Thursday, 1 June 2017

Tutorial 1st. June 2017


Contact us
1 June 2017.
11
Communication skills. Pre-pregnancy. Brother has cystic fibrosis.
12
EMQ. Epilepsy & pregnancy
13
EMQ. Abortion Act
14
EMQ. Anti-Müllerian hormone

11.   Communication skills.
Candidate's Instructions.
This is a roleplay station. You are a year 4 SpR and are in the gynaecology clinic.
The consultant has just left you in charge as she is feeling unwell and has gone to lie down.
Your task is to deal with the patient as you would in real life.
GP referral letter.
Best Medical Centre,
High Road,
Anytown.
Phone: 01882 78998.
Practice Manager: Mary Wright. B.SC., RGN.
Phone: 01882 78998 ext. 23.
Re. Mrs. Bonnie Black,
25 Low Road,
Anytown.
DOB: 28 January 1990.
Phone: 07889 888 132.
Dear Doctor,
Please see Mrs Black who is planning her first pregnancy. Her main concern is that her brother has cystic fibrosis.
This was the first time I had met her although she has been registered with us for 5 years – her health is good and she has no history of serious illness or surgery.
I have explained that I don’t know much about the implications of the brother’s cystic fibrosis for her potential pregnancies and that she needs to talk to an expert.
Yours sincerely,
John P. Clatter.

12.   EMQ. Epilepsy & pregnancy.
Epilepsy & Pregnancy. Question.
Some of the questions are not SBAs as there is more than one correct answer – it should be obvious when this is the case. I have tried to squeeze in all of the facts that might score points in the exam and having several in one question makes the document a bit shorter and saves me a lot of typing.
In the exam there will only be one correct answer.
Lead in.
Use the option list below unless the question comes with its own.
Abbreviations.
Adab:                  “Management of women with epilepsy during pregnancy”:  Naghme Adab & David W Chadwick. TOG. 2006;8: P.20–25. This is a bit dated, but the basics are still valid.
AED:                    anti-epileptic drug.
APS:                    antiphospholipid syndrome
Artama:              “AED use of women with epilepsy and congenital malformations in offspring”: Artama M, Auvinen A, Raudaskoski T, Isojärvi I, Isojärvi. J. Neurology. 2005 Jun 14;64(11):1874-8.
BF:                       breastfeeding
Campbell:          “Malformation risks of antiepileptic drug monotherapies in pregnancy: updated results from the UK and Ireland Epilepsy and Pregnancy Registers”: Campbell E, Kennedy F, Russell A, Smithson WH, Parsons L, Morrison PJ, et al.
                            J Neurol Neurosurg Psychiatry 2014;85:1029–34.
CG107:               NICE’s Clinical Guideline 107: “Hypertension in Pregnancy”.
CG137:               NICEs Clinical Guideline 137: “Epilepsies: diagnosis and management”. 2012
CG192:               NICE’s Clinical Guideline 192: “Antenatal and postnatal mental health”.
CNP:                    Catherine Nelson-Piercy’s Handbook of Obstetric Medicine. Fifth Edition. 2015.
Cs:                       Caesarean section.
CuIUCD:             copper intrauterine contraceptive device
Dewhurst:         Dewhurst’s Textbook of O&G. 8th. edition. Edmonds D.K. Wiley-Blackwell. 2012.
Edey:                  Edey, Moran & Nashef: “SUDEP and epilepsy-related mortality in pregnancy”. Epilepsia. Volume 55, Issue 7, July 2014; Pages e72–4.
EEG:                    electroencephalography.
EFM:                   electronic fetal heart monitoring.
Entonox:            nitrous oxide + oxygen.
FACS:                  fetal anticonvulsant syndrome.
FASD:                  fetal alcohol spectrum disorder.
Gooneratne:     “Contraception advice for women with epilepsy”; Gooneratne I, Wimalaratna M, Ranaweera A & Wimalaratna S. BMJ. 2017;357:j2010. 13 May 2017.
GTG68:               RCOG’s Green-top Guideline 68: “Epilepsy in Pregnancy”. June 2016.
HDN:                   haemorrhagic disease of the newborn.
James:                High Risk Pregnancy. 4th. Edition. James et al. 2010. Elsevier.
L&K:                    Luesley & Kirby’s Obstetrics & Gynaecology: An Evidence-based Text for MRCOG”. Third Edition. 2016.
LNGIUS:              levonorgestrel intrauterine system
MDT:                  multi-disciplinary team.
Meador:             “Pregnancy outcomes in women with epilepsy: a systematic review and meta-analysis of published pregnancy registries and cohorts”: Meador K, Reynolds MW, Crean S, Fahrbach K & Probst C. Epilepsy Res 2008;81:1–13.
MPA:                   medroxy-progesterone acetate
MRHA16:           MRHA guidance and toolkit.
NEAD:                 non-epileptic attack disorder.
NTD:                   neural tube defect.
Oxford O&G:     Oxford Desk Reference: Obstetrics and Gynaecology. Arulkumaran et al. Oxford. 2011.
PFI:                      pill-free interval.
Schaefer:           Drugs during Pregnancy and Lactation. Schaefer et al. 3rd. Edition. 2015. Elsevier
SUDEP:                sudden, unexplained death in epilepsy.
TENS:                  transcutaneous electrical nerve stimulation.
Thomas:             “Predictors of seizures during pregnancy in WWE”: Thomas S., Syam U. & Devi J.
                            Epilepsia, 53(5):e85–e88, 2012.
TTAS:                  Use of Serum Prolactin in Diagnosing Epileptic Seizures: Report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology 2005;65(5):668–675.
TTP:                     thrombotic thrombocytopenic purpura.
Turner:               “Epilepsy and postpartum depression”: Turner et al.
                            Epilepsia, 50(Suppl. 1):24–27, 2009.
UGT1A4:            uridine diphosphate-glucuronosyl transferase.
Viale:                  “Epilepsy in pregnancy and reproductive outcomes: a systematic review and meta-analysis”: Viale L et al.  Lancet 2015;386:1845–52.
VPA:                    valproic acid. Often known as “valproate” and “sodium valproate”.
Williams:            “Self-discontinuation of antiepileptic medication in pregnancy: detection by hair analysis”: Williams J, Myson V, Steward S, Jones G, Wilson JF, Kerr MP, et al.
                            Epilepsia 2002;43: 824–31.
WWE:                 women with epilepsy.
Option list.
a.        benzodiazepine
b.         carbamazepine
c.         coumarin
d.        diazepam
e.         lamotrigine
f.         levetiracetam
g.        phenobarbitone
h.        phenothiazine
i.           phenytoin
j.          primidone
k.         valproate
l.          < 0.5%
m.      0.5 - ≤1%
n.        1%
o.        2%
p.         3%
q.        4%
r.         5%
s.         10%
t.         20%
u.        50%
v.        true
w.      false
x.         none of the above.

