonalloimmunethrombocytopaenia(NAIT):

A) ItismostcommonlycausedbyantibodiesbindingtoglycoproteinIIaIIIa
B) Itisaclinicaldiagnosismadebyexcludingothercausesofneonatalthrombocytopaenia
C) Itwillalwaysrecurinfuturepregnancies
D) Complicationsaremostcommonlypreventedbyuseofimmunoglobulins
E) ManagementmaybeassistedbyfreefetalDNAstudies

Answer206

A) False
B) False
C) False
D) True
E) True

AntibodiesagainsttheplateletglycoproteinIIbIIIacomplexcauseITP.ItisantibodiesagainstHuman
PlateletAntigen1a,andlesscommonly5b,thatareresponsibleforNAIT.Thediagnosisismost
securelymadebyfindingantibodiesagainstHPA1aor5binmaternalserum,inthesettingof
neonatalthrombocytopaenia(intheabsenceofotherobviouscauses).
NAITwillonlyrecurifthefetushasplateletsexpressingtheantigenagainstwhichtheantibodies
bind.IfthefatherofthenextbabyisHPA1anegative,forexample,orheterozygous,thefetuswill
eitherdefinitelybeHPA1anegativeoratonly50%riskofbeingpositive.Whereafetusisatonly
50%riskofbeingHPA1apositive,freefetalDNAtestingcannowbeemployedtoascertaintheHPA
1astatusatanearlypointinthepregnancy.IfthefetusisHPA1anegative,nosteroidsor
immunoglobulinswillneedtobeadministeredtothewoman,andnofetalbloodsamplingrequired.
ImmunoglobulinsareprovingtobethemainstayoftreatmentforNAIT,bothduringpregnancyand
intheneonatalperiod.Fetalplatelettransfusionsareusedfarlessfrequentlynow,andplateletsare
usuallygiventothenewborninassociationwithintravenousimmunoglobulins.

Question207

Twintotwintransfusion:

A) Occursin1730%ofmonochorionictwinpregnancies
B) Canbediagnosedbydiscordantliquorvolumes
C) Isbesttreatedbyserialamniodrainage
D) CanbeclassifiedusingtheQuinteroclassification
E) Canbemanagedbyselectivecordocclusion

Answer207

A) False
B) True
C) False
D) True
E) True

Twintotwintransfusionsyndrome(TTTS)affects1in5to1in6monochorionictwinpregnancies
andisdiagnosedbydiscordantliquorvolumes,discordantfetalsizeandabnormalDopplerblood
flows.TheQuinteroclassificationisusedtogradeTTTS,althoughitisrecognisedthatmildTTTS
(stageI)doesnotalwaysprogressinastepwisemannerthroughtostagesIVandV.TheEurofetus
trialshowedthatoutcomesarebetterwhenTTTSistreatedbylaserablationofAVanastamoses,as
comparedwithserialamniodrainage.However,thereremainsuncertaintyaboutthevalueof
treatmentofstageITTTS,andlatergestationcasesofTTTSmaystillbemanagedwith
amniodrainage.Inseverecasestheremaybeextremefetalgrowthrestrictionofoneofthetwins
andselectivecordocclusionmaybeapreferredoptioninthesecases.

Question208

Withregardtotheroutinedetailedanatomyscanat1821weeksgestationinalowriskpopulation:

A) Fourfifthsofallmajoranomalieswillbedetected
B) Theincidenceofmajoranomalieswillbe12%
C) Almostallseriouscardiacabnormalitieswillbedetected
D) Threequartersofallcleftlipswillbedetected
E) Only1in50casesofanencephalyshouldbemissed

Answer208

A) False
B) True
C) False
D) True
E) True

Thebackgroundincidenceofmajorcongenitalabnormalitiesisusuallyquotedasapproximately2%,
althoughthisdoesdependonthedefinitionofmajor.Previousstudiesofroutinescreeninghave
demonstratedverylowdetectionrates(2050%),althoughmorerecentstudiesaremore
encouraging(butdonotreach80%).Improvedmachinesandsonographerskills,withamore
systematicapproachtothedetailedscan,mayberesponsible.Manystudieshaveshownonlya50%
detectionriskforcardiacanomalies,butmanyareoldandbetterfigureshavebeenquoted.Itis
importantthoughthatwomenandtheirpartnersunderstandthelimitsofthescreeningscan.
Approximately3outof4facialcleftsshouldbepickedup,anditshouldbeveryuncommonforan
anencephalytobeoverlooked.

