MRCOGManchester: Tutorial 14th. June 2018

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29	EMQ. Warfarin and pregnancy
30	EMQ. MBRRACE & maternal mortality
31	EMQ. Access to medical records
32	EMQ. Borderline ovarian tumours
33	EMQ. Aneuploidy screening

29. EMQ. Warfarin & pregnancy.

Scenario 1.

How does warfarin produce its anticoagulant effect? Which, if any, of the following are true?

Option list.

A	↑ levels of Protein C
B	↑ levels of Protein S
C	↓ levels of Factor I
D	↓ levels of Factor II
E	↓ levels of Factor III
F	↓ levels of Factor IV
G	↓ levels of Factor V
H	↓ levels of Factor VI
I	↓ levels of Factor VII
J	↓ levels of Factor VIII
K	↓ levels of Factor IX
L	↓ levels of Factor X

Scenario 2.

Which of the following is used to monitor the effect of warfarin?

Option list.

A	bleeding time
B	clotting time
C	factor IXa levels
D	factor Xa levels
E	international normalised ratio
F	platelet levels

Scenario 3.

What are the main teratogenic effects of warfarin taken in the 1^st. trimester?

There is no option list to make things harder – just write out what you know about the teratogenic effects.

Scenario 4.

Which, if any, of the following statements are true in relation to the risk of warfarin?

Option list.

A	warfarin embryopathy is most likely if the drug is taken between 4 and 10 weeks
B	warfarin embryopathy is most likely if the drug is taken between 6 and 12 weeks
C	the cut-off dose for high and low risk of warfarin embryopathy is 3 mg. in the 1^st. trimester
D	the cut-off dose for high and low risk of warfarin embryopathy is 5 mg. in the 1^st. trimester
E	the cut-off dose for high and low risk of warfarin embryopathy is 7.5 mg. in the 1^st. trimester

Scenario 5.

What is the approximate risk of warfarin embryopathy if the drug is taken at the time of greatest risk in the 1^st. trimester?

Option list.

A	1%
B	2.5%
C	5%
D	7.5%
E	≥ 10%

Scenario 6.

Which of the following adverse outcomes are associated with warfarin use in pregnancy?

Option list.

A	↑ risk of APH
B	↑ microcephaly
C	↑ risk of miscarriage
D	↑ risk of PPH
E	↑ risk of stillbirth

Scenario 7.

Which, if any, of the following statements are true in relation to warfarin and breastfeeding?

Option list.

A	Warfarin is contraindicated because of the risk of neonatal intracranial haemorrhage
B	Warfarin is contraindicated because of the risk of PPH
C	Warfarin is contraindicated because of its variable effects on neonatal coagulation
D	Warfarin is highly bound to plasma proteins
E	Warfarin is not contraindicated as insufficient transfers to breast milk to be a hazard to the neonate

Scenario 8.

What should be your ‘knee-jerk’ response to a question asking which is the one condition for which warfarin is indicated in pregnancy?

30. EMQ. MRRACE. Maternal mortality.

Abbreviations.

ICD-10: WHO’s International Classification of Diseases. Version 10 from 1990.

ICD-MM: WHO’s use of ICD-10 for classification of maternal deaths.

MMR: Maternal mortality rate

MMRat Maternal mortality ratio.

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?

A	it covered three years, not two
B	it covered four years, not three
C	it was very amusing
D	it made serious criticisms of the funding of the NHS
E	it made serious criticisms of the hours worked by junior doctors
F	none of the above

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 adopted 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 the changes to the classification of maternal suicide made 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, if any, of the following topics were included in the confidential enquiries in the first MBRRACE Report in December 2014?

A	amniotic fluid embolism
B	epilepsy
C	haemorrhage
D	placenta accreta, increta & percreta
E	psychiatric causes

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 were 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 2013-15?

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 in pregnancy or the 6 weeks after were due to epilepsy in 2013-15?

Option list.

A	5
B	8
C	23
D	34
E	41

Question 37. Which, if any, of the following statements is true of the causes of death due to epilepsy in pregnancy in 2013-15?