Scenario 1.                
What is the incidence of epilepsy in pregnancy?
Scenario 2.                
Who, if any, of the following should make the diagnosis of epilepsy in pregnancy?
Option list
A
general practitioner
B
medical practitioner
C
medical practitioner with expertise in epilepsy
D
MDT
E
nurse practitioner
F
nurse practitioner with expertise in epilepsy
Scenario 3.                
With regard to the effect of pregnancy on seizures in WWE, which, if any, of the following statements are true?
Option list
A
about 1/2 experience worsening of seizures
B
about 1/3 experience worsening of seizures
C
about 2/3 experience worsening of seizures
D
the time the woman has been free from seizures is the best indicator of the risk of seizure deterioration
E
a 1st. trimester EEG is the best indicator of the risk of seizure deterioration
F
women who have been seizure-free for > 9/12 have a > 70% chance of remaining seizure-free during pregnancy
G
women with idiopathic generalised epilepsy are less likely to remain seizure-free in pregnancy than those with focal epilepsy
H
women with one of more seizures in the pre-conception year require close monitoring
I
status epilepticus is more common  in WWE when pregnant
M
status epilepticus in the 1st. trimester is the biggest risk factor for the increased incidence of congenital anomaly in the offspring of WWE
Scenario 4.                
What is the approximate incidence of seizures in labour?
Option list
A
1%
B
2.5%
C
5%
D
10%
E
15%
F
≥ 15%
Scenario 5.                
What is the approximate incidence of seizures in the 24 hours after delivery?
Option list
A
1%
B
2.5%
C
5%
D
10%
E
15%
F
≥ 15%
Scenario 6.           
Which, if any, of the following are more common in WWE in pregnancy compared to women who do not have epilepsy?
Option list
A
APH
B
anaemia
C
fetal growth restriction
D
Caesarean section
E
hypertension
F
induction of labour
G
instrumental delivery
H
low Apgar score at 1 minute
I
miscarriage
J
neonatal care unit admission
K
PPH
L
pre-term delivery
M
puerperal psychosis
Scenario 7.                
Which, if any, of the following are more common in WWE taking AEDs in pregnancy compared to women who do not take AEDs?
Option list
A
APH
B
anaemia
C
fetal growth restriction
D
Caesarean section
E
hypertension
F
induction of labour
G
instrumental delivery
H
low Apgar score at 1 minute
I
miscarriage
J
neonatal care unit admission
K
PPH
L
pre-term delivery                         
M
puerperal psychosis
Scenario 8.                
Which, if any, of the following does GTG68 say are more common in WWE taking AEDs in pregnancy as polytherapy compared to monotherapy?
Option list
A
APH
B
anaemia
C
fetal growth restriction
D
Caesarean section
E
hypertension
F
induction of labour
G
instrumental delivery
H
low Apgar score at 1 minute
I
miscarriage
J
neonatal care unit admission
K
PPH
L
pre-term delivery
M
puerperal psychosis
Scenario 9.                
What is the incidence of epilepsy in those with FASD?
Scenario 10.            
Approximately how many babies are born annually in the UK to women with epilepsy (WWE)?
Option list
A
1,000
B
2,500
C
5,000
D
7,500
E
10,000
Scenario 11.            
What is the MMR for WWE compared to those who do not have epilepsy?
Option list
A
decreased by a factor of 2
B
decreased by a factor of 5
C
decreased by a factor of 10
D
increased by a factor of 2
E
increased by a factor of 5
F
increased by a factor of 10
G
roughly the same
H
none of the above
Scenario 12.            
Write down the classification you would use in the exam for seizures in pregnancy?
Scenario 13.            
Which, if any, of the following women can be considered no longer to have epilepsy?
Conditions
A
A woman who has been seizure-free for 15 years
B
A woman who has been seizure-free for  15 years & has not taken AEDs for 2 years
C
A woman who has been seizure-free for 10 years & has not taken AEDs for 5 years
D
A woman who has been seizure-free for 5 years & has not taken AEDs for 3 years
E
A 30-year-old woman diagnosed with a childhood epilepsy syndrome
F
A 25-year-old woman diagnosed with a childhood epilepsy syndrome who has not had a seizure for 15 years
G
A woman who had excision of an area of brain scarring, thought to be the origin of focal seizures, two years ago and has not had a seizure since
H
your fiancée, with whom you are besotted, has been off AEDs for 5 years and remained seizure-free is keen to have you certify that she can have his driving licence renewed
I
None of the above
Scenario 14.            
Which WWE in pregnancy can be managed as low-risk?
I have not given an option list as that would make it too easy. Here we have one of the “buzz phrases” that are worth memorising for the exam.
