6 June 2016.
|
11
|
SBA. AMH.
|
|
12
|
EMQ. Parvovirus
|
|
13
|
EMQ. Mental Capacity Act
|
|
14
|
SBA. Cowden syndrome
|
11. SBA. AMH.
Abbreviations.
AFC: antral follicle count
AFP: antral follicle pool
AMH: anti-Müllerian
hormone
COC: combined
oral contraceptive
COS: controlled
ovarian stimulation
GnRHA: gonadotrophin
releasing hormone analogue
PCOS: polycystic
ovary syndrome
POF: premature
ovarian failure
SHBG: sex
hormone binding globulin
Question 1.
Lead-in
Which of
the following statements best describes AMH.
Option List
|
A.
|
AMH is a
GnRH analogue
|
|
B.
|
AMH is a decapeptide
|
|
C.
|
AMH is an octopeptide
|
|
D.
|
AMH is a glycoprotein
|
|
E.
|
AMH is an aromatase inhibitor
|
Question 2.
Lead-in
Option List
From whom
does the word “Müllerian” originate?
|
A.
|
Andreas
John Müller
|
|
B.
|
Johannes Peter Müller
|
|
C.
|
Heinrich Müller
|
|
D.
|
Jacob Müllerian
|
|
E.
|
Peter Müllerian.
|
Question 3.
Lead-in
Where is
AMH produced?
Option List
|
A.
|
anterior
pituitary
|
|
B.
|
granulosa cells
|
|
C.
|
granulosa and Leydig cells
|
|
D.
|
granulosa and Sertoli cells
|
|
E.
|
Sertoli cells
|
Question 4.
Lead-in
What is
the story about AMH and Swyer’s syndrome in the fetus?
Option List
|
A.
|
AMH and
testosterone are produced in normal amounts
|
|
B.
|
AMH and
testosterone are produced at about half the normal levels
|
|
C.
|
AMH is
produced in normal amounts; testosterone is deficient
|
|
D.
|
AMH is
deficient; testosterone is produced in normal amounts
|
|
E.
|
AMH and
testosterone are both deficient
|
Question 5.
Lead-in
Which of
the following statements best apply to AMH and the female?
Option List
|
A.
|
ovarian
granulosa cells produce AMH from 20 weeks’ gestation and production continues throughout life
|
|
B.
|
ovarian granulosa cells produce AMH from 36 weeks’
gestation and production continues throughout life
|
|
C.
|
ovarian granulosa cells produce AMH from 20 weeks’
gestation and production continues until puberty
|
|
D.
|
ovarian granulosa cells produce AMH from 20 weeks’ gestation and production
continues until the menopause
|
|
E.
|
ovarian granulosa cells produce AMH from 36 weeks’
gestation and production continues until the menopause
|
Question 6.
Lead-in
Where is
AMH mostly produced?
Option List
|
A.
|
granulosa
cells of pre-antral and small antral follicles
|
|
B.
|
granulosa cells of the dominant follicle
|
|
C.
|
granulosa cells of primordial follicles
|
|
D.
|
corpus luteum
|
|
E.
|
anterior pituitary
|
Question 7.
Lead-in
What is
the relationship between AMH and the AFP?
Option List
|
A.
|
AMH
levels correlate well with the AFP
|
|
B.
|
AMH levels fluctuate throughout the menstrual cycle and
only correlate with the AFP between days 1 and 5
|
|
C.
|
AMH levels fluctuate throughout the menstrual cycle and
only correlate with the AFP about 7 days before menstruation
|
|
D.
|
AMH is inversely proportional to the AFP
|
|
E.
|
AMH does not correlate well with the AFP.
|
Question 8.
Lead-in
What is
the relationship between a woman’s reproductive potential and her age?