Option list.

A	the main cause was asphyxia
B	the main cause was drowning in the bath
C	the main cause was falling
D	the main cause was intracranial bleeding
E	the main cause was status epilepticus
F	the main cause was SUDEP

Question 38. Which, if any, of the following statements is true of the women who died due to epilepsy in pregnancy in 2013-15?

Option list.

A	90% had good pre-pregnancy control of the epilepsy
B	80% had good pre-pregnancy control of the epilepsy
C	70% had good pre-pregnancy control of the epilepsy
D	60% had good pre-pregnancy control of the epilepsy
E	50% had good pre-pregnancy control of the epilepsy
F	40% had good pre-pregnancy control of the epilepsy
G	30% had good pre-pregnancy control of the epilepsy
H	20% had good pre-pregnancy control of the epilepsy
J	10% had good pre-pregnancy control of the epilepsy
I	8 of the 9 did not have good control and the quality of control was unknown for the 9^th.
K	None of the above

Question 39. Which, if any, of the following statements is true of non-epileptic attack disorder (NEAD) as discussed in MBRRACE17?

Option list.

A	is less common than epilepsy in pregnancy
B	is more common than epilepsy in pregnancy
C	is as common as epilepsy in pregnancy
D	NEAD is a diagnosis that should not be made in pregnancy
E	NEAD is most common in male adolescents
F	Most women with NEAD also have epilepsy

Question 40. Which, if any, of the following statements is most appropriate to describe notification of the women who died due to epilepsy in pregnancy in 2013-15 to the UK Epilepsy and Pregnancy Register?

Option list.

A	>90%
B	80-890%
C	70-79%
D	60-69%
E	50-59%
F	40-49%
G	<30%
H	<25%
J	<20%
I	<10%
K	<5%

Question 41. How many maternal deaths were due to cardiac causes in 2012-14?

Option list.

A	47
B	51
C	56
D	63
E	78
F	82
G	90

Question 42. How many maternal deaths were due to cardiac causes in 2012-14?

Option list.

A	47
B	51
C	56
D	63
E	78
F	82
G	90

Question 43. 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

Question 44. What is the definition of a stillbirth?

Question 45. What is the definition of the maternal mortality ratio?

Question 46. How many maternal deaths were due to cardiac causes in 2012-14?

Option list.

A	47
B	51
C	56
D	63
E	78
F	82
G	90

Question 47. 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 48. 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 49. 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 50. 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

Question 51. 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 52. 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 53. 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 54. 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 55. 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 56. What “overall messages for future care” in relation to cardiac disease were included in MBRRACE16?

Option list. There is none.

Question 57. 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 58. 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 symptom is severe chest pain radiating to the back
E	the classical symptom is severe chest pain radiating to the left arm
F	the classical symptom is 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 59. What were the “Key messages” about cardiovascular disease in MBRRACE16?

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

Question 60. 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 61. Approximately how many women died of myocardial disease / cardiomyopathy?

Option list.

A	5
B	10
C	15
D	20
E	25

Question 62. Approximately how many women died of peripartum cardiomyopathy?

Option list.

A	5
B	10
C	15
D	20
E	25

Question 63. 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 64. 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 65 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 66. 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 67. When are women with peripartum cardiomyopathy most likely to die?

Option list.

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

Question 68. 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 69. 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 70. 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 71. What were the key messages re hypertensive disease in MBRRACE16?

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

Question 72. 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 73. 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 74. 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 75. Which of the following ranked top in the causes of death < 24 weeks in 2009-2014?

Option list.

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

Question 76. Why did MBRRACE16 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 77. What were the key messages in relation to early pregnancy deaths in MBRRACE16?

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

Question 78. 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 79. 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 80. 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 81. What “red flags” does MBRRACE highlight in relation to maternal sepsis?

Option list. There is none.

* There was a query in the January 2017 tutorial about whether the upper limit of lactate of 2 or 4. MBRRACE14 has the following on page 34: “serum lactate >2mmol/L indicates severe sepsis

and > 4mmol/L indicates septic shock”.