Scenario 15.            
List the conditions you would consider in the differential diagnosis of epilepsy in pregnancy?
I have not given an option list as it would make this too easy.
GTG68 deals with this in section 4.3.
Scenario 16.            
Which, if any, of the following statements are true in relation to non-epileptic attack disorder?
Option list.
A
about 5% of those with NEAD also have epilepsy
B
about 15% of those with NEAD also have epilepsy
C
about 25% of those with NEAD also have epilepsy
D
about 40% of those with NEAD also have epilepsy
E
about 50% of those with NEAD also have epilepsy
Scenario 17.            
Which, if any, of the following statements are true in relation to distinguishing non-epileptic attack disorder from epilepsy in pregnancy?
Option list.
A
NEAD is more likely with extensor plantar reflexes
B
NEAD is more likely with a +ve conjunctival reflex
C
NEAD is more likely with resistance to eye-opening
D
NEAD is more likely with seizures but no cyanosis
E
NEAD is more likely with elevated post-ictal prolactin levels
Scenario 18.            
Which, if any, of the following does GTG 68 say should be considered in the differential diagnosis of a seizure in pregnancy.
Option list.
A
cerebral malaria
B
cerebral venous sinus thrombosis
C
meningitis
D
posterior reversible leucoencephalopathy syndrome
E
reversible cerebral vasoconstriction syndrome
F
space-occupying lesions
Scenario 19.            
Which, if any, of the following does GTG 68 say should be considered in the differential diagnosis of a seizure in pregnancy.
Option list.
A
aortic regurgitation
B
aortic stenosis
C
atrial fibrillation
D
atrial septal defect
E
carotid sinus sensitivity
Scenario 20.            
Which, if any, of the following does GTG 68 say should be considered in the differential diagnosis of a seizure in pregnancy.
Option list.
A
Addisonian crisis
B
asthma
C
hypoglycaemia
D
hypomagnesaemia
E
hyponatraemia
F
renal failure
Scenario 21.            
What classification is used in the MMRs for deaths due to epilepsy?
Option list
A
accidental
B
coincidental
C
direct
D
fortuitous
E
inevitable
F
indirect
G
late
Scenario 22.            
How many maternal deaths were caused by epilepsy from 2011-13?
Option list
A
0
B
1
C
5
D
7
E
15
F
22
G
34
Scenario 23.            
What is the relative risk of maternal death for WWE compared with women without epilepsy?
Option list
A
0.5
B
0.75
C
1
D
1.5
E
2
F
5
G
10
Scenario 24.            
What is the main cause of maternal death due to epilepsy?
Option list
A
asphyxia
B
aspiration of vomit
C
drowning
D
falling from a height
E
intracranial haemorrhage
F
SODEP
G
SUDEP
Scenario 25.            
Which, if any, of the following are risk factors for SUDEP?
Option list
A
anaemia
B
late age of onset of epilepsy
C
higher number of seizures
D
higher number of AEDs
E
high IQ
F
PET
Scenario 26.            
Which type of epilepsy is most often associated with maternal death?
Option list
A
grand mal epilepsy
B
petit mal epilepsy
C
frontal lobe epilepsy
D
drug-related epilepsy
E
post-traumatic epilepsy
F
none of the above
Scenario 27.            
Which, if any, of the following statements are true in relation to WWE in pregnancy and the puerperium?
Option list
A
ideally they should be accommodated in single rooms to reduce noise and stress
B
they should not be accommodated in single rooms
C
they should have shorter visiting times to reduce stress
D
existing children should not be allowed to visit
E
partners should not be allowed to visit
Scenario 28.            
AEDs are used in the treatment of which, if any, of the listed conditions?
Conditions
A
asthma
B
adolescent depression
C
bipolar disorder
D
chronic pain
E
leprosy
F
migraine
G
NEPD
H
tinnitus
Option list
1
A + B + C + D + E + F + G + H
2
A + B + C + D + E + F + G
3
B + C + D + E + F + G + H
4
B + C + D + F + G
5
C + D + E + F
6
C + D + G
7
C + D
Scenario 29.            
A primigravida with no history of epilepsy is admitted at 38 weeks after a seizure. This had been witnessed by her sister, a trained nurse, who described it as tonic / clonic with loss of consciousness. She is now drowsy but can be roused and has no recollection of events. It is not clear that this is a first manifestation of epilepsy. What should the immediate management be?
Option list
A
arrange brain CT scan
B
arrange brain MR scan
C
call for the on-call neurologist to attend urgently
D
lumbar puncture
E
start eclampsia protocol
F
urgent blood sugar assay
G
urgent urea / electrolytes assay
H
urgent clotting screen
Scenario 30.            
Which of the listed drugs are enzyme-inducing drugs (EIDs)?
Option list