Option List
|
A.
|
Reproductive
potential is directly proportional to age
|
|
B.
|
Reproductive potential is inversely proportional to age
|
|
C.
|
Reproductive potential declines with age
|
|
D.
|
Reproductive potential declines exponentially with age
|
|
E.
|
Reproductive potential declines linearly with age
|
Question 9.
Lead-in
What is
the main effect of AMH in the female fetus?
Option List
|
A.
|
promotion
of the development of the para-mesonephric system
|
|
B.
|
promotion of the development of the mesonephric system
|
|
C.
|
suppression of the development of the para-mesonephric
system
|
|
D.
|
suppression of the development of the mesonephric
system
|
|
E.
|
none of the above
|
Question 10.
Lead-in
What is
the main effect of AMH in the male fetus?
Option List
|
A.
|
promotion
of the development of the para-mesonephric system
|
|
B.
|
promotion of the development of the mesonephric system
|
|
C.
|
suppression of the development of the para-mesonephric system
|
|
D.
|
suppression of the development of the mesonephric
system
|
|
E.
|
none of the above
|
Question 11.
Lead-in
What is
the main role of AMH in the woman of reproductive years?
Option List
|
A.
|
acts to encourage primordial follicles to mature and
join the pool of antral follicles
|
|
B.
|
acts to prevent primordial follicles maturing and
joining the pool of antral follicles
|
|
C.
|
is the trigger for the LH surge and ovulation
|
|
D.
|
maintains the corpus luteum
|
|
E.
|
none of the above
|
Question 12.
Lead-in
What is
the main effect of AMH on FSH within the ovary?
Option List
|
A.
|
it acts
to increase the effect of FSH
|
|
B.
|
it acts synergistically with FSH
|
|
C.
|
it acts to decrease the effect of FSH
|
|
D.
|
it blocks the effect of FSH
|
|
E.
|
none of the above
|
Question 13.
Lead-in
When is the
best time to measure AMH in a woman whose menstrual cycles are 28 days long?
Option List
|
A.
|
days 1 –
5
|
|
B.
|
days 6 – 10
|
|
C.
|
days 11 – 15
|
|
D.
|
about day 21
|
|
E.
|
none of the above
|
Question 14.
Lead-in
What is
the significance of low AMH levels?
Option List
|
A.
|
indicative of reduced AFP
|
|
B.
|
indicative of reduced AFP and ovarian reserve
|
|
C.
|
indicative of hyperprolactinaemia
|
|
D.
|
indicative of PCOS
|
|
E.
|
indicative of POF
|
Question 15.
Lead-in
What is
the significance of raised AMH levels?
Option List
|
A.
|
indicative of increased AFP and ovarian reserve
|
|
B.
|
indicative of reduced AFP and ovarian reserve
|
|
C.
|
indicative of hyperprolactinaemia
|
|
D.
|
indicative of PCOS
|
|
E.
|
indicative of POF
|
Question 16.
Lead-in
What
happens to AMH levels in pregnancy?
Option List
|
A.
|
levels
fall with conception due to follicular suppression and become normal with the
return of ovulation after delivery
|
|
B.
|
levels remain normal until about 12 weeks, then
decline, returning to normal in the early puerperium
|
|
C.
|
levels remain normal until about 20 weeks, then
decline, returning to normal in the early puerperium
|
|
D.
|
levels remain normal until about 12 weeks, then
decline, returning to normal with the return of ovulation after delivery
|
|
E.
|
none of the above
|
Question 17.
Lead-in
A woman
takes a COC for 3 months. What is the likely effect on her AMH levels?
Option List
|
A.
|
no
significant effect
|
|
B.
|
reversible reduction
|
|
C.
|
irreversible reduction
|
|
D.
|
reduction to undetectable levels
|
|
E.
|
none of the above
|
Question 18.
Lead-in
A woman
takes a COC for 18 months. What is the likely effect on her AMH levels?
Option List
|
A.
|
no
significant effect
|
|
B.
|
reversible reduction
|
|
C.
|
irreversible reduction
|
|
D.
|
reduction to undetectable levels
|
|
E.
|
none of the above
|
Question 19.