MBRRACE16 in Box 6.1 which lists maternal sepsis red flags includes lactate ≥2 mmol/l.

Question 82. What were MBRRACE16’s “key messages” for critical care?

Option list.

* There was a query in the January 2017 tutorial about whether the upper limit of lactate of 2 or 4. MBRRACE14 has the following on page 34: “serum lactate >2mmol/L indicates severe sepsis

and > 4mmol/L indicates septic shock”.

MBRRACE16 in Box 6.1 which lists maternal sepsis red flags includes lactate ≥2 mmol/l.

Question 83. What were MBRRACE16’s “key messages” for critical care?

Question 84. The following topics were covered in the first 3 MBRRACE Reports? Sort them by Report: 1^st. Report 2014, 2^nd. Report 2015, 3^rd. Report 2016.

AFE,
anaesthesia,
cardiac causes,
coincidental deaths,
early pregnancy deaths,
eclampsia & PET,
haemorrhage,
late deaths,
malignancy,
neurological disorders,
psychiatric causes,
respiratory, endocrine and other indirect causes,
sepsis.
thrombosis and thromboembolism.
women admitted to critical care
women with artificial heart valves

Question 85. How many anaesthetic deaths were recorded in MBRRACE17?

Option list.

A	1
B	2
C	5
D	8
E	10
F	12

Question 86. Which, if any, of the following statements are included by MBRRACE17?

Option list.

A	BP is the best measure of cardiac output
B	pulse rate is a good indicator of cardiac output
C	external cardiac compressions should be started early if cardiac output is inadequate
D	external cardiac compressions are contraindicated in the presence of cardiac activity because of the risk of ventricular rupture
E	if there has been massive haemorrhage, extubation should not be done until the bleeding has ceased and adequate resuscitation has taken place.

Question 87. Which of the following sizes of endotracheal tubes are recommended for inclusion in resuscitation carts by MBRRACE17?

Option list.

A	4 mm
B	5 mm
C	6 mm
D	7 mm
E	8 mm
F	9 mm

31. EMQ. Access to medical records.

Question 1.

Lead in.

A woman is admitted at 36 weeks’ gestation with a massive APH due to placental abruption. She dies 12 hours later despite best possible care. The death is reported to the coroner who requests access to her medical records. Which, if any, of the following would be the correct response?

Option list.

A.	deny access to the medical records as the cause of death is clear
B.	consult the Caldicott Guardian
C.	consult the Trust’s legal team.
D.	provide restricted access to the records
E.	provide unrestricted access to the records

Question 2.

Lead in.

A woman had TVT 3 years ago for stress incontinence. She now has recurrence of stress incontinence plus urgency and urge incontinence.

She discussed this with a friend who said that she thought the operation had not been done correctly and that she should get here medical records as a preliminary to suing the hospital.

You see her in the clinic. Which of the following options best indicates what you will advise her?

Option list.

A.	she is entitled to full access apart from the rare possibility that this would cause harm to her or anyone else
B.	she is entitled to access to the parts of the notes dealing with the treatment she had relating to the TVT, with the proviso that this would not cause harm to her or anyone else
C.	she must submit an application which will be considered by the hospital’s legal advisors
D.	she must submit an application which will be considered by the medical records committee
E.	she is not entitled to access unless she makes successful application to the Court of Protection

Question 3.

Lead in.

A woman is entitled to access her medical records. Which, if any of the following statements are true?

Statements

A.	access is free and the Trust must bear any costs
B.	the Trust is entitled to charge a reasonable sum
C.	the Trust is entitled to charge what it likes
D.	the Trust is entitled to charge a reasonable sum for producing hard copies of the records
E.	the Trust is entitled to charge a what it likes for producing hard copies of the records

Option list.

i.	A
ii.	B
iii.	B + D
iv.	C
v.	C + D

Question 4.

Lead in.

A woman is entitled to access her medical records. What will be your advice about time scales for access including copies, if required?

Option list.