Drug
Yes
No
A.       
carbamazepine


B.       
clonazepam


C.       
diazepam


D.       
eslicarbazepine


E.        
ethosuximide


F.        
gabapentin


G.       
lamotrigine


H.       
levetiracetam


I.         
oxcarbazepine


J.         
phenobarbital


K.        
phenytoin


L.        
primidone


M.     
topiramate


N.       
valproic acid


Scenario 31.            
Classify the following drugs as “new” or “old” AEDs.
Option list
A
carbamazepine

B
clonazepam

C
eslicarbazepine

D
ethosuximide

E
gabapentin

F
lamotrigine

G
levetiracetam

H
oxcarbazepine

I
phenobarbital

J
phenytoin

K
pregabalin

L
topiramate,

M
valproic acid

N
vigabatrin

Scenario 32.            
Which, if any, of the following statements are true in relation to AEDs & pregnancy.
Option list
A
levels of most AEDs fall in pregnancy
B
levels should be measured monthly until within the recommended levels for pregnancy
C
once normal levels have been attained, levels should be checked at 28 & 36 weeks
D
levels should be checked on day 10 of the puerperium to reduce the risk of toxicity
E
levels of carbamazepine are particularly likely to fall below recommended levels
Scenario 33.            
The GTG mentions one study that gives a figure for the percentage of WWE who stop their AEDs in pregnancy.
Pick the option from the list below that is closest to the figure cited.
Option list.
A
  1%
B
  5%
C
  7.5%
D
10%
E
15%
F
20%
Scenario 34.            
Which, if any, of the following are listed in GTG68 as signs of AED toxicity.
Option list
A
diplopia
B
drowsiness
C
strabismus
D
tremor
E
unsteadiness
Scenario 35.            
Which, if any, of the following are features of the fetal anticonvulsant syndrome.
Option list
A
anomalies of distal phalanges
B
cleft palate
C
developmental dysplasia of the hip
D
fetal growth restriction
E
hypoplasia of the mid-face
F
microcephaly
G
talipes equinovarus
Scenario 36.            
Which, if any, of the following statements are true in relation to WWE and the puerperium?
Option list
A
seizure frequency is higher in the early puerperium compared with pregnancy
B
seizure frequency occurs at a low rate in the early puerperium
C
the risk of postpartum seizures is highest in women who had seizures in the 1st. trimester
D
AED dosage should be reviewed in the 1st. 7 days if changed during pregnancy
E
depression is no more common in WWE compared to women without epilepsy
Scenario 37.            
Which AED is particularly associated with reduced levels in pregnancy of potential clinical significance and with need for monitoring.
Option list
A
carbamazepine
B
clonazepam
C
lamotrigine
D
levetiracetam
E
phenytoin
F
pregabalin
G
topiramate,
H
valproic acid
Scenario 38.            
By how much are the levels of this drug reduced in pregnancy?
Option list
A
up to 20%
B
up to 30%
C
up to 40%
D
up to 50%
E
up to 60%
F
up to 70%
Scenario 39.            
What advice does GTG 68 give about the dosage of antenatal steroids in WWE who take enzyme-inducing AEDs and are at sufficient risk of premature delivery that steroids would normally be recommended?
Option list
A
the dosage should be halved
B
the dosage should be doubled
C
the dosage should be trebled
D
the dosage should be unaltered
E
the course of steroids should be repeated after 1 week
Scenario 40.            
How many maternal deaths from 2011-13 were caused by epilepsy?
Option list
A
2
B
5
C
7
D
15
E
36
Scenario 41.            
What is the approximate risk of a child developing epilepsy if its mother has epilepsy
Option list
A
1%
B
2.5%
C
5%
D
10%
E
15%
F
≥ 15%
Scenario 42.            
What is the approximate risk of a child developing epilepsy if its father has epilepsy
Option list
A
1%
B
2.5%
C
5%
D
10%
E
15%
F
≥ 15%
Scenario 43.            
What is the approximate risk of a child developing epilepsy if its father & mother have  epilepsy
Option list
A
1%
B
2.5%
C
5%
D
10%
E
15%
F
≥ 15%
Scenario 44.            
What is the approximate risk of a child developing epilepsy if it has a sibling with epilepsy
Option list
A
1%
B
2.5%
C
5%
D
10%
E
15%
F
≥ 15%
Scenario 45.            
Which, if any, of the following methods of analgesia are appropriate for pain relief in labour for WWE?
Option list
A
diamorphine
B
Entonox
C
epidural anaesthesia
D
pethidine
E
TENS
Scenario 46.            
Which, if any, of the following statements are true about the use of pethidine for WWE in labour?
Option list
A
diamorphine is preferable to pethidine
B
pethidine should be avoided or used with caution
C
pethidine should not be used
D
pethidine is epileptogenic
E
pethidine is metabolised to norpethidine, which is epileptogenic
Scenario 47.            
Which, if any, of the following statements is correct in relation to the administration of vitamin K to WWE?
Option list
A
vitamin K should only be considered for women on EIDs
B
vitamin K is used to reduce the risk of PPH
C
vitamin K is used to reduce the risk of HDN
D
vitamin K as a single, 1 mg. i.m. shot should be offered for babies born to WWE on EIDs
E
there is little evidence from clinical trials to support the use of vitamin K to reduce the risk of HDN
F
there is little evidence from clinical trials to support the use of vitamin K to reduce the risk of PPH
Scenario 48.            
Which, if any, of the following statements are true in relation to AEDs and congenital anomaly?
Option list
A
drug dosage is not a significant risk factor
B
older drugs generally carry more risk
C
older maternal age is the greatest risk factor
D
polypharmacy significantly increases the risk
E
the commonest congenital anomaly is reduced IQ.
Scenario 49.            
What is the risk of major congenital anomaly for WWE who do not take AEDs compared with the background population risk?
Option list
A
about half
B
about the same
C
roughly doubled
D
roughly trebled
E
roughly quadrupled
Scenario 50.            
What are the major risk factors for major congenital anomaly in babies born to WWE?
There is no option list to make things harder.
Just write what you know.
Scenario 51.            
What does GTG68 say are factors that may reduce the risk of major congenital anomaly?
There is no option list.
Scenario 52.            
Which, if any, of the following are listed in GTG68 as the most common major congenital anomalies linked to AED use?
Option list
A
cleft palate
B
congenital heart anomaly
C
gluten sensitivity
D
exomphalos
E
Hirschsprung’s disease
F
NTD
G
sacro-coccygeal tumour
H
skeletal anomaly
I
urinary tract infection
Scenario 53.            
Which of the following are particularly associated with carbamazepine consumption in the 1st. trimester?.
A
cleft lip
B
cleft palate
C
congenital heart anomaly
D
gluten sensitivity
E
exomphalos
F
Hirschsprung’s disease
G
hypospadias
H
microcephaly
I
NTD
J
sacro-coccygeal tumour
K
skeletal anomaly
L
urinary tract anomaly
Scenario 54.            
Which of the following are particularly associated with phenobarbital consumption in the 1st. trimester? Use the option list for question 54.
Scenario 55.            
Which of the following are particularly associated with phenytoin consumption in the 1st. trimester? Use the option list for question 54.
Scenario 56.            
Which of the following are particularly associated with valproate consumption in the 1st. trimester?
Use the option list for question 54.
Scenario 57.            
Match the following drugs to the % risk of major congenital anomaly in the option list.
Drug                                 
Drug
% risk
Carbamazepine