Lead-in
A woman
uses a GnRHA for 3 months. What is the likely effect on her AMH levels?
Option List
|
A.
|
no
significant effect
|
|
B.
|
reversible reduction
|
|
C.
|
irreversible reduction
|
|
D.
|
reduction to undetectable levels
|
|
E.
|
none of the above
|
Question 20.
Lead-in
A woman
uses a GnRHA for 18 months. What is the likely effect on her AMH levels?
Option List
|
A.
|
no
significant effect
|
|
B.
|
reversible reduction
|
|
C.
|
irreversible reduction
|
|
D.
|
reduction to undetectable levels
|
|
E.
|
none of the above
|
Question 21.
Lead-in
Which of
the following statements is correct?
Option List
|
A.
|
ART is
futile and should be declined in women with AMH levels < 0.1 mcg/l
|
|
B.
|
ART is futile and should be declined in women with AMH
levels < 0.5 mcg/l
|
|
C.
|
ART is futile and should be declined in women with AMH
levels < 1 mcg/l
|
|
D.
|
ART is futile and should be declined in women with AMH
levels < 5 mcg/l
|
|
E.
|
none of the above
|
Question 22.
Lead-in
Which, if
any, of the following statements is the most accurate in relation to AMH as a
marker for ovarian reserve?
Statements
|
A.
|
AMH is equivalent
to AFC as a marker for ovarian reserve
|
|
B.
|
AMH is inferior to AFC as a marker for ovarian reserve
|
|
C.
|
AMH is superior to AFC as a marker for ovarian reserve
|
|
D.
|
AMH is inferior to FSH & inhibin B assay as a
marker for primordial follicle numbers
|
|
E.
|
AMH is superior to FSH & inhibin B assay as a
marker for primordial follicle numbers
|
Option List
|
1
|
A + D
|
|
2
|
A + E
|
|
3
|
B + D
|
|
4
|
B + E
|
|
5
|
C + D
|
|
6
|
C + E
|
Question 23.
Lead-in
Which, if
any, of the following statements is true in relation to reduced ovarian reserve?
Statements
|
A.
|
AFC
<10 from both ovaries is indicative
|
|
B.
|
day 2 FSH <10 u/l is indicative
|
|
C.
|
ovarian volume <10 cm3 is indicative
|
|
D.
|
AFC and ovarian volume are accurate markers
|
|
E.
|
↓ AMH levels are indicative
|
Option List
|
1
|
A + B +
C + D + E
|
|
2
|
A + D + E
|
|
3
|
B + C + D
|
|
4
|
C + D + E
|
|
5
|
D + E
|
Question 24.
Lead-in
Which of
following statements is true about predicting the age at the menopause?
Option List
|
A.
|
FSH
>30 u/l in the early follicular phase is the most useful predictor
|
|
B.
|
pre-auricular
dermal elasticity is the most useful predictor
|
|
C.
|
the
woman’s mother’s age at the menopause is the most useful predictor
|
|
D.
|
the AMH
level is the most useful predictor
|
|
E.
|
the AMH
level in conjunction with the woman’s age is the most useful predictor
|
Question 25.
Lead-in
Which of
the following statements are true of AMH levels and response to fertility
treatment?
Statements
|
A.
|
AMH
levels are strong indicators of the quantitative response to COS
|
|
B.
|
AMH levels help with tailoring COS protocols to the
individual
|
|
C.
|
about 10% of women have a poor response to COS
|
|
D.
|
high AMH levels justify the use of lower doses of FSH
|
|
E.
|
AMH levels are equivalent to basal FSH & inhibin as
predictors of quantitative response to COS
|
Option List
|
1
|
A + B + C + D + E
|
|
2
|
A + B + C + D
|
|
3
|
A + C + E
|
|
4
|
A + D + E
|
|
5
|
B + C + E
|
|
6
|
B + D + E
|
Question 26.