A.	access within 5 days
B.	access within 10 days
C.	access within 20 days
D.	access within 40 days
E.	access within 60 days

Question 5.

Lead in.

A woman is admitted at 36 weeks’ gestation with an unexplained fetal death in-utero. Full investigation is normal. The father of the baby is unhappy about the lack of explanation for the death and visits the coroner’s office. He is interviewed by a coroner’s officer who writes to the obstetric unit requesting copies of the mother’s medical records. Which, if any, of the following would be the correct response?

Option list.

A.	deny access to the medical records, despite the death being unexplained
B.	consult the Caldicott Guardian
C.	consult the Trust’s legal team.
D.	provide restricted access to the records
E.	provide unrestricted access to the records

Question 6.

Lead in.

A woman of 56 years was diagnosed with severe dyskaryosis and referred for colposcopy. Shortly after she moved house and did not receive any colposcopy appointments. She was referred to the hospital six months later with bleeding and was found to have advanced cervical cancer. She died one year later, despite best treatment. The coroner requests access to the notes. Which, if any, of the following responses by the Trust are correct?

Option list.

A.	deny access to the records as the death was due to administrative, not clinical, failure
B.	consult the Caldicott Guardian
C.	consult the Trust’s legal team
D.	provide restricted access to the records
E.	provide unrestricted access to the records

Question 7.

Lead in.

A woman has a normal delivery at term. A 3.5 kg. baby is delivered normally. Initially it appears to do well, but at 36 hours it is found dead in its cot. Full investigation, including post-mortem examination fail to identify a cause of death. The death is attributed to “sudden infant death syndrome”. The father reports the case to the coroner who requests the maternal and paediatric notes. Which, if any, of the following responses by the Trust are correct?

Option list.

A.	deny access to the records as the death has been fully investigated
B.	consult the Caldicott Guardian
C.	consult the Trust’s legal team
D.	provide restricted access to the maternal records and full access to the baby’s records
E.	provide unrestricted access to the records of mother and baby

Question 8.

Lead in.

A woman has a normal delivery at term. A 3.5 kg. baby is delivered normally. Initially it appears to do well, but at 16 hours it is found dead in its cot. Post-mortem examination attributes the death to Fallot’s tetralogy. The father reports the case to the coroner who requests the maternal and paediatric notes. Which, if any, of the following responses by the Trust are correct?

Option list.

A.	deny access to the records as the cause of death has been found
B.	consult the Caldicott Guardian
C.	consult the Trust’s legal team
D.	provide restricted access to the maternal records and full access to the baby’s records
E.	provide unrestricted access to the records of mother and baby

Question 9.

Lead in.

A 75-year-old woman has Wertheim’s hysterectomy for cancer of the cervix and dies 3 days later of pulmonary embolism, despite appropriate prophylaxis. During the post-operative care she had made it clear that her husband should be kept fully informed about events. Three months after her death the husband requests access to her notes without stating why. Which, if any, of the following responses by the Trust are correct?

Option list.

A.	deny access to the records as they are not his records
B.	consult the Caldicott Guardian
C.	consult the Trust’s legal team
D.	provide restricted access to the wife’s records
E.	advise about the criteria for access and how to apply

32. EMQ. Borderline ovarian tumours.

Abbreviations.

BOT: borderline ovarian tumour.

Ca125: Ca125 as iu/ml.

COC: combined oral contraceptive.

EOT: epithelial ovarian tumour.

IOC: invasive ovarian cancer.

MOV: mean ovarian volume.

MS: menopause score.

POI: premature ovarian insufficiency.

RMI: Risk of Malignancy Index.

SOT: serous ovarian tumour.

US: ultrasound score.

Scenario 1.

Which, if any, of the following statements are true in relation to BOTs?

Option list.

A	show more proliferation than benign ovarian tumours
B	stromal invasion is absent
C	stromal invasion is < 5 mm from the ovarian surface
D	comprise 10-15% of EOTs
E	comprise 10-15% of GCTOs
F	comprise 10-15% of SOTs

Scenario 2.

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

Option list.