Question209
Folicacid:
A) IsthepopularnameforvitaminB9
B) Isfoundmostlyinredmeat
C) IscrucialinthesynthesisoftheDNAconstituentcytosine
D) Isabsorbedbetterasasupplementthanfromnaturalfoodsources
E) Levelsareaffectedbygeneticvariants

Answer209
A) True
B) False
C) False
D) True
E) True

Folicacidandfolatearethepreferredsynonymsforpteroylglutamicacidandpteroylglutamate,
respectivelyandarebothformsofthewatersolublevitaminB9.Foodslikeleafygreen
vegetables,brusselsprouts,turnipgreens,potatoes,yeast,driedbeans,legumes,orangesand
organfoodssuchasliverarethenaturalsourcesoffolicacid.Folicacidisusedbythehuman
cellsfordenovosynthesisofthymidine,adenineandguanine,threeofthefournucleotides
neededtoassembleDNAinacell.Cookingmaydestroyfolicacid,andabsorptionratesareonly
50%fromnaturalfoodsources.Thefolateinfortifiedfoodsisabsorbedbetter(85%)andallthe
folicacidinvitaminsupplementsisabsorbed.1in6to1in10ofthegeneralpopulationcarrya
variantofthe5,10methylenetetrahydrofolatereductaseenzymeessentialforcatalyzingthe
transferofamethylgrouptohomocysteinetoformmethionineandthiscancompromisethe
tissuefolatelevels.

Question210
ACochraneanalysisconcludesthatpericonceptualfolicacidsupplementationhelpstopreventthe
followingpregnancycomplications:

A) Microcyticmaternalanaemia
B) Neuraltubedefects
C) Cleftlipandpalate
D) Placentalabruption
E) Fetalgrowthrestriction

Answer210
A) False
B) True
C) False
D) False
E) False

Folicaciddeficiencyhasbeenassociatedinanumberofstudieswithavarietyofcomplications
andcongenitalanomaliesotherthanjustneuraltubedefectsandmegaloblasticmaternal
anaemia.However,arecentCochraneanalysisdidnotfindbeneficialeffectsontheratesof
craniofacialabnormalitiesorplacentalproblemsinwomenwhousedfolicacid
supplementation.

Question211
Thefollowinggroupsofwomenshouldbeadvisedtotake5mgofpericonceptualfolicacid:

A) Thosewithahistoryofapregnancywithfetalmyelomeningocoele
 B) Thosewithahistoryofgestationaldiabetes
C) WomenwithaBMIgreaterthan30
D) Thosewithapreviouspregnancycomplicatedbycongenitalheartdisease
E) Alcoholabusers

Answer211
A) True
B) False
C) True
D) False
E) True

Avarietyofriskfactorsarerecognisedforfolicaciddeficiency,includingobesityandalcohol
misuse,alongwiththeuseofanumberofmedications,e.g.antiseizuredrugs,trimethoprim
andmethotrexate.Otherwomenareatincreasedriskofhavingapregnancycomplicatedby
aneuraltubedefect(e.g.previoushistoryandthosewithpreexistingdiabetes)andshould
alsotakethehigherdoseofsupplements.Althoughcongenitalheartdiseasehasbeen
associatedwithfolicaciddeficiency,thereisnodefinitecausallinkandthereisnonational
advicecurrentlythatwomenwithahistoryofcongenitalheartdiseaseintheiroffspring
shouldtakethehigherdoseregime.

Question212

RegardingDopplersinfetalgrowthrestriction(FGR):

A) TheumbilicalarteryDopplervaluesusuallyliewithinthenormalrangeinlateonset
FGR
B) MiddlecerebralarteryDopplerPulsatilityIndex(PI)increasesinFGR
C) AhighcerebroumbilicalDopplerindexisreassuring
D) ChangesintheuterinearteryDopplervaluesoccurlate
E) ChangesintheMCADopplerPIareakeydeterminantinthetimingofdeliveryofearly
pretermgrowthrestrictedfetuses

Answer212
A) True
B) False
C) True
D) False
E) False

Atleast30%ofplacentalfunctionmustbelostbeforetheumbilicalarteryDopplerresistancevalues
begintorisesignificantly.Itisrareforlateonsetfetalgrowthrestrictiontobeheraldedbyabnormal
umbilicalarteryDopplerrecordings.However,cerebralvasodilatationdoesoccurinbothearlyand
latefetalgrowthrestrictionandthiscausesafallintheresistancepicturewithinthemiddlecerebral
artery.Bycombiningtheshiftsinthesevalues(thecerebroumbilicalorcerebroplacentalratio),late
fetalgrowthrestrictionmaybemoresensitivelydetected,whentheindexvaluedecreasesbelow1.
UterinearteryDopplermeasurementshelptopredictgrowthrestrictionwellbeforeitismanifested
throughfetalbiometryorfetalDopplerchanges,buttheyarenotusefulformonitoringFGR.With
earlyonsetFGR,timingofdeliveryisusuallybasedonvenousDopplerchanges,computerisedCTG
analysisofshort termvariability,orumbilicalarteryabsentorreversedflow.