Lamotrigine

Levetiracetam

Oxcarbazepine

Phenobarbital

Phenytoin

Topiramate

Valproic acid

Option list
4.7 - 10
4.2 - 7.7
5.5 - 7.4
2.9 - 6.7
2.6 - 5.6
2.0 –3.4
1.8 - 3.3
    0 - 2.4
Scenario 58.            
Match the following drugs to the most common types of congenital anomaly in the option list.
Drug                                 
Drug
Anomaly
Carbamazepine

Lamotrigine

Levetiracetam

Oxcarbazepine

Phenobarbital

Phenytoin

Topiramate

Valproic acid

Option list
cardiac abnormalities
cardiac abnormalities, hypospadias
cardiac abnormalities, hypospadias, NTDs
cardiac abnormalities, NTDs
cardiac abnormalities, oro-facial clefts
NTDs
oro-facial clefts
Scenario 59.            
Which, if any,  of the following are recommended in the immediate management of epileptic seizures in pregnancy?
Option list
A
use of the recovery position
B
use of i.v. phenobarbitone to end the seizure
C
induction of labour
D
Caesarean section
E
continuous EFM until delivery
F
expedite delivery if FHR anomaly for > 10 minutes
G
use tocolytic drug to reduce fetal hypoxia
Scenario 60.            
What should be done if the initial drug treatment fails to control the seizures?
Option list
A
consider i.v. pethidine
B
consider i.v. phenytoin
C
consider i.v. fosphenotoin
D
consider general anaesthesia
E
consider general anaesthesia + transfer to ICU
Scenario 61.            
When does GTG68 recommend that clobazam around the time of delivery?
There is no option list.
Scenario 62.            
What should be done if the initial drug treatment fails to control the seizures?
Option list
A
consider i.v. pethidine
B
consider i.v. phenytoin
C
consider i.v. fosphenotoin
D
consider general anaesthesia
E
consider general anaesthesia + transfer to ICU
Scenario 63.            
Which, if any, of the following statements is true in relation to breastfeeding (BF) for WWE taking AEDs?
Option list
A
BF is contraindicated
B
carbamazepine & lamotrigine produce similar umbilical cord and maternal serum levels
C
inconsolable crying is seen in babies
D
inconsolable crying is seen in mothers
E
lamotrigine transfers more readily to the baby than valproate
F
psychomotor development is only impaired until the age of 2 years
Scenario 64.            
Which, if any of the following methods of contraception should be promoted for WWE taking AEDs according to GTG68?
Option list
A
COC in normal dose
B
COC with 50 microgram dose of oestrogen
C
CuIUCD
D
LNGIUS
E
MPA injections
Scenario 65.            
Which, if any, of the following statements are true in relation to WWE taking EIDs?
Option list
A
the failure rate of COCs is ~ 3 times greater
B
the failure rate of COCs is ~ 7 times greater
C
↑ the dose of oestrogen in a COC to 50 micrograms restores its efficacy
D
↑ the pill-free interval to 10 days restores its efficacy
E
motorcycling restores its efficacy
F
the POP is unaffected
G
barrier contraception in should be advised in addition if oral contraception is used
Scenario 66.            
Which, if any, of the following statements are true in relation to progesterone contraception in WWE on EIDs?
Option list
A
the efficacy of Implanon may be reduced
B
the efficacy of Nexplanon is unaffected
C
the efficacy of the LNGIUS is believed to be unaffected
D
the efficacy of the POP is unaffected
E
the efficacy of the POP is increased
Scenario 67.            
What is advised in relation to COC and lamotrogine?                          