A	BOTs constitute 5-10% of ovarian epithelial neoplasia
B	BOTs constitute 10-15% of ovarian epithelial neoplasia
C	BOTs constitute 15-20% of ovarian epithelial neoplasia
D	BOTs constitute 5-10% of ovarian germ-cell neoplasia
E	BOTs constitute 10-15% of ovarian germ-cell neoplasia
F	BOTs constitute 15-20% of ovarian germ-cell neoplasia

Scenario 3.

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

Option list.

A	BOTs are less common in women who have taken the COC for > 5 years
B	BOTs are less common in women with a history of lactation
C	BOTs are more common after the menopause
D	BOTs are more common in multiparous women
E	BOTs are more common in women with BRCA1 & 2 mutations

Scenario 4.

Which, if any, of the following statements are true in relation to BOTs.

Option list.

A	p53 mutations are more common than in invasive ovarian tumours
B	BRAF/KRAS mutations are common than in invasive ovarian tumours
C	BRCA 1 & 2 mutations are more common in women with BOTs
D	BOTs are more common in women from a Lynch syndrome family with a known MSH6 mutation
E	BOTs are more common in women with red hair

Scenario 5.

Which, if any, of the following statements are true in relation to BOTs.

Option list.

A	Brenner tumours are the most common
B	endometrioid tumours are the most common
C	mucinous tumours are the most common
D	serous tumours are the most common
E	< 10% are bilateral

Scenario 6.

Which, if any, of the following statements are true in relation to mucinous BOTs.

Option list.

A	are subdivided into endocervical / Müllerian or intestinal categories
B	are subdivided into endocervical / Müllerian, intestinal or renal categories
C	are subdivided into endometrial or intestinal categories
D	pseudomyxoma peritonei occurs in < 1% of cases
E	pseudomyxoma peritonei occurs in about 10% of cases

Scenario 7.

Which, if any, of the following statements are true in relation to BOTs.

Option list.

A	↑ Ca 125 levels are rare, normally indicating malignancy
B	Ca 19-9 levels are often ↑ in mucinous BOTs
C	CEA levels are often ↑ in serous tumours
D	Ca 15-3 is commonly ↑ in both mucinous and serous BOTs
E	TVS and MRI are useful in the assessment of BOTs

Scenario 8.

Which, if any, of the following statements are true in relation to BOTs.

Option list.

A	the 5-year survival rate is approximately 80% for stage I disease
B	the 5-year survival rate is approximately 95% for stage I disease
C	the 5-year survival rate is approximately 50% for stage III disease
D	the 5-year survival rate is approximately 60% for stage III disease
E	the overall 10-year survival rate is approximately 75%

Scenario 9.

Which, if any, of the following statements is true in relation to calculation of the RMI score?

Option list.

A	uses the formula age x Ca125 x US
B	uses the formula Ca125 x MS x MOV
C	uses the formula (Ca125 + MS) x US
D	uses the formula Ca125 + MS + US
E	uses the formula Ca125 x MS x US
F	none of the above

Scenario 10.

Which, if any, of the following describes the formula used for the calculation of the MOV as used in the RMI score?

Option list.

A	total ovarian volume / 2
B	total ovarian volume / average ovarian number
C	total ovarian volume / ovarian number
D	total volume of the larger ovary
E	p x (mean diameter)³ / 4 of the larger ovary
F	none of the above

Scenario 11.

Which, if any, of the following as used in the calculation of the MS as used in the RMI score

Option list.

A	prepubertal: score = 0
B	1ry. amenorrhoea: score = 1
C	POI: score = 2
D	perimenopausal: score = 3
E	menopausal: score = 4
F	none of the above

Scenario 12.

Which, if any, of the following statements is true in relation to calculation of the RMI score?

Option list.

A	uses the formula age x Ca125 x US
B	uses the formula Ca125 x MS x MOV
C	uses the formula (Ca125 + MS) x US
D	uses the formula Ca125 + MS + US
E	uses the formula Ca125 x MS x US
F	none of the above

Scenario 13.