Lead-in
Which of
the following statements are true in relation to the pre-antral and antral
follicles?
Statements
|
A.
|
antrum
means “door” or “entrance”
|
|
B.
|
“pre-antral”
and “primordial” describe the same follicles
|
|
C.
|
pre-antral follicles show separate granulosa and luteal
layers
|
|
D.
|
pre-antral follicles are readily seen on ultrasound
|
|
E.
|
antral follicles have a fluid-filled cavity
|
Option List
|
1
|
A + B +
C + D + E
|
|
2
|
B + C +
D
|
|
3
|
C + E
|
|
4
|
D + E
|
|
5
|
E
|
Question 27.
Lead-in
Which of
the following statements are true about the incidence of OHSS?
Statements
|
A.
|
the
incidence varies with the type of ovarian stimulation used
|
|
B.
|
mild OHSS occurs in about 30% of conventional IVF
cycles
|
|
C.
|
moderate / severe OHSS occurs in about 1% of
conventional IVF cycles
|
|
D.
|
about 0.3% of women need hospitalisation for OHSS after
IVF
|
|
E.
|
OHSS does not occur with clomiphene use
|
Option List
|
1
|
A + B +
C + D + E
|
|
2
|
A + B +
C
|
|
3
|
A + B +
D + E
|
|
4
|
A + B +
D
|
|
5
|
A + C +
D + E
|
Question 28.
Lead-in
Which of
the following statements is true?
Statements
|
A.
|
basal
AMH levels are increased in PCOS
|
|
B.
|
high basal levels of AMH are linked to an ↑ risk of
OHSS with ovarian stimulation
|
|
C.
|
low basal levels of AMH are linked to an ↑ risk of OHSS
with ovarian stimulation
|
|
D.
|
↑ BMI is linked to an ↑ risk of OHSS with ovarian
stimulation
|
|
E.
|
older age is linked to an ↑ risk of OHSS with ovarian
stimulation
|
Option List
|
1
|
A + B +
D + E
|
|
2
|
A + C +
D + E
|
|
3
|
A + B +
D
|
|
4
|
A + B + E
|
|
5
|
A + C +
D
|
Question 29.
Lead-in
Which of
the following statements are true?
Statements
|
A.
|
there is
evidence of a +ve link between AMH levels and pregnancy rates
|
|
B.
|
there is evidence of a –ve link between AMH levels and
pregnancy rates
|
|
C.
|
AMH levels are a practical means of predicting
pregnancy rates
|
|
D.
|
AMH levels are best used with BMI in predicting
pregnancy rates
|
|
E.
|
AMH levels are best used with FSH levels in predicting
pregnancy rates
|
Option List
|
1
|
A + B +
C + D + E
|
|
2
|
A
|
|
3
|
B
|
|
4
|
C
|
|
5
|
D
|
Question 30.
Lead-in
Which of
the following statements are true?
Option list
|
A.
|
PCOS is
associated with an increased basal AMH level
|
|
B.
|
PCOS is associated with a decreased basal AMH level
|
|
C.
|
elevated AMH levels are included in the diagnostic
criteria for PCOS
|
|
D.
|
reduced AMH levels are included in the diagnostic
criteria for PCOS
|
|
E.
|
PCOS-associated increase in antral follicle numbers
explains the ↑ AMH levels
|
Option List
|
1
|
A + C + E
|
|
2
|
A + D + E
|
|
3
|
B + C + E
|
|
4
|
B + D + E
|
|
5
|
A
|
|
6
|
B
|
|
7
|
C
|
|
8
|
D
|
|
9
|
E
|
Question 31.
Lead-in
Bhide et
al say that women with PCOS can be sub-divided into two groups which do no
overlap on the basis of AMH levels. Which of the following statements is true?
