Tutorial 30th. January 2017

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30 January 2017.

64	EMQ. MBRRACE. Updated to include 2016 Report
65	SBA. Non-invasive testing. NIPT.
66	EMQ. AMH. Anti-Müllerian hormone

64.         MBRRACE & maternal mortality.

MBRRACE. Maternal mortality.

Lead-in.

The following questions relate to MBRRACE and maternal mortality.

Pick one option from the option list.

Each option can be used once, more than once or not at all.

Question 1.    What is the meaning of the acronym MBRRACE-UK”?

Option list.

There is none, to make things more testing.

Question 2.    Which organisation does it replace?

Question 3.    How does it differ structurally from its predecessor?

Question 4.    How will the format of its reports differ from those of its predecessor?

Question 5.    When was MBRRACE’s first Report published?

Question 6.    What was unusual about MBRRACE’s first Report?

Question 7.    What is ICD-MM?

A	ICD-10 as applied to maternal death
B	ICD-11 as applied to maternal death
C	International classification of maternal madness
D	International chocolate delice- Mmmmm!
E	none of the above

Question 8.    When was ICD-MM introduced by MBRRACE?

A	2014
B	2015
C	2016
D	ICD-MM does not exist
E	ICD-MM will be introduced in 2017
F	none of the above

Question 9.    What changes were made to the classification of maternal suicide by MBRRACE?

A	maternal suicide was reclassified as direct death
B	maternal suicide was reclassified as indirect death
C	maternal suicide was reclassified as late death as most occur > 6/52 post-delivery
D	maternal suicide was reclassified as coincidental, as most women were already very ill
E	maternal suicide was reclassified as irrelevant as these women were suicide-likely
F	none of the above

Question 10.  When  were changes made to the classification of maternal suicide by MBRRACE?

A	2014
B	2015
C	2016
D	the changes are planned for 2017
E	no changes have been made and none are planned
F	none of the above

Question 11.  What geographical innovation was included in MBRRACE’s first Report?

Question 12.  What alterations were made to the timings of maternal death to be considered in its Reports?

Question 13.  What was the latest MMR reported by MBRRACE?

Question 14.  How did this compare with the final MMR reported  by CMACE?  

A	MMR was lower, but the difference was not statistically significant
B	MMR was lower and the difference was  statistically significant
C	MMR was higher, but the difference was not statistically significant
D	MMR was higher and the difference was statistically significant
E	MMR was similar

Question 15.  Which topics were reviewed in detail in the first MBRRACE Report?

Question 16.  Which topics were reviewed in detail in the second Report in 2015?

Question 17.  Which topics were reviewed in detail in the third Report in 2016?

Question 18.  Which topics will be reviewed in detail in the fourth Report in 2017?

Question 19.  What is the definition of a maternal death?

Question 20.  What is the definition of a direct maternal death?

Question 21.  What is the definition of indirect maternal death?

Question 22.  What was the leading direct cause of death in the first MBRRACE Report?

Question 23.  What was the leading indirect cause of death in the first Report?

Question 24.  What were the 5 top causes of direct maternal death in the triennium 2011 – 2013?

Question 25.  What observation was made in the first Report about deaths due to hypertensive diseases?

Question 26.  Which condition was linked to 1 in 11 maternal deaths in the first Report in 2014?

Question 27.  What key messages were singled out in the first MBRRACE Report in 2014?

Question 28.  What key messages were singled out in the second MBRRACE Report in 2015?

Question 29.  What key messages were singled out in the third MBRRACE Report in 2016?

Question 30.  What messages relating to critical care were included in the third MBRRACE Report in 2016?

Question 31.  What is the definition of the maternal mortality rate?

Question 32.  What is the definition of a “maternity”?

Question 33.  What is the definition of a live birth?

Question 34.  What is the definition of a stillbirth?

Question 35.  What is the definition of the maternal mortality ratio?

Question 36.  How many maternal deaths were due to cardiac causes in 2012-14?

Question 37.  How many deaths due to cardiac causes were considered in detail in the Confidential Enquiry into cardiac deaths in the 2012-14 Report?

Option list.