Which, if any, of the following statements are true in relation to the RMI and BOTs.

Option list.

A	the RMI is particularly useful and should always be considered in the early assessment
B	the RMI is not particularly useful in the majority of possible BOTs
C	the strength of the RMI in the assessment of possible BOTs lies with the elevated Ca125 levels
D	weakness of the RMI in the assessment of possible BOTs is, in part, due to the wide range of Ca125 levels found with BOTs
E	none of the above

Scenario 14.

Which, if any, of the following statements are true in relation to the measurement of Ca125 in calculating a RMI score.

Option list.

A	the units used are mg/L
B	the units used are mg/mL
C	the units used are mol/L
D	the units used are mol/mL
E	the units used are iu/L
E	the units used are iu/ml

Scenario 15.

Which, if any, of the following are part of the measurement of US?

Option list.

A	ascites
B	hydrothorax
C	multilocular cysts
D	↑ ovarian blood flow
E	↑ ovarian number
E	↑ ovarian volume

Scenario 16.

Which, if any, of the following statements describes the best management of BOTs.

Option list.

A	the best management is hysterectomy + BSO + infracolic omentectomy + lymphadenectomy + appendicectomy + excision of extra-ovarian lesions
B	the best management is hysterectomy + BSO + infracolic omentectomy + appendicectomy
C	the best management is hysterectomy + BSO + appendicectomy
D	the best initial management is ovarian cystectomy + histology of frozen section
E	chemotherapy should be offered when the stage is > I
F	none of the above

Scenario 17.

Which, if any, of the following statements describes the recommended management of BOT in the woman who does not wish to retain her fertility?

Option list.

A	the best management is hysterectomy + BSO + infracolic omentectomy + lymphadenectomy + appendicectomy + excision of extra-ovarian lesions
B	the best management is hysterectomy + BSO + infracolic omentectomy + appendicectomy
C	the best management is hysterectomy + BSO + appendicectomy
D	the best initial management is ovarian cystectomy + histology of frozen section
E	none of the above

Scenario 18.

Which, if any, of the following statements describes the recommended additional management of BOT in the woman who does not wish to retain her fertility and whose tumour is mucinous?

Option list.

A	appendicectomy
B	appendicectomy after histology of frozen section
C	removal of the other ovary
D	removal of the other ovary after histology of frozen section
E	bilateral salpingectomy

Scenario 19.

What advice is usually given in relation to the use of clomifene in women treated for BOTs?

Option list.

A	clomifene is contraindicated
B	only offer treatment to women < 35 years
C	only offer treatment to women who have screened –ve for BRCA 1 & 2
D	only offer treatment to women with stage 1 & 2 disease
E	restrict the number of treatment cycles

Scenario 20.

What is the role of chemotherapy in the management of women with BOTs?

Option list.

A	chemotherapy should be offered routinely after surgery as for invasive disease
B	pre-operative chemotherapy reduces recurrence rates
C	routine chemotherapy is of unproven benefit
D	the main role for chemotherapy is for recurrent disease
E	the main role for chemotherapy is for recurrent disease unsuitable for surgery

Scenario 21.

Which, if any, of the following statements are true in relation to restaging in the management of women with BOTs?

Option list.

A	should be offered routinely if definitive surgery is not performed initially
B	restaging improves 5-year recurrence rates
C	restaging improves 10-year survival
D	restaging may be appropriate for those with invasive implants
E	restaging may be appropriate for those with DNA aneuploidy

Scenario 22.

What advice is usually given in relation to the management of women found unexpectedly to have a BOT on histology?

Option list.

A	further surgery, if needed, to remove the ovary and tube
B	adjuvant chemotherapy
C	pelvic radiotherapy
D	close follow-up
E	none of the above

Scenario 23.

What is the role of laparoscopy in women with actual or suspected BOT?

Option list.

A	laparoscopy has replaced laparotomy in most cases
B	concerns about the risk of recurrence limit its use
C	concerns about worse survival limit its use
D	concerns about port metastasis limit its used
E	none of the above

Scenario 24.