TOG questions.
Management of women with epilepsy during pregnancy
The following statements about antiepileptic drugs (AEDs) in pregnancy are true:
51 Approximately 0.5% of pregnancies are exposed to AEDs. T F
52 The adverse outcomes reported in pregnant women with epilepsy are mainly attributable to AEDs. T h F h
53 No long-term adverse effects have been described following AED exposure in utero. T  F
Maternal risks during pregnancy in women with epilepsy include
54    an increase in the seizure frequency in over 40% of women. T  F
55    an increased caesarean section rate. T  F  
56    a fall in total serum AED levels. T  F  
Risks to the fetus in women with epilepsy taking AEDs include
57    a 10-fold increase in fetal loss. T  F  
58    a 2 to 3-fold increase in major malformations. T  F  
59    a lower birth weight. T  F
60    developmental delay in the first two years of life. T  F  
The following statements about risks to the fetus in women with epilepsy taking AEDs are true:
61    The risks are equal in all three trimesters. T  F  
62    There is an increased risk from convulsive compared with non-convulsive seizures. T  F
The following statements regarding major fetal malformations are correct:
63    They are not increased through polytherapy exposure in utero. T  F  
64    The risk is highest with phenytoin exposure. T  F  
65    They are significantly reduced in women taking 0.4 mg folic acid in the first trimester. T  F  
66    Orofacial clefts are more likely to be associated with valproate. T  F  
The following statements about the dosage of AEDs in pregnancy are true:
67    Lower doses of AEDs are associated with lower risks. T  F  
68    Withdrawal of medication is best planned several months before conception. T  F  
With regard to neonatal care and delivery,
69    approximately 40% of women with epilepsy will experience a tonic-clonic seizure during delivery and the first 24 hours after delivery. T  F  
70    breastfeeding is not recommended in women who continue to take AEDs.

13.   EMQ. Abortion Act.
Abortion Act & TOP.
Lead-in.
TOP and the Abortion Act are likely to feature in every written exam.
Question 1
Lead in.
What was the approximate rate of abortion in the UK in 2015?
Option list
A
1 per 1,000 resident women aged 15-44
B
10 per 1,000 resident women aged 15-44
C
15 per 1,000 resident women aged 15-44
D
20 per 1,000 resident women aged 15-44
E
50 per 1,000 resident women aged 15-44
F
100 per 1,000 resident women aged 15-44
Question 2
Lead in.
The rate of abortion has declined by > 20% in the UK in the past ten years.
Option list
A
False
B
Haven’t a clue
C
Maybe
D
No data exist
E
True
Question 3
Lead in.
What proportion of TOPs were performed at gestations < 10 weeks in 2015?
Option list
A
50%
B
60%
C
70%
D
80%
E
90%
Question 4
Lead in.
There has been a significant improvement in the proportion of TOPs performed early in the past decade.
Option list
A
False
B
Haven’t a clue
C
Maybe
D
No data exist
E
True
Question 5
Lead in.
What % of abortions were performed after 24 weeks?
Option list
A
< 1%
B
1 - 3%
C
4 – 6%
D
7 – 9%
E
≥ 10%
Question 6
Lead in.
What proportion of TOPs were performed using medical, not surgical techniques?
Option list
A
20%
B
30%
C
40%
D
50%
E
60%
F
70%
G
80%
Question 7
Lead in.
Which age had the highest rate of TOP?
Option list
A
18
B
19
C
20
D
21
E
22
F
23
G
24
H
25
Question 8
Lead in.
What happened to the rate of TOP in 2014 for girls < 18 years compared with 2013?
Option list
A
the rate was much lower
B
the rate was slightly lower
C
the rate was much higher
D
the rate was slightly higher
E
the rate was unchanged
Question 9
Lead in.
What happened to the rate of TOP in 2015 for girls < 16 years compared with 2014?
Option list
A
the rate was much lower
B
the rate was slightly lower
C
the rate was much higher
D
the rate was slightly higher
E
the rate was unchanged
Question 10
Lead in.
What happened to the rate of TOP in 2015 for girls < 16 years compared with 2004?
Option list
A
the rate was much lower
B
the rate was slightly lower
C
the rate was much higher
D
the rate was slightly higher
E
the rate was unchanged
Question 11
Lead in
Approximately what proportion of women having TOP in 2014 had previously had one or more TOPs?
Option list
A
1%
B
5%
C
10%
D
20%
E
30%
F
40%
G
50%
Question 12
Lead in
What age group of women 1n 2015 were most likely to have had previous TOP?
Option list