A	35
B	48
C	51
D	78
E	108
F	135
G	153
H	178
I	201

Question 38.  Which day was singled out as the most dangerous for cardiac death?

Option list.

A	the day of onset of labour
B	the 24 hours after the administration of a general anaesthetic in labour
C	the 24 hours after the delivery of a baby by Caesarean section
D	the 24 hours after instrumental delivery of a baby
E	the day of delivery
F	the day of delivery after the birth of the baby
G	the first day at home

Question 39.  What percentage of cardiac deaths took place on the day highlighted as the most dangerous?

Option list.

A	5%
B	10%
C	15%
D	20%
E	25%
F	30%

Question 40.  What were the three most common causes of cardiac death recorded in MBRRACE16?

Option list.

A	Aortic dissection
B	Congenital heart disease (CDH)
C	Hypertension
D	Ischaemic heart disease
E	Myocardial disease / cardiomyopathy
F	Other
G	Rheumatic heart disease.
H	SADS/MNH
I	Valvular heart disease

Condition	Number
SADS/MNH	47
Ischaemic heart disease	34
Myocardial disease / cardiomyopathy	27
Aortic dissection	21
Valvular heart disease	11
Other	7
Hypertension	6
Total	153

Question 41.  How many deaths due to congenital heart disease were recorded in MBRRACE16?

Option list.

A	0
B	3
C	5
D	11
E	15
F	24
G	35

Question 42.  What were the main causes of congenital heart disease deaths recorded in MBRRACE16?

Option list.

A	Aortic dissection
B	Aortic rupture
C	Left heart failure
D	Right heart failure
E	Pulmonary artery hypertension
F	Pulmonary vein hypertension
G	Valvular heart disease

Question 43.     Approximately what proportion of the women who died of cardiac disease in MBRRACE16 were known to have cardiac disease before the pregnancy?

Option list.

A	10%
B	20%
C	30%
D	40%
E	50%
F	60%
G	70%
H	80%
I	90%

Question 44.     What other risk factors were noted in MBRRACE16 in relation to the women who died of cardiac causes?

Option list.     There is no option list to make your life harder. But you know the risk factors!

Question 45.  What proportion of the cardiac deaths in MBRRACE16 occurred in ambulances or emergency departments?

Option list.

A	5%
B	10%
C	20%
D	30%
E	40%
F	50%

Question 46.  What “overall messages for future care” in relation to cardiac disease were included in MBRRACE16?

Option list. There is none.

Question 47.  How many deaths occurred due to aortic dissection in 2009-14?

Option list.

A	0
B	3
C	6
D	9
E	15
F	18
G	21
H	24
I	30

Question 48.  Which, if any of the following statements are true in relation to the deaths from aortic dissection in MBRRACE16?

Option list.

A	most occur in late pregnancy / puerperium, the risk being 25 times greater than at other times
B	the most common cause of death is tamponade
C	20 of the deaths involved the descending aorta
D	the classical symptoms are severe chest pain radiating to the back
E	the classical symptoms are severe chest pain radiating to the left arm
F	the classical symptoms are severe chest pain radiating to the neck
G	most cases occurred in women with known aortopathy, especially Marfan’s syndrome
H	surgical repair of congenital, complex coarctation was identified as a risk factor.
I	8 of the 21 women had presented in the days before death but aortic dissection had not been considered
J	42% of the women died at home or before reaching the emergency department.
K	better care might have made a difference to the outcome in almost 60% of cases.

Question 49.  What were the “Key messages” about cardiovascular disease in MBRRACE16?

Option list.     There is none. Write as many as you know.

Question 50.     Acute coronary syndrome. I have written an EMQ about myocardial infarction. It has data from the UKOSS survey. https://www.ncbi.nlm.nih.gov/pubmed/22127355 and https://www.npeu.ox.ac.uk/research/ukoss-myocardial-infarction-136. I’ll add the data from MBRRACE 16 and put it in one of the tutorials..

Question 51.     Approximately how many women died of myocardial disease / cardiomyopathy?

Option list.

A	5
B	10
C	15
D	20
E	25

Question 52.     Approximately how many women died of peripartum cardiomyopathy?

Option list.

A	5
B	10
C	15
D	20
E	25

Question 53.     What type of cardiomyopathy is peripartum cardiomyopathy?