Statements
|
A.
|
Group 1
is linked to high AMH levels, high androgen levels, insensitivity to insulin
and anovulation
|
|
B.
|
Group 1 is linked to lower AMH levels, high androgen
levels, insensitivity to insulin and anovulation
|
|
C.
|
Group 2 is linked to high AMH levels, lower androgen
levels, better sensitivity to insulin and anovulation
|
|
D.
|
Group 2 is linked to lower AMH levels, lower androgen
levels, better sensitivity to insulin and ovulation
|
|
E.
|
None of the above
|
Option List
|
1
|
A + C
|
|
2
|
A + D
|
|
3
|
B + C
|
|
4
|
B + D
|
|
5
|
E
|
12. EMQ. Parvovirus & pregnancy.
Lead-in.
The following scenarios relate to parvovirus infection
Pick one option from the option list.
Each option can be used once, more than once or not at
all.
Abbreviations.
GOVRIP: Guidance
on Viral Rash in Pregnancy. HPA. 2011
PSVMCA: peak
systolic velocity middle cerebral artery.
PvB19: parvovirus
B19
PvIgG: parvovirus B19 IgG
PvIgM: parvovirus B19 IgM
Option list.
There is none: make up your own
answers!
Scenario 1.
What type of virus is
parvovirus?
Scenario 2.
Is the title B19 something to do with the American B19
bomber, its potentially devastating bomb load and the comparably devastating
consequences of the parvovirus on human erythroid cell precursors?
Scenario 3.
PVB19 in the UK occurs in mini-epidemics at 3 – 4 year
intervals, usually during the summer months. Is this true?
Scenario 4.
Which animal acts as the main
reservoir for infection?
Scenario 5.
What percentage of UK adults are immune to parvovirus
infection?
Scenario 6.
What names are given to acute
infection in the human?
Scenario 7.
What is the incubation period for parvovirus infection?
Scenario 8
What is the duration of infectivity for parvovirus
infection?
Scenario 9.
What are the usual symptoms of parvovirus infection in
the adult?
Scenario 10.
What is the incidence of parvovirus infection in
pregnancy?
Scenario 11.
How is recent infection diagnosed?
Scenario 12.
How long does PvIgM persist and why is this important?
Scenario 13.
What is the rate of vertical transmission of parvovirus
infection?
Scenario 14.
Are women with parvovirus infection who are asymptomatic
less likely to pass the virus to their fetuses?
Scenario 15.
To what degree is parvovirus infection teratogenic?
Scenario 16.
What proportion of pregnancies infected with parvovirus
are lost?
Scenario 17.
What is the timescale for the onset of hydrops?
Scenario 18.
Laboratories are advised to retain bloods obtained at
booking for at least 2 years for possible future reference. True or false?
Scenario 19.
What ultrasound features would trigger consideration of
cordocentesis?
Scenario 20.
Must suspected parvovirus infection be notified to the
authorities? Yes or No.
Scenario 21.
Possible parvovirus infection
does not need to be investigated after 20 week’s gestation. True or false?
Scenario 22
If serum is sent to the
laboratory from a woman with a rash in pregnancy for screening for rubella, the
laboratory should automatically test for parvovirus infection too. True or false?
13. EMQ.
Mental Capacity Act 2005.
Lead-in.
The following scenarios relate to the Mental Capacity Act
2005.
Pick one option from the option list.
Each option can be used once, more than once or not at
all.
Abbreviations.
CAD: Court-appointed Deputy.
COP: Court of Protection.
FGR: fetal growth restriction.
LPA: Lasting Power of Attorney.
MCA: Mental
Capacity Act 2005.
PoA: Power of Attorney.
Option list.
A.
Yes
B.
No
C.
True
D.
False
E.
Does not exist
F.
The husband
G.
A parent
H.
The child
I.
the General
Practitioner
J.
the Consultant
K.
the Registrar
L.
The Consultant
treating the patient
M. A Consultant not involved in treating the patient
N.