Age
A
< 18
B
18-19
C
20-24
D
25-29
E
30-34
F
≥ 35
Question 13
Lead in
There were 185,824 TOPs in 2015. How many deaths occurred?
Option list
A
0 - 9
B
10 – 19
C
20 – 39
D
40 - 59
E
≥ 60
Question 14
Lead in
There were 185,824 TOPs in 2015. What was the rate of significant complications?
Option list
A
<1%
B
1%
C
3%
D
5%
E
10%
Question 15
Lead in
The RCOG recommends that women having TOP should have chlamydia screening. What proportion of women had this done in 2015?
Option list
A
<10%
B
10- 24%
C
25- 49%
D
50- 79%
E
80- 89%
F
≥ 90%
Question 16
Lead in.
The Abortion Act gives a number of legal grounds for TOP. Which of the following is listed as “1 (1) a”?
Option list
1
that the pregnancy has not exceeded its 24th. week and that the continuance of the pregnancy would involve risk, greater than if the pregnancy were terminated, of injury to the physical or mental health of the pregnant woman or any existing children of her family
2
the pregnancy has not exceeded its 24th. week and that the continuance of the pregnancy would involve risk, greater than if the pregnancy were terminated, of injury to the physical or mental health of any existing children of the family of the pregnant woman
3
the continuance of the pregnancy would involve risk to the life of the pregnant woman greater than if the pregnancy were terminated
4
the termination is necessary to prevent grave permanent injury to the physical or mental health of the pregnant woman
5
there is a substantial risk that if the child were born it would suffer from such physical or mental abnormalities as to be seriously handicapped
Question 17
Lead in.
The Abortion Act gives a number of legal grounds for TOP. Which of the following is listed as “1 (1) b”?
Option list
1
that the pregnancy has not exceeded its 24th. week and that the continuance of the pregnancy would involve risk, greater than if the pregnancy were terminated, of injury to the physical or mental health of the pregnant woman or any existing children of her family
2
the continuance of the pregnancy would involve risk to the life of the pregnant woman greater than if the pregnancy were terminated
3
the termination is necessary to prevent grave permanent injury to the physical or mental health of the pregnant woman
4
there is a substantial risk that if the child were born it would suffer from such physical or mental abnormalities as to be seriously handicapped
5
none of the above
Question 18
Lead in.
The Abortion Act gives a number of legal grounds for TOP. Which of the following is listed as “1 (1) c.
Option list
1
that the pregnancy has not exceeded its 24th. week and that the continuance of the pregnancy would involve risk, greater than if the pregnancy were terminated, of injury to the physical or mental health of the pregnant woman or any existing children of her family
2
the continuance of the pregnancy would involve risk to the life of the pregnant woman greater than if the pregnancy were terminated
3
the termination is necessary to prevent grave permanent injury to the physical or mental health of the pregnant woman
4
there is a substantial risk that if the child were born it would suffer from such physical or mental abnormalities as to be seriously handicapped
5
none of the above
Question 19
Lead in.
The Abortion Act gives a number of legal grounds for TOP. Which of the following is listed as “1 (1) d”?
Option list
1
that the pregnancy has not exceeded its 24th. week and that the continuance of the pregnancy would involve risk, greater than if the pregnancy were terminated, of injury to the physical or mental health of the pregnant woman or any existing children of her family
2
the continuance of the pregnancy would involve risk to the life of the pregnant woman greater than if the pregnancy were terminated
3
the termination is necessary to prevent grave permanent injury to the physical or mental health of the pregnant woman
4
there is a substantial risk that if the child were born it would suffer from such physical or mental abnormalities as to be seriously handicapped
5
none of the above
Question 20
Lead in.
The Abortion Act gives a number of legal grounds for TOP. Which of the following is listed as “1 (1) e”?
Option list
1
the pregnancy has not exceeded its 24th. week and that the continuance of the pregnancy would involve risk, greater than if the pregnancy were terminated, of injury to the physical or mental health of the pregnant woman
2
the pregnancy has not exceeded its 24th. week and that the continuance of the pregnancy would involve risk, greater than if the pregnancy were terminated, of injury to the physical or mental health of any existing children of the family of the pregnant woman
3
the continuance of the pregnancy would involve risk to the life of the pregnant woman greater than if the pregnancy were terminated
4
the termination is necessary to prevent grave permanent injury to the physical or mental health of the pregnant woman
5
there is a substantial risk that if the child were born it would suffer from such physical or mental abnormalities as to be seriously handicapped
6
none of the above
Question 21
Lead in.
With regard to the wording of the Abortion Act and grounds “F” and “G”. Which of the following statements are true?
1
“F” & “G” are grounds for TOP in an emergency with only one doctor needing to sign the legal form necessary for the TOP to take place
2
 “F” & “G” are grounds for TOP after 24 weeks.
3
“F” relates to TOP to save the woman’s life
4
“F” relates to TOP to prevent grave permanent injury her physical or mental health
5
“F” & “G” do not exist.
Option list
A
1  + 3
B
1  + 4
C
2 + 3
D
2 + 4
E
5
Question 22
Lead in
In relation to terms such as “substantial risk”, “grave permanent injury” and “seriously handicapped”, which of the following is true?
Option list
A
The terms were defined by a Parliamentary sub-committee, examples were given and are included in Appendix 2 (b) to the Act.
B
The terms were defined by a Parliamentary sub-committee, examples were given and are included in Appendix 2 (c) to the Act.
C
The terms were defined by the General Medical Council, examples were given and the information can be downloaded from the GMC website.
D