Option list.

A	congenital cardiomyopathy
B	dilated cardiomyopathy
C	hypertrophic cardiomyopathy
D	obesity-related cardiomyopathy
E	restrictive cardiomyopathy

Question 54.     With regard to cardiomyopathy, which symptom is singled out in MBRRACE 16 as particularly needing full investigation?

Option list.

A	angina
B	“drop” attacks
C	dyspnoea
D	nocturnal sweats
E	palpitations

Question 55       Which of the following are especially problematic for women with hypertrophic cardiomyopathy?

Option list.

A	bradycardia
B	epilepsy
C	hyperglycaemia
D	hypertension
E	hypotension
F	tachycardia

Question 56.     MBRRACE 16 records that investigation ceased once a particular diagnosis had been excluded in a number of cases of cardiovascular compromise and the women died later of undiagnosed cardiac disease. What was the diagnosis?

Option list.

A	acute coronary syndrome
B	aortic stenosis
C	atrial fibrillation
D	pulmonary embolism
E	ventricular fibrillation

Question 57.     When are women with peripartum cardiomyopathy most likely to die?

Option list.

A	1st. trimester
B	2nd. trimester
C	3rd. trimester
D	1st. stage of labour
E	2nd. stage of labour
F	3rd. stage of labour
G	1st. 24 hours after delivery
H	in the puerperium
I	from 6 weeks to 1 year after the delivery

Question 58.     Which, if any, of the following statements are true  in relation to obesity-related cardiomyopathy (ORC) ?

Option list.

A	ORC is not a recognised condition
B	MBRRACE16 reported 2 deaths from ORC
C	ORC is associated with cardiac enlargement
D	ORC is associated with fatty infiltration of the ventricular muscle
E	is characterised by myocyte depletion and left ventricular hypoplasia
F	is characterised by myocyte hypertrophy and left ventricular hypertrophy

Question 59.     How many deaths were due to valvular heart disease ?

Option list.

A	1
B	2
C	3
D	4
E	5
F	6
G	7
H	8
I	9
J	10
K	11

Question 60.     Why am I going to write a separate EMQ on valvular heart disease?

Option list.

A	I am now bored with this topic
B	I find it so fascinating that I feel it deserves its own EMQ
C	I don’t know enough about it and need to do some research
D	UKOSS conducted a study from 2013 – 2015 and this needs to be included
E	none of the above.

Question 61.     What were the key messages re hypertensive disease in MBRRACE16?

Option list. There is none. Write as many as you can think of.

Question 62.     How many deaths due to hypertensive disease occurred in 2009-14?

Option list.

A	2
B	5
C	14
D	20
E	23

Question 63.     Which, if any, of the following was the most common cause of death from hypertensive disease in 2009-14?

Option list.

A	acute fatty liver of pregnancy
B	eclampsia / cerebral oedema
C	haemorrhage due to thrombocytopenia
D	HELLP /hepatic necrosis
E	hepatic rupture
F	intracranial haemorrhage
G	left ventricular failure
H	pulmonary oedema

Question 64.     Which, if any, of the following conditions does MBRRACE16 say are usually attributable to poor fluid management?

Option list.

A	acute fatty liver of pregnancy
B	eclampsia / cerebral oedema
C	haemorrhage due to thrombocytopenia
D	HELLP /hepatic necrosis
E	hepatic rupture
F	intracranial haemorrhage
G	left ventricular failure
H	pulmonary oedema

Question 65.     What upper gestational limit was used by MBRRACE16 in the definition of early pregnancy?

Option list.

A	10 weeks
B	12 weeks
C	16 weeks
D	18 weeks
E	20 weeks
F	24 weeks
G	26 weeks

Question 66.     Which of the following ranked top in the causes of death < 24 weeks?

Option list.

A	Cardiac
B	Ectopic
C	Haemorrhage
D	Mental health problems
E	Miscarriage
F	Sepsis
G	Thrombosis & thrombo-embolism
H	TOP

Question 67.     Why did MBRRACE recommend FAST for women presenting to emergency departments with pulmonary embolism in the list of differential diagnoses?

Option list.