The Medical Director
O.
A person with Powers
of Attorney
P.
The sheriff or
sheriff’s deputy
Q.
Balance of
probabilities
R.
Beyond reasonable
doubt
S.
None of the above.
Scenario 1.
A person with LPA is normally
not a family member.
Scenario 2.
A Sheriff’s Deputy is normally
not a family member.
Scenario 3.
A person with PoA can consent
to treatment for the patient who lacks capacity.
Scenario 4.
A Court-appointed Deputy can consent to treatment for the
patient who lacks capacity, but must go back to the Court of Protection if
further consent is required for additional treatment.
Scenario 5.
A person with PoA can authorise
withdrawal of all care except basic care in cases of individuals with
persistent vegetative states.
Scenario 6.
An advance decision can
authorise withdrawal of all but basic care in cases of persistent vegetative
states.
Scenario 7
A person with PoA cannot
overrule an advance direction about withdrawal or withholding of
life-sustaining care.
Scenario 8
A woman is seen in the
antenatal clinic at 39 weeks’ gestation. Her blood pressure is 180/110 and she
has +++ of proteinuria on dipstick testing. She has mild epigastric pain. A
scan shows evidence of FGR with the baby on the 2nd. centile.
Doppler studies of the umbilical artery are abnormal and a non-stress CTG shows
loss of variability and variable decelerations. She is advised that she appears
to have severe pre-eclampsia and is at risk of eclampsia and of intracranial
haemorrhage. She is told of the associated risk of mortality and morbidity. She
is also advised that the baby is showing evidence of severe FGR and has
abnormal Doppler studies and CTG which could lead to death or hypoxic damage.
She declines admission or treatment. She says she trusts in God and wishes to
leave her fate and that of her baby in His hands. She is seen by a psychiatrist
who assesses her as competent under the MCA and with no evidence of mental
disorder. The obstetrician wants to apply to the COP for an order for
compulsory treatment. Can he do this?
Scenario 9
A woman is admitted at 36
weeks’ gestation with evidence of placental abruption. She is semi-comatose and
shocked. There is active bleeding and the cervical os is closed. Fetal heart
activity is present but with bradycardia and decelerations. The consultant
decides that Caesarean section is the best option to save her live and that of
the baby. When reading the notes, the registrar comes across an advance notice
drawn up by the woman and her solicitor. It states that she does not wish
Caesarean section, regardless of the risk to her and the baby. The consultant
tells the registrar that they can ignore it now that she is no longer competent
and get on with the Caesarean section for which she will be thankful
afterwards. The registrar says that the advance notice is binding. Who is
correct?
Scenario 10
An 8 year old girl is admitted
with abdominal pain. Appendicitis is diagnosed with peritonitis and surgery is
advised. The parents decline treatment on religious grounds. Can the consultant
in charge overrule the parents and give consent?
14. SBA. Cowden syndrome.
Scenario 1.
Lead in.
Which
feature is associated with Cowden syndrome?
Option list.
A. albinism
B. hamartoma
C. hammer-toe
D. hypertrichosis
E. stammer
Scenario 2.
Lead in. Which condition has the highest risk
of occurrence in women with Cs?
Option list.
A. breast
cancer
B. bowel
cancer
C. congenital
absence of Mullerian tract derivatives
D. hypertension
E. hypothyroidism
Scenario 3.
Lead in. Which gynaecological cancer is a
particular risk for women with Cs?
Option list.
A. Bartholin’s
gland cancer
B. cervical
cancer
C. choriocarcinoma
D. endometrial
cancer
E. vulval
cancer
Scenario 4.
Lead in. Which cancer has increased risk for
men with Cs?
Option list.
A. breast
cancer
B. colon
cancer
C. melanoma
D. renal
cancer
E. thyroid
cancer
F. all
of the above
Excellent effort
ReplyDeleteThank you Shazia. Tom.
ReplyDelete