The terms were defined by the RCOG, examples were given and the information can be downloaded from the RCOG website.
E
The terms have not been defined.
Question 23
Lead in
Which of the following statement is true about the most common grounds for TOP?
Option list
1
TOP is most commonly done on ground A from Certificate A.
2
TOP is most commonly done on ground B from Certificate A.
3
TOP is most commonly done on ground C from Certificate A.
4
TOP is most commonly done on ground D from Certificate A.
5
TOP is most commonly done on ground E from Certificate A.
6
TOP is most commonly done on ground F from Certificate A.
7
TOP is most commonly done on ground G from Certificate A.
8
TOP is most commonly done on ground H from Certificate A.
Question 24
Lead in
Which of the following statements is true in relation to the upper gestational limit for TOP to be legal in the UK.
1
Termination of pregnancy is legal to 24 weeks
2
Termination of pregnancy is legal after 24 weeks if the mother is at serious risk of death or grave, permanent injury or there is a major risk of the fetus having a serious anomaly.
3
Termination of pregnancy is legal after 24 weeks if the mother is at serious risk of death or grave, permanent injury or there is a major risk of the fetus having a serious anomaly, but only if approved by the Department of Health’s “Late Termination of Pregnancy Assessment Panel”.
4
Termination of pregnancy is illegal after 24 weeks, but is still done if the mother’s life is at serious risk or there is a major risk of the fetus having a serious anomaly and there is a long-standing agreement that the police and legal authorities will “turn a blind eye”.
Option list
A
1 + 2 
B
1 + 3
C
1 + 4
D
2 + 4
E
5
Question 25
Lead in
Which of the following statement are true in relation to TOP after 24 weeks?
Statements
1
TOP is illegal after 24 weeks
2
The mother must agree to feticide pre-TOP
3
Feticide must be offered
4
There must be very serious grounds for the TOP
5
Gender-selection TOP is unacceptable
Option list
A
1
B
1 + 2
C
2 + 3 + 5
D
3 + 4
E
3 + 4 + 5
Question 26
Lead in
TOPs done under ground E are those done at any gestation because of fetal abnormality. The anomalies are coded using ICD10. The HSA4 notification form relating to each TOP should have details of the ICD10 code for the fetal anomaly.
Which of the following statements is the most accurate in relation to the percentage of HSA4 forms that contain the required information?
A
0- 24%
B
25- 49%
C
50- 59%
D
60- 69%
E
≥ 70%
Question 27
Lead in
TOPs done under ground E are those done at any gestation because of fetal abnormality. Which, if any, of the following statements are true of TOPs under ground E in 2015?
A
the average of the woman was 34, compared to 21 for the average for all grounds
B
congenital malformations were the grounds in > 80% of cases
C
Down’s syndrome was the most common reason for ground E TOP
D
fetal cardiac anomalies were the most common reason for ground E TOP
E
fetal nervous system anomalies were the most common reason for ground E TOP
Question 28
Lead in
Which form relates to certifying that a woman requesting a TOP can have it done legally?
Option list
A
HSA1
B
HSA2
C
HSA3
D
HSA4
E
HSA5
Question 29
Lead in
Which form must the practitioner performing the TOP complete to notify the Department of Health that a TOP has been done?
Option list
A
HSA1
B
HSA2
C
HSA3
D
HSA4
E
HSA5
Question 30
Lead in
A doctor signing the form giving the grounds for a TOP must have seen the woman.
Option list
A
True
B
False
C
Sometimes
D
Don’t know & don’t care
Question 31
Lead in
A doctor performing a TOP must be one of the doctors who signed the initial form giving the grounds for the TOP.
Option list
A
True
B
False
C
Sometimes
D
Don’t know & don’t care
Question 32
Lead in
What is the time scale for the return of the form notifying that a TOP has taken place?
Option list
A
3 working days
B
5 working days
C
1 week
D
2 weeks
E
1 month
Question 33
Lead in.
A woman seeks 1st. trimester TOP on social grounds which she declines to discuss in detail.
Which of the following statements apply?
Option List
A
TOP can be done under clause A of Certificate A
B
TOP can be done under clause B of Certificate A
C
TOP can be done under clause C of Certificate A
D
TOP can be done under clause D of Certificate A
E
TOP can be done under clause E of Certificate A
F
TOP can be done under clause F of Certificate A
G
TOP can be done under clause G of Certificate A
F
there is no clause authorising TOP on social grounds
Question 34
A woman seeks 1st. trimester TOP. She has pulmonary hypertension and has been advised of the risks of pregnancy by her cardiologist.
Which of the following statements apply?
A
TOP can be done under clause A of Certificate A
B
TOP can be done under clause B of Certificate A
C
TOP can be done under clause C of Certificate A
D
TOP can be done under clause D of Certificate A
E
TOP can be done under clause E of Certificate A
F
TOP can be done under clause F of Certificate A
G
TOP can be done under clause G of Certificate A
F
there is no clause authorising TOP on these grounds
Question 35
A woman books at 26 weeks. She has an unplanned pregnancy. She has pulmonary hypertension and has been advised of the risks of pregnancy by her cardiologist.
Which of the following statements apply?
A            TOP should be offered under clause A of Certificate A
B            TOP should be offered under clause B of Certificate A
C            TOP should be offered under clause C of Certificate A
D            TOP should be offered under clause D of Certificate A
E            TOP should be offered under clause E of Certificate A
F            TOP should be offered under clause F of Certificate A
G            TOP should be offered under clause G of Certificate A
F            there is no clause authorising TOP on these grounds

14.   EMQ. Anti-Müllerian hormone
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, if any, 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, 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
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, 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





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