What is the definition of conservative surgery in the management of BOTs?

Option list.

A	surgery with conservation of uterus and at least one ovary
B	surgery with conservation of uterus and at least part of one ovary
C	surgery with complete staging + conservation of uterus and at least one ovary
D	surgery with complete staging + conservation of uterus and at least part of one ovary
E	complete staging + omentectomy + conservation of uterus and at least part of one ovary

Scenario 25.

A nulliparous 24-year-old woman has a right-sided BOT. She has opted for conservative surgery with conservation of the uterus and left ovary and tube. She has asked about the advisability of biopsy of the left ovary at the time of surgery. Which of the following options would reflect your advice.

Option list.

A	biopsy of the apparently normal ovary is recommended
B	biopsy of the apparently normal ovary is not recommended
C	biopsy of the apparently normal ovary is decided on an ad hoc basis by the MDT
D	biopsy of the apparently normal ovary is a matter for informed consent
E	none of the above

Scenario 26.

A nulliparous 24-year-old woman has a right-sided BOT. She has conservative surgery with conservation of the uterus and left ovary and tube. She has asked about the advisability of removal of the left ovary and tube once she has completed her family.

Option list.

A	LSO is recommended once her family is complete
B	LSO is not recommended
C	LSO once her family is complete is decided on an ad hoc basis by the MDT
D	LSO once her family is complete is a matter for informed consent
E	none of the above

Scenario 27.

What advice can be given about fertility rates after conservative surgery for a BOT?

Option list.

A	about half of women conceive spontaneously
B	fertility rates are unimpaired by conservative surgery
C	fertility rates are improved by conservative surgery
D	fertility rates after conservative surgery are unknown
E	none of the above

29. EMQ. Aneuploidy screening.

Lead-in.

The following scenarios relate to screening for aneuploidy.

Pick one option from the option list.

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

Abbreviations.

Ds:	Down’s syndrome.
FASP:	Fetal Anomaly Screening Programme.
MSAFP:	maternal serum alpha-fetoprotein.
NSC:	UK National Screening Committee.
PAPP-A	pregnancy-associated plasma protein A.
SS16:	NSC’s NHS public health functions agreement. 2016-17. Screening for Down’s, Edward’s and Patau’s syndromes.
uE₂	unconjugated oestradiol.
uE₃	unconjugated oestriol.

Scenario 1.

Which of the following statements are included in the WHO criteria for a good screening test?

Statements.

1.	The condition should be important
2.	There should be a recognisable latent or early symptomatic stage
3.	The natural course of the condition should be adequately understood
4.	There must be a suitable test that is acceptable to the population to be screened
5.	There must be an accepted, effective treatment for those identified by screening
6.	Diagnostic and treatment facilities must exist
7.	There must be an agreed policy about which of those identified by screening are to be treated
8.	The cost of screening, diagnosis and treatment must be valid within the budget for overall medical care

Option list.

A.	1 + 2 + 3 + 4 + 5 + 6
B.	1 + 2 + 5 + 6 + 7 + 8
C.	1 + 2 + 3 + 4 + 5 + 8
D.	1 + 5 + 6 + 7 + 8
E.	1 + 2 + 5 + 6 + 7 + 8
F.	1 + 2 + 3 + 4 + 5 + 6 + 8
G.	1 + 2 + 3 + 4 + 5 + 7 + 8
H.	All of the above

Scenario 2.

What is the latest NSC criterion for the minimum sensitivity of the combined 1^st trimester test?

Option list.

A.	≥ 75%
B.	≥ 80%
C.	≥ 85%
D.	≥ 87.5%
E.	≥ 90%
F.	≥ 92.5%
G.	≥ 95%
H.	≥ 97.5%
I.

Scenario 3.

What is the latest NSC criterion for the maximum false +ve rate for the combined 1^st trimester test?

Option list.

A.	≥ 10%
B.	≥ 9%
C.	≥ 8%
D.	≥ 7%
E.	≥ 6%
F.	≥ 5%
G.	≥ 4%
H.	≥ 3%
I.	≥ 2%
J.	≥ 1%
K.	≥ 0.5

Scenario 4.