A	to exclude aortic dissection before thrombolysis
B	to exclude acute coronary syndrome before thrombolysis
C	to exclude intra-peritoneal bleeding from ectopic pregnancy before thrombolysis
D	to exclude intra-uterine pregnancy before thrombolysis
E	to exclude Bornholm disease before thrombolysis

Question 68.     What were the key messages in relation to early pregnancy deaths?

Option list. There is none. Write as many as you can think of.

Question 69.     What proportion of pregnant / recently delivered women needing critical care survive?

Option list.

A	50%
B	60%
C	70%
D	80%
E	90-94%
F	≥ 95%

Question 70.     MBRRACE16 looked at the cause of death in 144 women admitted to critical care from 2009-14. What was the most common cause of death?

Option list.

A	Amniotic fluid embolism
J	Anaesthetic
I	Cardiac
L	Coincidental
B	Early pregnancy death
D	Haemorrhage
E	Neurological
K	Other indirect
C	PET / eclampsia
H	Psychiatric
G	Sepsis
F	Thrombosis / thrombo-embolism
M	Unascertained

Question 71.     What are the key facts to remember about critical care?

Option list. There is none. Write what you think are the key facts and numbers.

Question 72.     What “red flags” does MBRRACE highlight in relation to maternal sepsis?

Option list. There is none.

Question 73.     What were MBRRACE16’s “key messages” for critical care?

Option list. There is none: write your own.

65.         SBA. Non-invasive testing.

Non-invasive prenatal testing. NIPT.

Question 1.

Lead-in

What is the definition of NIPT?

Option List

A.	any test to detect fetal anomaly, disease or significant problem that does not involve invasive testing of the mother
B.	any test to detect fetal anomaly, disease or significant problem that does not involve invasive testing of the mother, excluding TVS
C.	any test for fetal chromosomal anomaly that does not involve invasive testing of the mother
D.	any test for fetal chromosome or genetic anomaly that does not involve invasive testing of the mother.
E.	none of the above

Question 2.

Lead-in

What is the potential of NIPT using cffDNA and DNA?

Option List

A.	description of the full fetal genome
B.	description of the full fetal genome with the exception of disorders arising from mitochondrial DNA
C.	description of the full fetal genome with the exception of disorders arising from mitochondrial RNA
D.	description of the full fetal genome and most structural anomalies
E.	none of the above

Question 3.

Lead-in

Which, if any,  of the following statements is true?

Option List

A.	cffDNA is found in maternal serum in greater quantities than maternal cell-free DNA
B.	cffDNA is found in maternal serum in  lesser quantities than maternal cell-free DNA
C.	the quantity of cffDNA rises throughout pregnancy, peaking at delivery
D.	cffDNA diminishes after placental delivery but remains detectable for at least 6 weeks
E.	cffDNA diminishes after placental delivery but remains detectable for at least 1 year

Question 4.

Lead-in

Which, if any, of the following statements is true about cffDNA in maternal blood?

Statements.

1.       cffDNA originates in the placenta, not the fetus

2.       cffDNA originates in fetal squames

3.       cffDNA originates in fetal blood cells

4.       cffDNA occurs in maternal blood due to trans-membrane osmosis

5.       cffDNA occurs in maternal blood due to feto-maternal transfusion

Option List

A.	1
B.	2
C.	3
D.	4
E.	5
F.	1 + 4
G.	2 + 4
H.	2 + 5
I.	3 + 5

Question 5.

Lead-in

Which. if any, of the following statements are true?

Statements.

1.       tests using cffDNA are based on detecting paternally-derived fetal DNA in maternal blood.

2.       tests using cffDNA are based on detecting maternally-derived fetal DNA in maternal blood.

3.       tests using cffDNA are based on detecting DNA from the fetal Y chromosome.

4.       tests using cffDNA may involve shotgun sequencing.

5.       tests using cffDNA may involve shotgun nuptials.

Option List

A.	1
B.	2
C.	3
D.	4
E.	5
F.	1 + 4
G.	1 + 5
H.	2 + 4
I.	2 + 5
J.	3 + 4
K.	3 + 5

Question 6.

Lead-in

Which. if any, of the following statements are true?