What is the latest NSC criterion for the minimum sensitivity of the 2^nd. trimester quadruple test?

Option list.

A.	≥ 75%
B.	≥ 80%
C.	≥ 85%
D.	≥ 87.5%
E.	≥ 90%
F.	≥ 92.5%
G.	≥ 95%
H.	≥ 97.5%
I.	none of the above

Scenario 5.

What is the latest NSC criterion for the maximum false +ve rate for the 2^nd. trimester quadruple test?

Option list.

A.	≥ 10%
B.	≥ 9%
C.	≥ 8%
D.	≥ 7%
E.	≥ 6%
F.	≥ 5%
G.	≥ 4%
H.	≥ 3%
I.	≥ 2%
J.	≥ 1%
K.	≥ 0.5

Scenario 6.

Which of the following markers are used in the 1^st. trimester combined test?

Markers

1	beta-hCG
2	free beta-hCG
3	hCG
4	inhibin A
5	inhibin B
6	MSAFP
7	PAPP-A
8	PAPP-B
9	uE₂
10	uE₂

Option list.

A.	beta-hCG + free beta-hCG + hCG +inhibin A + inhibin B + MSAFP + PAPP-A + PAPP-B + uE₂ + uE3
B.	beta-hCG + free beta-hCG + hCG +inhibin A + inhibin B + MSAFP + PAPP-A + PAPP-B + uE₂ + uE3
C.	beta-hCG + free beta-hCG + hCG +inhibin A + inhibin B + MSAFP + PAPP-A + PAPP-B + uE₂ + uE3
D.	beta-hCG + free beta-hCG + hCG +inhibin A + inhibin B + MSAFP + PAPP-A + PAPP-B + uE₂ + uE3
E.	beta-hCG + free beta-hCG + hCG +inhibin A + inhibin B + MSAFP + PAPP-A + PAPP-B + uE₂ + uE3
F.	beta-hCG + free beta-hCG + hCG +inhibin A + inhibin B + MSAFP + PAPP-A + PAPP-B + uE₂ + uE3
G.	beta-hCG + free beta-hCG + hCG +inhibin A + inhibin B + MSAFP + PAPP-A + PAPP-B + uE₂ + uE3
H.	beta-hCG + free beta-hCG + hCG +inhibin A + inhibin B + MSAFP + PAPP-A + PAPP-B + uE₂ + uE3
I.	beta-hCG + free beta-hCG + hCG +inhibin A + inhibin B + MSAFP + PAPP-A + PAPP-B + uE₂ + uE3
J.	beta-hCG + free beta-hCG + hCG +inhibin A + inhibin B + MSAFP + PAPP-A + PAPP-B + uE₂ + uE3
K.	beta-hCG + free beta-hCG + hCG +inhibin A + inhibin B + MSAFP + PAPP-A + PAPP-B + uE₂ + uE3
L.	beta-hCG + free beta-hCG + hCG +inhibin A + inhibin B + MSAFP + PAPP-A + PAPP-B + uE₂ + uE3
M.	beta-hCG + free beta-hCG + hCG +inhibin A + inhibin B + MSAFP + PAPP-A + PAPP-B + uE₂ + uE3
N.	beta-hCG + free beta-hCG + hCG +inhibin A + inhibin B + MSAFP + PAPP-A + PAPP-B + uE₂ + uE3

Scenario 7.

Which of the following markers are used in the 2^nd. trimester quadruple test?

Markers & option list as for the previous question.

Scenario 8.

What is the approximate age-related risk of Ds at term for a woman of 21?

Option list.

A.	1 in 20
B.	1 in 35
C.	1 in 50
D.	1 in 85
E.	1 in 100
F.	1 in 200
G.	1 in 350
H.	1 in 500
I.	1 in 1,000
J.	1 in 1,500
K.	none of the above

Scenario 9.

What is the approximate age-related risk of Ds at term for a woman of 25?