Option List

A.	detection of the SRY sequence in cffDNA means that the fetus is female
B.	detection of the SRY sequence in cffDNA means that the fetus is male
C.	detection of the SRY sequence in cffDNA means that the fetus is male unless it has a DSD
D.	detection of the SRY sequence in cffDNA means that the fetus has Klinefelter’s syndrome
E.	detection of the SRY sequence in cffDNA means that the fetus has 45X0/46XY mosaicism.

Question 7.

Lead-in

Which. if any, of the following statements are true?

Option List

A.	Rhesus D status can be determined accurately from 12 weeks’ gestation using cffDNA
B.	Rhesus D pseudogene is more common in Africans than Caucasians
C.	People with the RhD pseudogene are at risk of isoimmunisation.
D.	People with the RhDu blood type may be identified as Rh-ve or Rh+ve on routing testing
E.	People with the RhDu blood type are particularly prone to isoimmunisation

Question 8.

Lead-in

Which. if any, of the following statements are true in relation to cffDNA in maternal blood?

Option List

A.	Checking the fetal RhD status is best left until > 16 weeks’ gestation
B.	Checking the fetal Kell status is not yet routinely available
C.	Checking the fetal Kell status is best left until > 20 week’s gestation
D.	Routine screening of Rh –ve women for fetal RhD status reduces the use of RAADP by up to 10%
E.	Routine screening of Rh –ve women for fetal RhD status reduces the use of RAADP by up to 40%

Question 9.

Lead-in

List the other situations in which cffDNA in maternal serum can be used for clinical benefit.

Other questions.

1.     cffDNA levels in maternal blood are raised in pregnancies affected by Down’s syndrome.

2.     screening for Down’s syndrome using cffDNA has both sensitivity and specificity close to 100%

3.     What is the value of cffDNA in women at risk of having a baby with CAH?

5.     What is the role of amniocentesis if a cffDNA screen for a condition such as cystic fibrosis proved +ve?

6.     cffDNA screening for achondroplasia and thanatophoric dysplasia is now available on the NHS for women at risk of an affected baby.

7.     What is meant by “contingent” screening using cffDNA in relation to Down’s syndrome?

8.     What is an “allele”?

9.     What is a “wild-type” allele?

10.   What is the alternative to a “wild-type” allele?

66.         EMQ. AMH.

Question 1.

Lead-in

Which, if any, of the following statements best describes AMH.

Option List

F.	AMH is a GnRH analogue
G.	AMH is a decapeptide
H.	AMH is an octopeptide
I.	AMH is a glycoprotein
J.	AMH is an aromatase inhibitor

Question 2.

Lead-in

Option List

From whom does the word “Müllerian” originate?

F.	Andreas John Müller
G.	Johannes Peter Müller
H.	Heinrich Müller
I.	Jacob Müllerian
J.	Peter Müllerian.

Question 3.

Lead-in

Where is AMH produced?

Option List

F.	anterior pituitary
G.	granulosa cells
H.	granulosa and Leydig cells
I.	granulosa and Sertoli cells
J.	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, if any, 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

L.	granulosa cells of pre-antral and small antral follicles
M.	granulosa cells of the dominant follicle
N.	granulosa cells of primordial follicles
O.	corpus luteum
P.	anterior pituitary

Question 7.

Lead-in

What is the relationship between AMH and the AFP?

Option List

F.	AMH levels correlate well with the AFP
G.	AMH levels fluctuate throughout the menstrual cycle and only correlate with the AFP between days 1 and 5
H.	AMH levels fluctuate throughout the menstrual cycle and only correlate with the AFP about 7 days before menstruation
I.	AMH is inversely proportional to the  AFP
J.	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

F.	Reproductive potential is directly proportional to age
G.	Reproductive potential is inversely proportional to age
H.	Reproductive potential declines with age
I.	Reproductive potential declines exponentially with age
J.	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, if any, 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

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

Question 24.

Lead-in

Which, if any, 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, if any, 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

Question 26.

Lead-in

Which, if any, 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

Question 27.

Lead-in

Which, if any, 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

Question 28.

Lead-in

Which, if any, of the following statements are 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, if any, 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

Question 30.

Lead-in

Which, if any, 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

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, if any, 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